Gray-haired doctors (Veer)

My guest on my January 12, 2017, American Journal of Managed Care Podcast was Dr. Richard Baron, the president and CEO of the American Board of Internal Medicine (ABIM) and the American Board of Internal Medicine Foundation. We talked about the role the Foundation has been playing in fostering professionalism in medicine.

You can listen to the Podcast below:

Or, you can read a transcript of the podcast which has been edited for better readability:

 

The mission and focus of the ABIM Foundation

Richard: The mission of the ABIM Foundation is to improve healthcare by strengthening medical professionalism. Although that sounds like kind of a hokey airy-fairy thing to talk about, the core assumption is that one of the ways that healthcare could be a lot better is if policymakers and leaders and administrators thought more about the role of medical professionalism and the intrinsic motivation of clinicians who go to work and want to do the right thing.

A lot of the conversation that goes on in healthcare is about trying to optimize performance or figure out what’s the right payment system, right staffing model, or regulations to have. Our foundation spends a lot of time thinking about what approaches could be used that would appeal to professionalism and then use that as an intentional policy lever to make healthcare better.

Pat: Interesting. I bet most non-physicians already think that all physicians are professionals. What really is the problem you’re trying to solve with the focus on professionalism?

Richard: In 2002, ABIM together with the American College of Physicians and the European Federation of Internal Medicine created a document called a Charter on Medical Professionalism. It was meant to be a 21st-century code of ethics. Quite frankly, I began my service on the board in 2001 around the time the Charter was being developed and I was pretty unenthusiastic about it. I wondered, “Why do we need one more code of ethics reciting various kinds of expectations?

The Charter talked about patient welfare and patient autonomy, which are old concepts, but it also called out social justice as a core responsibility of physicians, which was a major new focus. It enumerated a series of commitments, one of which related to stewardship of finite resources as a core professional obligation.

 

Choosing Wisely

Richard: The strongest example of how the foundation does its work is its signature campaign, Choosing Wisely. Choosing Wisely was developed to help address the issue of responsible stewardship of scarce resources.

We now live in the world where patients have high deductible health plans and significant co-pays. They may be bearing much of the cost of their healthcare. We know that patients are very interested in knowing whether they really need that test.

We are interested in ways that don’t feel to physicians like something the CFO or the head of the practice group wants them to do. You don’t want to go into a roomful of doctors and say, “Gosh, if you guys can reduce MRI scans, we can make a fortune on this new value-based contract we have.” That’s an unethical, unprofessional, and terrible conversation to have. If you said, instead, “You know, there are things we do more than we should do and we shouldn’t do those things,” it is better. An example is getting MRIs for low back pain early on. Most people with low back pain are going to get better.

The Foundation asked medical societies to come up with a list of 5 things that physicians do too much of. The work was guided by four simple rules:

  • It has to be in your area of practice.
  • It has to be consequential either because it has a high impact on patients’ costs or complications or it’s frequently done.
  • It had to be evidence-based.
  • The process had to be transparent.

The Foundation worked with 80 different subspecialty societies to generate lists of five things that you should question—not that you should never do them but that you should question them.

Choosing Wisely is an example of taking the abstract concept of professionalism and stewardship and creating an activity that professional societies could engage in. It resulted in the creation of tools that doctors at the point of care could pick up and use.

It really took off. It’s now in 20 different countries and 80 different societies and it’s had two rounds of funding from the Robert Wood Johnson Foundation for dissemination strategies. It’s been a very high impact, high visibility campaign. And it’s all based on the appeal to doctors to do the right thing. It gives them a way to actualize their own professional impulse not to harm patients by doing unnecessary services.

 

Stewardship challenges

Pat: I think that stewardship is absolutely one of the professional responsibilities that we have. But I have to say that there has been some criticism of the Choosing Wisely campaign, particularly the issue of whether the tests or the focus areas that were chosen were actually the ones that were going to have the biggest cost impact. It would be easy for me to throw out five things that won’t affect my bottom line, but I may be hesitant to throw out things that generate the revenue that sustains my practice. How have you been responding to that criticism?

Richard: There is some legitimacy to that criticism. If you were the chief medical officer of a health plan or someone else managing costs, you would start with the highest cost, highest impact things, and you would have various tools in your toolbox to try to make that happen. Choosing Wisely didn’t go that route. Instead, we said to the medical societies, you need to own this, you are the experts. The Foundation is not going to peer review what you do. We’re counting on you to do the right thing here.

As you might expect with the involvement of 80 societies, some didn’t go very deep or get very aggressive in some of their recommendations. But there were other societies, like my own, the Society of General Internal Medicine that advised giving up the annual physical, an important part of how general internists make a living. So, there were societies that went very deep and took real risks, but the important thing from our point of view was that it was physician-owned—there was a ton of buy-in and legitimacy. The recommendations were not coming from a financial savings framework. They were coming from a harm reduction framework (i.e., don’t do unnecessary things that may hurt people).

