Doctors are the canaries in the coal mine of medicine

Doctors are the canaries in the coal mine of medicine

Back in the day, coal miners always carried a canary with them in a small cage whenever they would go down in the mine. The canary is a very talkative bird, always singing and tweeting in a constant background noise. Canaries have one more characteristic important to a miner.

When there is bad air in the mine, the canary’s sensitive lungs will cause it to drop over dead before the miners notice any shortness of breath. When the bird stops singing, the miners head for the surface fast. It is a life saving maneuver.

Here in 2013 as we start to implement the provisions of Obamacare and projections of physician shortages as high as 91,500 by 2020 come from respected sources, I believe we have a similar “coal mine” situation in healthcare.

Unfortunately, physicians appear to be the canary in the mine.

Even before the pseudo-shortages of the Affordable Care Act, physicians were not in good shape. Symptomatic burnout is present in an average of one in three doctors on any given office day. A 2012 survey by the Physician’s Foundation reported that 60% of doctors would retire today if they “had the means.”

High patient volumes, the hassles of electronic medical records (EMR), political uncertainty and changing reimbursement rates are all cited in surveys and online forums as new and increasing sources of stress for doctors. Online patient complaints always center on “the doctor seemed, rushed, didn’t listen or seem to care,” which are classic signs of overwork and burnout.

The biggest new burnout threat may be pay for performance (P4P)

Healthcare organizations will soon be paid bonuses for reaching certain care quality indicators and patient satisfaction thresholds. Patient satisfaction is incredibly important and should be tracked and rewarded. At the same time, if care organizations simply use these reimbursement changes to dump more stress on the doctors they will actually block the doctor’s ability to be present and care for their patients more effectively. Where is the tipping point, where the canary falls off the perch?

How did we get here in the first place?

Healthcare is a classic giving profession. Doctors and nurses learn early that patients come first. Our job is to serve them as best we can, no matter how tired or drained we may be feeling. Their needs come before ours. Simply acknowledging our own needs is a challenge. Finding time and tools to get them met is a struggle for most physicians.

Many healthcare organizations systemize this self care blind spot

It is rare for the physicians and staff to appear in the mission statement of a care organization. The patients and care quality will always be front and center in the mission. Any mention of the providers and staff is very rare.

Take a quick look at your organization’s mission statement. Does it mention provider or staff health, wellness and satisfaction? If so, is your organization actually doing something about it?

This creates a double bind where the providers are challenged to get their needs met and their organizations fail to acknowledge we have any in the first place.

The last American sweatshop

As a result, many healthcare workplaces feel like a classic sweatshop environment. There are too many patients to be seen, multiple systems come between the doctor and patient (EMR for instance) there are quotas to be made and no regard whatsoever is paid to the health, wellness or stress levels of the physicians and staff.

The workplace resembles a mine. We are waiting for the physician/canary to drop.

In my work with doctors with career threatening burnout, it is common to hear of hospital departments and group practices where the entire staff is just barely making it through their work week.

Thank god for work hardening

The only reason these toxic workplaces don’t implode is the stamina and work ethic of the doctors and staff in the system. On one level, residency is a work hardening program for physicians. We can take a tremendous licking and keep on seeing patients. Our organizations know this and just pile it on. The leaders count on the doctors to carry any load they pile on while taking no responsibility for the stress involved. It is just like putting a canary in a shaft where you know the air is bad and hoping it survives.

Everyone loses

Tragically, unless your group actually monitors for physician health and satisfaction, the toll burnout exacts on the doctors and their patients remains invisible.

Research shows burnout has a pervasive negative effect on every aspect of a physician’s practice and life. Physician burnout has been linked to:

  • Lower quality of care and lower patient satisfaction rates
  • Higher rates of medical errors and malpractice risk
  • Higher physician and staff turnover
  • Higher levels of divorce, alcohol and drug use and suicide for the physician – our canary

So how much longer can we simply pile more and more stress on the doctors? When will this canary be stretched beyond its limit and simply topple off its perch and crash to the bottom of the cage? Does anyone care or is this something doctors just have to take care of on their own?

There is a different path available to healthcare organizations.

This path results in a win:win:win situation.

  • More patient satisfaction and higher quality care
  • Happier, healthier doctors
  • Higher profitability as the P4P trend continues

The key is to stop taking the canary down the mineshaft in the first place. Focus the same amount of effort on creating a healthy environment for your physicians and staff as you do on patient satisfaction for one simple reason.

Your doctors cannot produce consistently high patient satisfaction scores if they are not consistently healthy and happy at work.

Happy doctors naturally have happier patients. Put the canary in a sunny window and change the papers in the bottom of her cage. This is a fundamental shift with positive consequences for everyone in healthcare.

