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Loss of Professional Joy

April 10, 2013
By

Larry Bauer, who is a leader in family medicine education in the northeast U.S., sent out a link to a piece written by teacher who complained about the over-emphasis on standardized tests in secondary education. He felt so bad about it, he quit teaching.  Here is the link:

http://www.washingtonpost.com/blogs/answer-sheet/wp/2013/04/06/teachers-resignation-letter-my-profession-no-longer-exists/

Larry asked a group of family physicians what they thought about this, and if they felt this way in family medicine.  Here is how I responded:

We are going through this silly meaningful use hoop-jumping now. This journey is made worse with the limitations of EMRs. Here are some of my frustrations:

  • The bureaucrats want us to measure processes that have been proven to be essentially ineffective, i.e.  weight  loss counseling in the primary care center.
  • Similarly, we will have to check boxes that we provided tobacco cessation counseling, which everyone knows will mostly be delivered as a quick statement, probably by an MA, that will have no impact on cessation rates (and even if it worked, it doesn’t lower healthcare costs).
  • The diabetes quality measures can’t be directly tied to the diagnosis of diabetes in our EMR (one of the big company’s products), but must be entered separately so reports can be generated.
  • The more important outcome to measure in diabetes is blood pressure, because it reduces future events much more than the sugar level. But our EMR can’t find the blood pressure, but it can find the lab value.
  • Lots of patients have blood pressures that do not meet the ideal, and it’s nobody’s fault – the patient’s nor the doctor’s – they just have bad disease. There is now an incentive for us to dump these patients out of our practices so we look better on the scorecards, when in fact these are the very patients that relationships with family physicians result in lower costs and better care. It’s part of how we are so good at managing complexity and uncertainty.
  • The preventive reminders in our EMRs are tied to birthdays, so if a person had a test a week before the birthday, and shows up to clinic a day after her birthday, a reminder box will still pop up saying the service has not been provided.
  • Mammograms are required every year, but Medicare only pays for them every other year.
  • Eye screenings are required every year, but Medicare doesn’t pay for them.

That’s enough. So yeah, I know how the teacher feels.

I will say that I accept that for the rest of my career, my decisions will be scrutinized by others. The problem for family medicine is that our world is complex and uncertain. Many of our decisions are made in a process of negotiations where we are balancing competing and conflicting interests. The problem is that the bureaucrats and EMRs are too simplistic to keep up with us.

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