There’s definitely a trade-off by not picking what you might call the most aggressive things. But I think the other side of that is we activated a lot of attention and engagement. The societies had to appoint committees to do this work. They have to devote resources to disseminating it. They were brought in and we’re proud of that. It is an example of how activating professionalism gets you things that you might not have gotten if you tried a “let’s find the highest cost things” approach instead.

Pat: It’s always a balance between getting people to buy into doing the right thing and then recognizing that at some point, at least in some areas of medicine, there’s a real conflict between stopping the things that don’t bring a lot of value and the success of a particular profession.

For example, we know that there’s a lot of unnecessary back surgery going on. However, first and foremost, orthopedic professional societies are trade associations that have, as one goal, the protection of the financial and mental health and well-being of their physician members. You can see how this creates a conflict and starts to raise questions in the mind of health policy people who are focused on the things that we really need to do to get costs under control. I know that Choosing Wisely has been documented to lower some costs but overall healthcare costs are still wildly out of control.

Richard: For sure! Choosing Wisely is not a panacea. It’s a tool in the toolbox. So, the price is also a part of the issue as is the impact of a fee-for-service reimbursement system that drives volume. Payment structures make a difference in what people do and what people don’t do.

Some people advocate that it’s all about transparency. They think if patients had access to prices and quality data that would be a very powerful lever. I think all of those things are powerful levers, but for something that is 17% of the GDP and rising, it isn’t going to be about one thing.

But, when system people decided to focus on a particular Choosing Wisely recommendation and organize things like electronic health record alerts, data reporting, and patient education around it, they were able to document substantial cost savings. A lot which may have come from the buy-in of the clinicians who were told The American College of Cardiology thinks this is something that doesn’t have a lot of value and we shouldn’t be doing. So, it’s not our CFO. It’s not the contracting officer. It’s not even our chief medical officer. It’s what your professional society says. And, by the way, we are going to monitor and measure it.

This has led to 10-20% reductions in unnecessary antibiotic use. It has led to substantial reductions in unnecessary laboratory testing. So, in particular applications, it’s been very effective in providing a moral and professional basis for physicians to focus on avoiding harmful and unnecessary care.

 

Social justice

Pat: I want to come back to an issue you raised earlier, the issue of social justice. I’ve always thought physicians should be on the leading edge of advocating for social justice, in particular, social justice around the issue of healthcare, itself.

And yet I’ve felt that some physicians have been reluctant to jump into the healthcare debate and willing almost to turn a blind eye to having so many people in our country that don’t have access to affordable healthcare insurance. Do you think doctors are doing as much as they should? And what’s the foundation doing in this arena since they pointed out that social justice was important?

Richard: As a personal matter, this was the issue that got me out of community practice. I had an incredible opportunity at the CMS Innovation Center to lead a group that focused on developing new models for payment and/or service delivery that increased quality and decreased cost. I worked in what was called the Seamless Care models group and was right in the middle of developing the comprehensive primary care initiative and the Pioneer ACO model. I was so involved in the work that I had to leave my practice. I did that because I think it is one of the critical issues of our time.

I also learned when I was at the Innovation Center, that the only thing that comes out of the CMS building is checks. Money flows out of the CMS building. That doesn’t take care of anybody. It is the way frontline clinicians practice and optimize the systems that they work in that are important. Everybody has the opportunity to lead from where they stand. If you’re in a small community practice, you can improve the service quality and efficiency of that practice. If you work in a hospital, you can serve on committees and try to upgrade the way the community hospital does its work.

I know that physicians are feeling overwhelmed and alienated, and kind of beaten down by electronic health records and various regulatory fiats that feel are descending upon them. But in the middle of all of that are physicians and patients. Patients have needs. They come to us because of our expertise. We’re in a position to offer service and help for that. That is a deeply meaningful work that we do.

Physicians, wherever they’re working in the healthcare system, have opportunities to improve it. And we need to encourage our colleagues to do that. We need to create systems where they are encouraged to do that and where they don’t feel disempowered.

Pat: I want to say that this idea of encouraging doctors to get involved as leaders in their own communities and organizations and even at the state and national level is really important. It certainly is a way in which docs could enact the mandate for social justice.

But, there was just a really interesting article in the New York Times called, “For Doctors, Age May Be More Than a Number,” that pointed out that a fifth of American doctors are now older than 65 and they are not leaving the field, they are sticking around for a long time. It doesn’t leave a lot of room for young physicians to step into leadership positions because those leadership positions are filled by older doctors who stay on and on and on.

But how do you think we can address that? Is there a way ABIM could encourage some of these older docs to not keep their leadership positions for 25 years and to understand that part of their obligation in terms of professionalism is to help young docs go up the ladder and acquire not only leadership skills but leadership positions?

Richard: There’s a lot going on in leadership. Doctors who are leaders and managers have had a career that took them from the bedside to the C-suite. They understand that those are very different ways of looking at the world. And they understand that some of the skills they have as a bedside clinician are absolutely foundational to successful management and some are lethal to successful management and leadership.