The most successful organizations in the near future will be those that acknowledge the universal presence of physician stress and burnout.

  • They will monitor for burnout and support the health of their providers and staff in multiple innovative ways.
  • They will put physician health and wellness in their mission statement as a priority equal to that of patient satisfaction.

There are hundreds of proven ways for both physicians and organizations to make real and lasting changes in the physician experience as soon as this fundamental shift is recognized.

I also predict this type of organization will be rare.

Leadership must stop simply loading on more work responsibilities and cracking the whip. Organizations must be committed to caring about the doctors and staff and constantly focused on creating a healthier and more efficient workplace.

With this new priority of physician wellness, these same organizations will be able to activate the power of a physician staff that is balanced and healthy, with their physical, emotional and spiritual needs met. This is the natural foundation for consistent quality care and patient satisfaction.

Just imagine a work environment where you enjoy your work team and the practice environment, the systems work to let you care for patients smoothly and effectively and you know that your leadership “has your back” and really cares about the quality of your experience as a member of the group. What would that be like? What quality of care would doctors and staff in that organization offer to their patients naturally and automatically.

Our healthcare workplaces don’t have feel like a coal mine. We don’t have to sit around and wait for the canary to drop.

Dike Drummond is a family physician and provides burnout prevention and treatment services for healthcare professionals at his site, The Happy MD.

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  • Melissa Oltman

    Hear hear!


    oh my goodness…someone is speaking up…we have become slaves to the business model of health and we need to do more to fight this ugliness…

    • drgg

      I think we need an organization for MDs that will lobby.–AMA has been ineffective— that i guess would take time and money but i see it as the only possible way out of this coal mine…

      • Dike Drummond MD

        drgg … you are part of a growing chorus of doctors online who are posting comments that are literally begging for a physician’s union. I think it is the sentiment captured in the article that explains this desire … we want collective bargaining rights to change the conditions on the front lines. I am pretty sure we don’t want the right to strike.

        I think a union of some type is probably inevitable as more and more doctors become employees (75% in 2012). And I am pretty sure it will do what unions always do … simply increase the adversarial relationship that now so often exists between the clinical care staff and administration.

        Dike Drummond MD

        • Margalit Gur-Arie

          Let’s not hasten the inevitable :-)
          About 60% were employed in 2012, which is expected to go up to about 64% in 2013.

          And self-employed people are less likely to suffer from this type of burnout, so maybe people should not volunteer for canary jobs….

          • Dike Drummond MD

            Right you are Marglit … the 75% is a projection for 2014 … here is the reference

            … and self employed doctors in general are more happy because they are the ones who built their own mine. Any time a doctor hires on as an employee they are submitting to the workplace environment their employer creates.

            Any time a doctor goes out solo, they must fill in the gaps in their medical education around leadership and sales and marketing that will make them successful on their own.

            Dike Drummond MD

          • Margalit Gur-Arie

            Solo is not for the faint of heart, but there are many other models where one can maintain reasonable control over his/her destiny and working conditions (e.g. partnerships, group practice, shareholder arrangements, etc.)

          • Dike Drummond MD

            Agreed … if the doctor is willing to play a leadership role and roll up their sleeves and get involved with the nuts and bolts of designing the systems of care. And I have seen incredibly abusive and dysfunctional physician run groups as well. No matter who is in charge, the health of the providers and staff is critically important.


            Dike Drummond MD

        • drgg

          I know your metaphor is with coal mines and labor unions but no I was thinking about how things work in this country. like it or not—pharmaceutical industry, insurance, hospitals all have strong organizations and lobbyists and lots of money and they get heard. That’s what i was referring to.

        • Suzi Q 38

          I had mentioned this idea for PCP doctors.
          The time is now. If the teachers can do this, why not the doctors? Why couldn’t the doctors refuse to do business with certain insurance companies that do not pay.
          Why should PCP’s be content with only a small percentage of what a specialist charges?

          • Eurobaby

            For physicians to join a union is to drag them into an unfavorable light. Unions today are regarded as ‘knuckle-dragger gangs’ by most professionals (politic or not). There are other ways of attaining power and influence i.e. a new stronger association/lobby vs AMA-an idea which apparently already has much favor. Please do not soil the reputation of one of the last remaining noble professions.

          • Suzi Q 38

            Oh Please…..
            I would not be “soiling the reputation…..,” if the FP’s no longer exist within a decade. The AMA is not doing much for these doctors, so this could be a distinct possibility.
            I personally do not like unions, but I am amazed at what the teacher’s union gets. Not that it is right, but they get what they want a lot of the time.

