Blog | Thursday, January 11, 2018

Fixing physicians' broken windows

I am honored to be a member of the medical profession. Being a physician is a great job and a highly rewarding thing to do. One of the aspects that I like most, unlike so many other desk or number jobs, is that you can never go home in this line of work thinking that you haven't done something good with your day (if you do, there's something seriously wrong). The everyday interactions with patients and families, getting to know them, and using ones' skills to serve them, are not only deeply rewarding, but also very humbling as well. It's those positive interactions that sustain me, even on the worst days. I have zero regrets becoming a physician, something which I've also written about previously.

Having said all of this, it's no secret there's an epidemic of physician burnout and job dissatisfaction out there. This is for a multitude of reasons, but everything ultimately boils down to a monumental loss of autonomy and independence among doctors, as there's been a dramatic shift of power and clout away from individual physicians, towards administrators and the business side of health care. Somewhere along the journey we have lost our direction completely. Unfortunately, in many ways, we have nobody but ourselves to blame collectively, because for any large and respected group of people to surrender so much autonomy so quickly, a lack of strong leadership must always be a factor.

I am a huge fan of the Broken Windows theory of starting to get a grip of a problem. In the 1980s and early 1990s, New York was a city in terminal decline. Growing up in England, I knew many people who came back from trips to America telling us about how terrible and dirty the city was. Times Square was basically a no-go area full of aggressive panhandlers. It was a dangerous and scary place. Enter Mayor Rudy Giuliani in 1994, and the city underwent a rapid transformation. I understand that some aspects of what Mayor Giuliani did were viewed by (some) as controversial, but not wanting to get into politics, however, the results were unquestionable.

The Broken Windows theory of turning around New York City went something like this: heavily target the minor offences first. Zero tolerance for broken windows, graffiti, and other things such as “squeegee men” who would aggressive approach you when your car was at a red light. So the philosophy goes: clamp down on the small infringements, and the bigger things will take care of themselves. The results of this clampdown for New York City were indisputable. By the time I first visited America in 1998, New York City being my first stop on a countrywide tour with my family, Manhattan had become one of the safest and most pleasant places in the country. There was a visible police presence on every street corner and the city was immaculately clean. Whatever people say, drastic circumstances call for drastic actions. Even today, Manhattan is still one of the safest cities in America and tourists from all over the world give glowing accounts of their stay in the Big Apple (in fact, low level crime is actually much lower than many European cities, including my home city of London). Thank you, Mayor Giuliani.

We all probably have our own personal experiences of how true the Broken Windows Theory is, and its everyday applicability. Teaching children behavior is one such example, when not allowing major bad habits to flourish starts with forbidding the small things first. But let's get back to health care, because for positive change to occur, here are Seven Broken Windows for physicians:

1. Completely reject the word “provider”

I have written previously about the implications of the now universal use of the word “provider”, and also penned an open letter with the President of the American College of Physician Specialties, William Carbone, to all medical societies and organizations. The word really has taken over, especially evident during the last decade. I am equally shocked by how new residents are being churned out of some of the most prestigious academic centers in the country (my experiences are with the ones in Boston), and are adopting the word so casually, happily describing themselves as “providers” on correspondence including their social media accounts.

The business and marketing world really has done a number on us and have run rings around the medical profession. Unfortunately, physicians are also very naïve as a group in understanding the immense power of words, and how not calling ourselves “doctors” or “physicians” anymore is extremely bad for our profession. I personally am okay with many other terms if a more encompassing one is required for certain correspondence, including “clinician” or “practitioner”—but provider is deliberately de-humanizing, and also in my view, an insult. If you refuse to use the word, and call people out on it, they will stop calling you one. It should be removed from all administrative correspondence including information technology systems.

2. Insist on a good physician lounge in your hospital

It's so much more than a physician lounge. It is a marker of professional respect and autonomy. This (very small) job perk has rapidly fallen away. I recently wrote an article on this, which went viral online, being shared over 20,000 times. That's because it struck a chord with thousands of physicians who have seen it happen. Lobby for its return in the hospital where you work, and encourage physicians to use it again in their downtime—even for brief meetings.