So, the first thing I would say to young physician leaders is that leadership skills need to be acquired by practice in the same way clinical medicine skills need to be acquired. People shouldn’t start by assuming, “I’m the one who really knows how to fix all this and everybody else should just get out of the way“.

My first leadership job was as the chief medical officer of a large Medicaid HMO in the late 80s, when the words Medicaid and HMO in the same sentence guaranteed that people would move away from me at a cocktail party, for sure. My friends would say, “We’re so glad you are there because everything’s going to be okay because you really understand what this is all about.”

I said, “Sure! It’s great that I’m there. But you know what? I don’t know how to run a marketing campaign. I don’t know how to hire people and not run afoul of the equal employment opportunities commission. I don’t know where to put a hundred million dollars tonight and find it tomorrow morning. And I don’t know how to get an HMO license. And if we don’t have people with those skills, we wouldn’t be in business as a company.” Physicians appreciating the skills that others have is a core element in leadership positions.

There are plenty of opportunities for younger physician leaders to get engaged and it’s not about paying dues, but it is about getting experience and not just assuming that because they’re doctors—and because they’ve identified a problem—that the solution that they have is the right for that problem. I often ask myself the question every time I ran into what seems like a completely insane policy, “Who could have thought this was a good idea? What problem might this have been trying to solve? What might a better way to solve that problem?

I think that’s a very helpful way for physician leaders to approach challenges that come up in clinical medicine, too. There are a lot of problems that are critical to clinical success that are being solved in healthcare every day including how to source drugs in an affordable way how to staff units to maintain an operating technology. Solving these problems is critical to clinical success. I think physicians do well to understand how many other people we need to help us be successful. How many other things have to go right for all of us to succeed in our mission of taking care of patients?

 

Physician burnout

Pat: Is there any intersection between the work that the Foundation is doing and burnout—a disturbing and widespread problem that’s leading doctors of all ages to leave medicine?

Richard: Absolutely. There are a few things that I can say about the Foundation and burnout. One, we funded Dr. Christine Sinski who was on the ABIM board and who is now on a Foundation board. She has become a national expert on physician resilience. She’s the person who coined the term “Finding Joy in Practice”. We funded the article she published on the topic.

Burnout has to do with dysfunctional systems, feeling disrespected, losing autonomy, and losing control. It is also about losing meaning and losing touch with purpose. Chris has focused a lot on re-engineering practice to create space for joy and space for the meaningful parts of medical practice. She is still in a part-time practice with her husband, an internist, but she’s also taken an administrative leadership job as a Vice President at the AMA.

Chris has developed a roundtable on the topic at the AMA. Some of those people are developing organizational metrics and formal strategies around burnout. That’s not our work, it’s her work and the AMA’s work. But we take some pride in having gotten her started in that area.

Pat: I love the idea of people working on “how to return joy to medicine?” I want to raise this issue, though, of whether it needs to be joy centered on the continued practice of medicine or whether it can apply to the many different ways that you can contribute to medicine, healthcare, and health of populations beyond being in the office. I wrote a story a while back based on my career that involved switching from one thing to another. I went from being a practicing emergency physician to a physician executive, a consultant, an entrepreneur, and now doing health media. All of this variety has allowed me to just stay in love with medicine. Do you think that there needs to be some focus on helping individuals understand that sometimes having new challenges can rekindle joy?

Richard: Well, even if you try to stay in the same field, the field changes out from under you. Any doctor who was in practice before the advent of electronic health records or email has seen the way they do their work change dramatically. So, new challenges come up all the time even if you try to stick where you are.

But I think you’re right, and your career illustrates it, that some people may get to a place where they feel there’s something else that may be more fulfilling. Nobody should feel locked into doing something that they hate. That was certainly advice I gave patients in practice whether they were bankers or lawyers or colleague physicians.

It’s important for all of us to take seriously how much joy we’re finding in work and what other kinds of the things we might find more joyful or more engaging or more rewarding. That’s going to vary by individual. Some people are going to want to stay in one place because they really appreciate the continuity. Other people are going to want more change and diversity.

Medicine is a very large tent that can accommodate all of those things. People should not stay in positions that they are miserable in and they should either take steps to try to make them more joyful or they should look for other opportunities altogether. And I think that’s true across the board, not just in medicine.

Pat: I’ve really enjoyed talking to you. I’m kind of in awe that we ended up having a conversation that included words like love and joy and happiness and fulfillment. Those are all words that at the end of the day all those people that are applying to medical school or struggling through the challenges of pre-med, medical school, or residency are hoping will be a big part of their life in medicine.

I’m delighted that you are in a position, through your role at the ABIM Foundation with its focus on professionalism, to help be sure that we keep on talking about joy and love in the context of medicine.

Richard: I think the future is bright and there is still plenty of meaning and value and human connection to be found in medical practice. I am enthusiastic about people finding pathways that do that.

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