            It takes about 6 years to become a teacher. How many years of education does it take to be an FP? 10 or 12 years? Not that this means that you are smarter in the “ways of the world.”
            This is evidenced by the low pay you have to accept to care for your patients. This is a huge responsibility.
            My hairstylist gets paid more per client, and she doesn’t have to repay medical school loans.

            It is not me that sullies your reputation with the suggestion that you form a group or union of sorts. It is you and your colleagues that have decided that the little you get paid is O.K. As if you do not value the worth of your specialty (FP).
            I guess I would have expected more resistance from what was a large group of doctors. This specialty is still needed and valued. You have enough brains to pass all of your exams and medical training. Use what you have “upstairs” and figure this out.

            If not a “union” call it a “group.” Unite and at least give it a “fight.” Waiting for someone else to do it, or being silent about it is not going to get you anywhere.

          • Virginia Scanlan

            Call it a guild. Maybe 40 years ago,when hospitals started pressuring doctors to release patients from the hospital on a strict time table, my dad, a GP, lost two patients who he was forced to release prematurely. He told the families to sue. This was an early example of a doctor’s judgment being ignored by bureacrats. As a result, he called a press conference in Chicago, and explained what was happeing to the practice of medicine and how bureacrats endangered patients. He advocated for a guild to protect the practice of medicine. He got good coverage in the Chicago Tribune and the Sun Times. But people thought he was nuts. No, he was prescient. Insurance companies and hospitals do not provide medical care. Doctors do. That is their inherent power. Until doctors can embrace this and act upon it and not be ashamed of their power, they and their patients will be abused and people will be injured, especially when doctors and hospitals will be financially penalized for re-admitting sick patients. Watch out for liberal fascism. When corporations join with the government to decide what s best for individual patients and doctors, great harm will come to all.

          • Suzi Q 38

            Thank you. Good Story and information.

      • John Henry

        The AMA has been op-opted by the U.S. government, its biggest client in the AMA’s trade in CPT coding data and services.

    • Dike Drummond MD

      There is a middle ground where the business can be successful and can simultaneously provide a healthy workplace for the providers and staff. Unfortunately, examples of this kind of thoughtfulness are few and far between. Those organizations who understand the secret to lasting success is to hire the best people and take really good care of them will establish a competitive advantage in the years ahead.

      Dike Drummond MD

  • cynholt

    This is happening clinical nurses as well. Nurses in so-called
    “leadership” positions are cracking the whip and tightening the screws
    on us worker bees, in hopes that this will somehow make our patient
    satisfaction scores go up. But the more we try to satisfy our patients,
    the further our satisfaction scores tend to fall. It’s sounds
    counter-intuitive, but there’s a lot of truth in it. And believe me, if
    any of our so-called “nurse leaders,” whose primary job is to chew the
    fat at board meetings all day long, were to do what they are REALLY
    trained to do, which is care for and treat patients, they would not only
    cause our satisfaction scores to drop precipitously, they’d also lose
    their license to practice in a heartbeat for being grossly incompetent!
    Another reason to put the entire nursing leadership tract of the
    chopping block and cut away gobs and gobs of cost-laden fat.

    • Dike Drummond MD

      Hello Cynholt and thanks for your comment. I speak of doctors here because they are the position in healthcare I am most familiar with. The same conditions and concerns exist at all levels of the care delivery team. Nurses, reception, MA’s, PA’s, NP’s all the ancillary care providers.

      We must offer our care from a place of having met our own needs. We have to have some gas in our own physical/emotional/spiritual tank to be there for others. To institutionalize our own individual blind spots around self care makes everything worse … especially for our patients.

      Dike Drummond MD

    • ProudOkie

      Jealous much? So no need for the nurse leader? Everyone just show up and chip in and things will get done like they are supposed to? Classic worker/management warefare rhetoric………myeh.

  • Shirie Leng

    I have often remarked that if another kind of business was run like health care it would never last. No other company assumes that you will do more with less, that you will accomplish the same amount with less resources.

    • militarymedical

      I disagree. Try being in today’s military – especially the medical part of it.

  • buzzkillerjsmith

    If you are employed by a corporate entity, you are lost. There is no hope for you. Your de-professionalization and suffering is guaranteed. This will not improve. It will worsen.

    I have a neurology buddy who wants to give his practice to the local hospital because it is dying. For him actually earning a living is more important than self-respect. Sad but true.

    The ugly truth is that unless primary care doctors get paid enough to be there own bosses, solo or in a group, PC medicine cannot be recommended to medical students. I can’t comment on the situation the subspecialists face.

    • buzzkillerjsmith

      are not is and their not there more coffee is required

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