HJAR Jan/Feb 2023

CHANGING THE WORLD 14 JAN / FEB 2023 I  HEALTHCARE JOURNAL OF ARKANSAS   they dominate my current organization. But, we must first confront the reality of the present while acknowledging the mistakes of the past. CONFRONTING THE REALITY OF THE PRESENT Since we successfully put a man on the moon, the world of healthcare has changed, much of it quite favorably. But with progress comes un- expected challenges. Though many of the epi- demics of the past — like yellow fever, small- pox, and polio — have been conquered, new challenges have replaced them. And although pandemics will continue to recur as they have throughout history, they will evolve and have dif- ferent impacts. In the 1918 influenza pandemic, the demographic that suffered the highest mortality were young, healthy people between the ages of 20 and 30. They died from a hy- peraggressive immune response that induced severe lung injury in the days prior to mechani- cal ventilation. This most recent pandemic tar- geted the weakened immune systems of the elderly and people suffering from chronic con- ditions like obesity and diabetes, which in turn correlated strongly with socioeconomic factors. Once we extended life expectancy by ef- fectively curing or preventing the infections of childhood and young adulthood, people began to live long enough to develop chronic conditions. Diseases of lifestyle and aging have replaced many of the acute illnesses that were so prevalent several decades ago. Obesity, diabetes, high blood pressure, chronic kidney disease, degenerative joint disease, and other chronic conditions now dominate the health- care landscape, requiring vastly different man- agement approaches than acute conditions, and healthcare spending on these chronic conditions makes up a disproportionately high share of medical expenditures. Yet the models for care delivery and the economic models that fund them have remained largely unchanged. Furthermore, the metrics we use to track our progress in healthcare are largely predicated around measures of volume, throughput, and efficiency, reflecting our reliance on the same economic model upon which current finan- cial viability depends. But this reliance on the economic and delivery models of the past have led to the consequences and seemingly insurmountable challenges of the present. Let’s take provider burnout as an example. The 2020 Medscape National Physician Burn- out and Suicide Report reported a burnout rate of about 43%, which has been fairly consistent for the last few years. Furthermore, according to the nationwide Future of Healthcare survey, 70% of physicians are unwilling to recommend their chosen profession to their children or oth- er family members. And more than half of phy- sicians say they’re contemplating retirement in a few years, including an alarming number of those younger than 50. These statistics are not just disconcerting, they are heartbreak- ing. Can you imagine not recommending the healthcare profession — this most sacred and noble of professions — where we have the po- tential not only to make a good living, but to engage in meaningful, purpose-driven work every day? Something is dreadfully wrong here. The term “burnout” can be insulting or at the very least may impugn our sense of resil- ience. A better term is “moral injury.” Although first applied during wartime, the moral injury of healthcare is not the offense of killing an- other human in the context of war. It is being unable to provide high-quality care and heal- ing within the context of our profession. Fail- ing to consistently meet patients’ needs has a profound impact on physician well-being, and therein lies the crux of moral injury. I am a primary care physician, which means that I relish creating collaborative, trusting relation- ships with patients. I love the challenge of solving complex clinical problems, of spend- ing time with and listening to patients, and of helping them manage chronic conditions so that they can avoid future problems that might impair their quality or quantity of life. However, in our current healthcare system, primary care has essentially become mission impossible. Primary care physicians manage a “panel” of patients — meaning the number of people who call them “their doctor” — typi- cally averaging around 2500 patients. Stud- ies from over a decade ago put the amount of time necessary to deliver high quality pri- mary care into proper perspective. One study showed that for a panel of 2500 patients, the amount of time necessary to adequately man- age their proportion of chronic conditions would be about 10.6 hours per day. Another study showed that to perform all of the recom- mended preventive health for that same size panel would take 7.4 hours per day. Presum- ably, the remaining 8 hours of that 24-hour day could be spent seeing sick patients. Is it any wonder then, why access to care is a problem or that, despite the best of intentions, experi- ence of care for patients and providers is less than ideal? Morrison and Smith labeled it ham- ster healthcare, citing that doctors “feel like hamsters on a treadmill” ... they are miserable because they have to keep running faster and faster just to stay in place. The typical 15-min- ute office visit afforded by current financing mechanisms for primary care is simply not enough time to sort through the myriad signs, symptoms, and complexity to enable excellent “One of the great myths in healthcare is that excessive healthcare spending is driven by inexorable forces, and that only by rationing beneficial care will we be able to reduce the total cost of care. The simple fact is that improving health reduces health expenditures. These two variables go hand in hand.”