3. Stand your ground with administrators

As much as hundreds of thousands of employed physicians across the country have a fraught and tense relationship with their administrations, let's be realistic: Administrators are very much needed in any organizational structure, and healthcare desperately needs good ones. However, if you sense that any directive is coming through which will interfere with, or be detrimental to frontline care, it's crucial you sensibly and of course diplomatically stand your ground. If you don't stick up for good healthcare and your patients, nobody else will.

4. Fix electronic health records

Almost every current study of physician job satisfaction and career burnout, lists the burden of cumbersome and clunky electronic medical records at or near top of the list of everyday frustrations. It's an issue that is almost invisible to bureaucrats and administrators, but no doctor went to medical school to spend the vast majority of their day filling out click boxes and typing out bloated notes for billing purposes. Most electronic medical record systems (and I've worked with nearly all of them, and in my opinion they all suck) can be optimized in small ways to improve workflow and reduce the “click burden”. What it does require is relentless feedback to your hospital IT department to do so (remember the main vendor has no motivation whatsoever to improve things, because they have a monopoly once installed). Electronic medical records are one of the only examples of technology where the end-user is not the “customer” (imagine how bad the iPhone would be if it worked like that). The companies sell to administrations, so it's up to physicians to be as vocal as they can.

5. Keep other physician perks

Being a physician is one of the most intense and grueling jobs one can have. Practicing medicine is not for the faint hearted. Yes, everyone in healthcare works hard—but no profession should be actively losing things. Are other useful perks like car parking, a nice office, or cleaning services being taken away from you? Well they shouldn't. What about the other useful workflow issues, like the transcription service, axed to save costs (now stuck with tremendous inefficiency, with what used to be a thorough logical note dictated in 5 minutes, now becoming a series of tick boxes, typed sentences and incoherent computer-generated mishmash)? It may take multiple emails, phone calls or face-to-face meetings, but you should insist on keeping job perks that a professional of your level of education and intelligence deserves. If the executives in your hospitals have reserved parking spots and secretaries to make their lives easier, there is no way that the physicians should not!

6. Collegiality

No profession is anything without collegiality. It's one of the reasons why the physician lounge issue is so important. Doctors need to see themselves again as a unified profession—not one that is fragmented where everyone is in their own little corner specialty. Get to know as many different specialties as you can, organize social events where all physicians can mingle, and talk to each other about how you can get things done. Along the same lines, the link between primary care and hospital-based specialists has been breached by the fact that primary doctors no longer come to the hospital (even as a hospital medicine doctor myself, I see immense drawbacks to this). We need to restore communication between all physicians, especially the primary care offices.

7. Professional respect

I am all for respecting everyone I work with, and healthcare is a team-based effort. But when it comes to a clinical situation, the physician is the leader of the team. Period. However, there are lots of ways in which I've noticed physicians nowadays being treated much more as “co-workers” rather than as the team leaders they are (and to be fair, physicians also need to step up to the mark).

One such example I've noticed is that many colleagues in the hospital now immediately address doctors by their first name instead of “doctor”. Now, I'm not someone that minds being called by my first name, and thankfully most people ask first—but I just find something inappropriate when someone in the hospital, who may actually be much younger than me (frequently also including administrators), walks up and calls me off the bat by my first name. Interestingly, I have heard feedback that this actually tends to happen much more to female than male doctors. Every physician has earned the title, and deserves to be addressed as such initially in the professional setting. Again, this is not to sound haughty, but most doctors will find anything else a bit uncomfortable and not protocol. The same for certain other professions—be it a university professor, airline pilot or even the military—titles are the norm of introduction until told otherwise.

These are just seven of many relatively low-hanging fruit scenarios that physicians can, on a daily basis, work towards making sure they retain their professional status. Most of them are free or with minimal associated cost. Remember, we are an ancient and noble profession, and being a doctor is very special. It's a privilege to use our education and skills to help people get better each and every day. If you want to advocate for the medical profession, deal with low-level stuff, and the rest will start to take care of itself. Of course, there are undoubtedly much bigger things than the seven seemingly small things noted above: Reimbursements, overwhelming bureaucracy and information technology—to name just a few. They will all have their time and place to be dealt with. But doctor, start fixing those broken windows first.
