番茄社区

Isn't it about time that the people who make the decisions about so much stuff in healthcare give us what we need, not what they think we need?

After writing about misadventures in healthcare for so many years, it feels like we keep pointing out that the people who make the decisions about what's the best way for healthcare to be delivered aren't the people actually doing the healthcare. How did we let this happen?

Clearly, I understand that there will always be a need for regulations and regulators, there will always be bureaucracy and bureaucrats, and there will always be a need to have an administrative structure to help keep things from crashing down. And there will always be vested interests, from pharmaceutical companies to insurance companies to hospitals that are employers to stockholders. But shouldn't the last word come down to those providing the care, and those to whom the care is being provided?

Figuring It Out On Our Own

Working together, I think patients and doctors can probably figure out on their own what we need to provide the best care possible. Sure, we're always going to need researchers; we need people doing randomized controlled trials, helping us figure out better ways to do things. But right now, it feels like for so long we have been functioning in a system that mostly ties our hands, that has built up so much stuff around the act of taking care of patients, that we can't actually take care of them.

Quite often, when we prescribe a medicine, we create an extra hour or two of administrative burden, messages back about prior authorization, demands for records to be faxed, and requests for us to appeal denials, fill out another form, or wait on hold for the next available operator to connect us to a peer-to-peer review that gets us nowhere. Every time we think our electronic health record may be helping, there are a dozen times where all the clicks and boxes and mandated screenings seem to do more to get in the way of care than to actually improve the lives of our patients or our providers.

Just recently, we had a consultant come through our practice who took a long, hard look at our infection control practices. In particular, they wanted to know if the nurses and medical assistants knew how long to disinfect each surface under each circumstance with each different type of antimicrobial cleaner wipes, and how they were able to verify that providers were actually performing hand hygiene correctly.

One of the solutions they recommended was that we get our institution to install sensors that we all wear throughout the day, so they can track how long we stand in front of the Purell dispensers, and whether we stand in front of the sink long enough to sing "Happy Birthday to You" twice while we wash our hands. Really, does this actually seem like a good idea?

But Does It Actually Work?

Somebody must think that having Big Brother watching over your shoulder would actually improve compliance with hand hygiene and decrease the levels of nosocomial infection transmission. Has anyone ever shown that this is cost-effective, efficient, safe, smart? In reality, this kind of thinking will more likely just lead to more anger and burnout -- the final straw that would break the back of everyone in healthcare already feeling overburdened.

Now they can be watching us to make sure we Purell often enough and wash our hands long enough. I know that no one can trust us, that we're obviously not doing the right things, that we're trying to get away with something. But before someone makes a suggestion like this, shouldn't they have to come up with some evidence, some data, something that shows that this is actually a good thing for everyone involved? And maybe if the providers weren't so overwhelmed by the lack of support, they'd have time to breathe -- in and out, in and out -- and then wash their hands?

Have any of us ever gone from one patient's room to another without performing perfect hand hygiene? Undoubtedly this has occurred. But ask anyone coming out of a room if they are planning to do the right thing, and they will undoubtedly look at you like you've lost your marbles. Thinking of ways to decrease errors in healthcare is a good thing, but suggesting nonsense that interferes with our lives and interferes with the care of our patients more than anything else is just wrong thinking.

Never Enough Time

Right now in our electronic medical record there are literally dozens of screening questionnaires that we are supposed to fill out at almost every visit: pain scores, tobacco use, alcohol use, substance use, depression screening, suicide screening, domestic violence screening, asthma severity, social determinants of health, falls, comprehensive geriatric screens, and on and on.

Yes, for the right patient these are often critically important, and we do need a way to make sure that everyone is screened appropriately, and that, even more importantly, we are then given the right tools to give them the right care they need. But in our 20-minute visit where we're trying to deal with their back pain, their headaches, their fatigue, and their diabetes that is uncontrolled for so many reasons. We need to address their blood pressure that is high because somehow they never got their prescriptions filled, their asthma that's impossible to control in the environment they're forced to live in, and their unmet mental health needs -- all of these worsened by so many factors beyond our control.

We're trying to get all their healthcare maintenance tasks updated, all of their recommended vaccines delivered, explained all their medications and health conditions so they can fully understand them and make the right choices through culturally-sensitive shared decision making, and answer the sheath of printouts from Dr. Google, not to mention the questions they've brought in from their cousin who had some suggestions for them to bring to their doctor.

Wouldn't it be better that instead of putting body cams on us to count how many seconds we wash our hands, if the powers-that-be would actually just listen to us and help us make the electronic health record how we want it, give us the resources to take care of our patients, and help us stand up and fight the fight that needs to happen for them to get the best care possible, no matter the cost?

If you give me this, I promise I'll wash my hands. Or else we need to wash our hands of the whole healthcare system.

Comment