The AAO’s “Why I Advocate?” Challenge. #MYF2018
I have been reading a lot about burnout and moral injury. Why is this issue important? Depression is on the rise within medicine and the physician suicide rate is nearly 2x that of the general population and even higher when compared to the military. This is absurd and appalling to me and we should not tolerate suicide in anyone. It is heart breaking to know that fellow colleagues are suffering along this potential continuum. We need to help everyone along this path. As a veteran myself, moral injury should not be used in this context of physician burnout, but it is a better phrase than burnout. I think most of us know what the problems are and disagreeing on what term to use is not as important as the solutions. Once we get beyond this et terms, we should use a new term, the “F Factor,” or Fulfillment Factor. As physicians, we sacrificed many years of our lives because we care about patients, driven to learn, and have a desire to be give back to others. We need to focus on a Physician’s “F Factor.” Irrespective of the term we use, we need to simply define what we are speaking about-conflict by the physician to put the patient first with other competing priorities- self interest and company interest.
Our first priority is to our patients. Physicians are second and anything the physician needs to enhance the physician-patient relationship, then it needs to be honored and respected. Do you need a scribe, then get a scribe. Do you need a stapler at your desk or a scanner or a printer, then get one. Arguments about adding a printer would be too expensive is where the problems are made worse. A printer at the physicians desk or in the exam room needs to happen if that is what will increase the physicians “F factor.” Albeit this is a simple example, create a list of issues that impede patient flow and limit time with the patient. Prioritize what will enhance the patient experience and increase your “F Factor,” and start addressing each one. Partner with your administrator to implement these solutions.
Next, move to the larger system within your practice. Do you have enough technicians, do you need a scribe? Are there too many do’s and don’ts from upper management that interfere with your clarity of thinking about the patient first. Are you driven more by economics than what the patient needs? Obviously, be mindful of the economics, but do not be driven by them!
Finally, focus on advocating for your patients at the national level by meeting with your legislators. Reduce burdens on physicians. The system focuses on physicians clicking too many times within their EHRs while ignoring the person, the patient. This reminds me of when I worked in the grocery business in high school and college where I saw customer service decline and more burdens were placed on the customer. We moved from manual cash register to scanners. We moved from serving the customer to the customer serving themselves by having them unload their own cart. Now, there are self check out stands, although it can be easier, it still requires a learning curve. The airline industry is doing the same thing, making the customer check-in on their own to print the boarding pass to even placing the sticker tag on the bags. The customer in this case is the Physician. We are burdened with so many bureaucratic lists. We have had to become coders, billers, clicking to oblivion to improve so-called quality of care, and we know that meeting MIPS standards does not equate to higher quality. This is merely a “C average” mentality which is contradictory to our mindset as physicians. We have strived to be far above a “C average” mentality. Standards should be set by physicians when it comes to the physician-patient relationship. I want all administrators to ask physicians, what resources do you need to be successful? Give them those resources and determine whether the “F Factor” increases, efficiency improves, morale is boosted, and most importantly, the patient’s and staff’s happy factor increases.
I know we can make a difference! We need to make sure we as individuals are doing our very best and practice self-awareness and avoid being a victim, but rather step up and voice our concerns and demonstrate leadership. We need to improve our EHR systems too by creating voice to text and improving communication across so many different platforms. Voice your concerns with your partners, practice, and larger systems. Own it.
Change will occur if we speak up as leaders.
Rob Melendez, MD, MBA
A must see video and references below:
Video by ZDoggMD: (Offensive language)
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Is Twitter dying for the Ophthalmologist?
Rob Melendez, MD, MBA and Pavan Angadi, MD
We performed a study to investigate whether ophthalmologists are joining Twitter at an increasing rate and to determine whether they are more active on the site. We searched for ophthalmologists using the following terms: “ophthalmologist”, “ophthalmology”, and “eye surgeon.” We found that ophthalmologists started joining in 2007 when Twitter started and the number of new users was at their maximum in 2009 (56) and has been declining since then and in 2017 only one ophthalmologist joined Twitter (See Figure 1). There were obviously more ophthalmologists on Twitter, but were difficult to identify because they failed to mention in their profiles that they were an ophthalmologist. This raises the issue of why some ophthalmologists are on Twitter. The ones who did not self identify themselves as ophthalmologists are likely on Twitter more for personal use and not professional reasons to educate others.
