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Physicians are said to grapple with their ‘moral injury’

An essay in STAT suggests that “moral injury,” not “burnout,” is the biggest problem for physicians now.

 The authors write:

“Moral injury is frequently mischaracterized. In combat veterans it is diagnosed as post-traumatic stress; among physicians it’s portrayed as burnout. But without understanding the critical difference between burnout and moral injury, the wounds will never heal and physicians and patients alike will continue to suffer the consequences.

“Burnout is a constellation of symptoms that include exhaustion, cynicism, and decreased productivity. More than half of physicians report at least one of these. But the concept of burnout resonates poorly with physicians: it suggests a failure of resourcefulness and resilience, traits that most physicians have finely honed during decades of intense training and demanding work”.

“The term ‘moral injury’ was first used to describe soldiers’ responses to their actions in war. It represents ‘perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.’ Journalist Diane Silver describes it as ‘a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”’

“The moral injury of healthcare is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of healthcare.”

To read the piece, please hit this link.

Survey suggests many physicians in no hurry to retire


Research by Hanover Research looked at why many older physicians don’t want to retire, or at least don’t want to completely retire from medicine. The study suggested that more physicians than expected want to keep working than many in the healthcare sector had believed. That may be good news for the U.S. healthcare “system,” which faces clinician shortages in some places.

The Hanover surveyors contacted more than 400 physicians 50 and older. The average respondent was  60 years old, worked about 45 hours a week, and had practiced medicine for an average of 28 years.

They found that overall, physician said they planned to retire at  68, compared with the average U.S. retirement age of 65.  51 percent of respondents indicated they’d be interested in working in regular part-time jobs or occasionally after formal retirement.



The challenge of leadership in complex care


In a NEJM Catalyst piece, three physicians discuss “Leadership for Complex Care: The Ship’s Ballast in Troubled Waters.” Among their observations:

“As clinical leaders who have developed teams in different organizations to navigate complex care environments, we have long maintained that the traditional focus on who captains the ship is misguided. In many complex clinical scenarios, there is often no single right way to do things. Having many different physicians bring their attention to a difficult problem can minimize the chance that something will be missed. Specialists tend to see care from their particular perspectives and, in the absence of collaboration, may not fully appreciate the effects of a therapeutic intervention in areas where they do not usually focus.”


“Novice clinicians sometimes look at the need to communicate intensively as a rite of passage — something that must be done until their colleagues gain confidence in their abilities. This thinking is misguided. The issue, again, is not that one is communicating because of a concern about competence, but because counterparts are equally invested in care. Indeed, the most experienced and skilled physicians often communicate about seemingly minor issues more frequently and adeptly than their more junior colleagues. Sharing small nuances and occurrences empowers all physicians to speak knowledgeably and consistently when they interact with families and referring doctors.”

To read the whole article, please hit this link.



Survey: Physicians’ biases against patients’ personal characteristics affect treatment

A Medscape survey of physicians found that many admitted to being biased against some of their patients because of the patients’ personal characteristics to the extent that it affected their treatment of those patients. To read the survey, please hit this link.

The top reported biases were linked to:

  • Language differences.
  • Patients’ emotional problems.
  • Their obesity.
  • Their low intelligence.
  • Their lack of insurance coverage.
  • Their physical unattractiveness.
  • Their low income.
  • Their race different from the physician.
  • Their  age.
  • Their gender different from the physician.


Ex-Turing CEO blames physicians for surging healthcare costs


 “The Worship of Mammon(1909)  by Evelyn De Morgan.

Former Turing Pharmaceuticals CEO Martin Shkreli  gained infamy for, among other things, raising the price of Daraprim, a generic anti-parasite drug for treating toxoplasmosis, from $13.50 per pill to $750 overnight. Despite angry public pushback against his greed-is-good approach to pharmaceutical sales, Mr. Shkreli says he doesn’t regret a thing.

When asked if he would do it all over again, Mr. Shkreli told Bloomberg News last week,  he responded: “Of course.  Everybody’s doing it. In capitalism, you try to get the highest price that you can for a product.”

Mr. Shkreli  also said drug prices are not to blame for the U.S.’s growing healthcare costs. “Drug pricing is only a small part of healthcare expenditures. Physicians are the biggest part. We don’t talk about physicians. Their prices are rising as fast, or faster, than drug prices, as are hospitals’ and medical-device companies’ [prices].”

To hear the interview, please hit this link.


Not too few physicians but bad distribution, not enough non-physician clinicians

It’s sort of a cliche to say that America has a  dangerous shortage of physicians. But a New York Times story challenges that.