We also investigated how active these ophthalmologist have been in 2016 and 2017. We found that the average number of tweets/month in 2016 was 60.6 and in 2017 it increased to 80.4 (38.6% increase). We also found that the total number of active users increased from 138 in 2016 to 169 in 2017 (22.5%). We also identified the total number of tweets from these ophthalmologists in 2016 was 3739 and 5865 in 2017, which was an 56.9% increase. We found that although the number of new users on Twitter has declined since 2009, the existing users of Twitter has increased. Given the paucity of ophthalmologists on Twitter, suggests that it is a great opportunity for more ophthalmologists to become leaders on Twitter to educate others. We also identified which types of ophthalmologist are most active on Twitter (see Figure 2).
Figure 1. Number of Ophthalmologists on Twitter and what year they started. Figure 2. Ophthalmologist Twitter Users by Subspecialty
What is wrong with Volume to Value based care? Focus on Hypervalue
Rob Melendez, MD, MBA @DrRobMelendez
The phrase “volume to value” is a misnomer. It implies that we are not currently providing any value to our patients and that we are providers who are simply focused on RVUs and FFS. I am appalled by such a phrase. Our focus should be on the term that I will use “hypervalue.” Hypervalue is a term that raises the bar for patients at all levels of patient contact using lean management principles. We need to improve the healthcare system for one reason: to improve the health of our patients. As we have seen over the last 5 years, clicking on boxes to simply satisfy a payment requirement hasn’t increased value for the patient. These programs drive some people to play the game to simply get paid. Our standards should be so high for our patients that when the government mandates so-called value targets, it will pale in comparison to what the increased value or hypervalue that we are providing for our patients. For starters, Let me review two hypervalue concepts for our patients. 1) Improving communication with the providers and patients. 2) Using technology to reduce waste and to analyze how we are caring for our patients.
- Communication: We need electronic health records (EHR) that communicate with other providers and healthcare systems to streamline healthcare. Often times, duplicative testing is being performed and we are not aware of the other ordered test. We also need to continue to improve communication with our patients. The Mayo Clinic has an excellent app for their patients to access their exam notes, labs, appointments etc. This app is an example of hypervalue for our patients. I personally have seen this app in action. Our practice currently uses a patient portal system to communicate with patients which brings value to the patient. We chose to implement EHR in 2005 before we had to because it provided a mechanism to access medical records across our 15 clinics around the state of New Mexico as well as the ability to analyze where we can improve processes and patient care points. Sadly, the cost is enormous for EHR. The costs of EHR can range from the cost of computer equipment, training, IT support and maintenance and beyond. The benefits of EHR are evident today, but when were first started, the costs outweighed the benefits. For example, the IRIS® Registry created by the American Academy of Ophthalmology is a prime example of the huge advantage of EHR. This will increase value to patients, hypervalue. Just think, you now have the ability to easily determine how many of your glaucoma patients had a visual field in the last year and how many of your patients with Diabetes had macular edema to cite 2 examples.
- Technology: Can you imagine a time where patients can input their medical histories online before seeing the doctor via home computer, tablet, or phone with an app? It’s available now, but cost prohibitive in some cases. We trialed a kiosk in the waiting room with little success. It required extra people to teach the patients how to use it. I believe this will come back with time. Think how you first felt when you had to use the kiosk at airports to check yourself in, it was frustrating at first and still is at times. I remember a time in high school when I was a clerk in a grocery store and personally unloaded the customer’s shopping cart and checked them out myself. Now a days, businesses are trying to use technology to improve efficiencies and convenience for certain type of customers with fewer items. Hypervalue would be providing the technology option plus a person to educate the user one to several times until they learn how to use it. The benefit of updating your information before the visit would be to decrease wait times in the clinic. What if there was a faster way to verify insurances before the visit? Perhaps there is, so please share any insights. As we move from so-called volume to value, let us remember that the patient is always first and trying to improve their experience while improving their health is paramount — Focus on hypervalue.
RVUs = Relative value units
FFS = Fee for Service
EHR = Electronic Health Records