It says, among other things:

“Some people think there’s no shortage at all — just a poor distribution of the doctors we have.”

“Adding data to this argument, the United States has fewer practicing physicians per 1,000 people than 23 of the 28 countries that reported data in 2013 (among nations in the Organization for Economic Cooperation and Development).”

“But there is strong evidence that we are thinking about this the wrong way. In 2014, the Institute of Medicine released a thorough analysis on graduate medical education that argued there was no doctor shortage, and that we didn’t really need to invest more in new physicians.

“The system isn’t undermanned, it said: It’s inefficient. We rely too heavily on physicians and not enough on midlevel practitioners, like physician assistants and nurse practitioners, especially because evidence supports they are just as effective in primary care settings. We don’t account for advances in technology, like telehealth and new drugs and devices that lessen the burden on physician visits to maintain health.”

“And we fail to recognize that what we really have is a distribution problem. Parts of this country have lots of doctors, perhaps too many. These are mostly in cities, especially in cities where it seems desirable to live. The problem is made worse by the ways we reimburse for care. Medicare, for instance, pays more to doctors who live in places that are more expensive. The argument for this is that the cost of living is higher, so reimbursements must be, too. But that also means that doctors can earn more in places where they already might want to live. A result is that many rural areas, and less popular cities, experience more of a doctor shortage than others.”

“The other distribution issue is in specialization. When it comes to generalists, we ranked 24th of 28 countries in doctors per 1,000 people. Specialists are a different story. There, we were 11th. This is an important fact about the American health care system. We sometimes hear that we have too many specialists and too few generalists. That’s not necessarily the case. We have an average number of specialists compared with other advanced countries, and even shortages in some specialties. It’s the ratio of specialists to generalists that’s the problem. …”

To read the full Times story, please hit this link.

Physicians’ ways to avoid burnout


In this Physicians Practice thread, doctors talk about  the methods, some quirky,  that they use to avoid burnout in a time of healthcare upheaval.

To read their observations, please hit this link.

Physicians in poll reject mandatory retirement age


Not ready for this yet.

Although the federal government, among other institutions, sets mandatory retirement ages for such  high-risk industries  as aviation and law enforcement, a hefty 73 percent of respondents to a Modern Healthcare online poll said that such measures aren’t needed for most physicians.

However,  the publication reported, “respondents overwhelmingly backed mandatory assessment programs, and many felt stricter age-related policies are needed for certain clinical specialties like surgery.”

“Mandatory retirement assumes cognitive decline is universal, which it is not, ” said one respondent. “Frankly the health system cannot afford to lose the manpower,” stated another.

The publication said that “Respondents did worry about the ability of aging physicians to stay abreast of new regulations, treatments and technologies. ‘It becomes impossible to keep up,’ one said.”

“Differences narrowed when poll-takers were asked whether retirement should be mandatory for certain specialists. About 46 perecent answered ‘yes,’ with surgeons the most frequently cited specialty. Those jobs are physically demanding, require fine motor skills, dexterity and eye-hand coordination, they noted. Invasive cardiologists, obstetricians, neurologists and emergency medicine doctors also were frequently cited.”

To read the Modern Healthcare article, please hit this link.


VA wants to expand role of advanced nurses


The Department of Veterans Affairs (VA) has formally proposed to let its advanced practice registered nurses (APRNs) work independently without physician supervision in its  healthcare network, the largest in the nation.

The VA said that expanding the APRN scope of practice in such a way would increase veterans’ access to care and shorten their notoriously long wait times for appointments.

Not surprisingly, the American Medical Association opposes the plan because it runs counter to physician-led, team-based care, which it called the best approach to improving quality.  Many physicians also worry that such change could reduce the influence and income of physicians.

Read more here.


Training physicians to avoid burnout


Some hospitals are training physicians to better manage their feelings in the face of what can be great stress on the job, as the problem of clinician burnout  (and the medical errors that may  sometimes be caused by it) seems to intensify.

As this Wall Street Journal story says:

“The increased focus on coping skills comes amid rising concern for the psychological health of physicians. A recent study found burnout rates among pediatrics residents at Seattle Children’s Hospital ranged from 41% to 77%, depending on the year of residency, says Maneesh Batra, who presented the findings at a recent meeting of the Pediatric Academic Societies. Dr. Batra, an associate professor of pediatrics at the University of Washington School of Medicine, says previous studies at other institutions have shown similar burnout rates among residents in other medical specialties. Research shows that higher doctor-burnout rates are associated with more medical errors, impacting patients.”


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