Dear Executive Committee of the American Academy of Pediatrics,
Please forgive me for this format. Every other time I’ve read an “open letter” to a particular audience, I have an urge to gag. And now I’m writing one, which means I’m suppressing my own stomach as I write this. I’ll certainly understand if you are less than thrilled with my methodology; I’m with you on that one.
My name is Jason Kesselring, MD. You may remember me from such academic papers as “How to Succeed When Your Ten Year Old Patients are Taller Than You” and “Floor Licking Behavior in the Pediatric Office: Immune Booster or Dancing with the Devil?” (Disclaimer: such articles may not actually exist or only have been reviewed and rejected by the French-Canadian Journal of Haughtiness and Irreproducible Results).
I’m writing because of the National Conference and Exhibition in Chicago, IL coming up September 16-19. Specifically, I’m writing due to the focus on physician burn-out and physician wellness at the conference this year. I have an interest in this arena.
After my pediatric residency, I worked for 10.5 years as a pediatrician (mostly in a medically underserved community). About 2 years ago, I realized I was drowning professionally, was stressed out of my mind, and didn’t really have any tools with which I could rely upon to improve my situation. After a lot of soul-searching and discussions with my family (who thought I needed to bail years ago), I decided to leave clinical practice. (If you want a full summary, please read my first three blogs at thetrialofmiles.blog entitled “On Stones, Ponds, Ripples, and Two-by-Fours,” “No Parachute,” and “Zoo Station.” The extremely short version is: meningitis, work overload, panic attacks, and then getting out while I still had my health and my soul.) I’m in the midst of a career change whilst taking a self-funded sabbatical year.
This decision was not made lightly. Even a burnt-out me served my community well. But it wasn’t tenable anymore. So when a friend/colleague of mine referred me to the presentation on physician wellness at this year’s NCE, I was pleasantly surprised to hear about it. It will be wonderful to have this issue brought up at the AAP’s major event. This is a really great happening. I hope it is well attended, and that there are substantive discussions about what can and NEEDS to be done for our colleagues that still have a “skin in the game.”
I feel like there’s finally some momentum here. It’s just a first step, but it’s a significant one. Your clientele now has an opportunity to hear the AAP perspective on this issue. If there’s a pediatrician at the conference that disagrees with an increased emphasis on physician wellness, they probably should have their membership suspended, be forced to sing “I’m a Little Teapot” during rush hour on Michigan Ave., and then be given lifetime tickets to Nickelback concerts. This, seriously, is an issue that your entire AAP base should be behind. In sports terms, this is a slam-dunk.
The real work is going to have to happen AFTER the conference. From my standpoint, this presentation is essentially being given in a “safe-space,” and I don’t mean that with any derision. Your pediatricians are going to be behind this 100%. The issue is going to come with trying to get the healthcare industry and culture of medicine to change.
This seems like a more daunting task. Why? “They” don’t have a vested interest in seeing through any change. While healthcare is still in flux on a national and local level, there are large systems in place that have found a way to make it work for them. And by “make it work” I actually mean they are filthy rich. Like Billy Corgan rich (minus the chemtrails and the anti-vaccine rhetoric). Like Jake Arrieta rich. Like Oprah rich. (See those Chicago celebrities? That’s creative.)
We could make humane arguments as to why the industry and healthcare settings ought to change willingly in their own long-term self interest. That usually doesn’t work, however. Large hospital systems, large healthcare organizations, and insurers speak one language: money, money, MONEY! You will have to find a way to win this argument on financial grounds (as will the AMA, AAFP, and any nursing advocacy organization – nurses need support, too). And until you are able to mobilize our colleagues on a national and local level, progress is going to be slow. Like the Dan Ryan at 7:30 on a Monday morning slow. Like a Metra traveling on train tracks that are under construction to the northwest suburbs slow. Like the Chicago Bears running game slow. You get the picture.
What follows here is not a specific plan, but a few general points as to how to proceed (who needs to be engaged and on what levels). I’m not smart enough, nor well connected enough, to arm twist and make this happen. But you are; you have numbers and influence. Keeping that in mind, here’s what I see as general areas to approach (and I’m sure you’ve thought of this and more):
• Lobby and discuss with insurers. Why? They control re-imbursement. Ergo, they control much of how one has to operate in the office in order to stay afloat. If you need to see 45 patients a day to stay afloat, it’s because of re-imbursement. They need to be convinced to change their model of payment before significant changes in workflow can begin. Action level – National and state chapters, as well as banding together with other professional organizations.
• Lobby and discuss with large healthcare organizations and hospitals. Why? Many more pediatricians are now employees of a larger organization and are treated as such. Take a number and get in line for the cattle call. Moo, moo, MOO! They control our schedules, our work-flow, what EHR system we use, etc… Action level – state chapters and banding together with other professional organizations. NOTED DIFFERENCE: many academic pediatricians may have a leg up here. Many children’s only institutions may already see the benefit of working on physician wellness; these institutions frequently have more resources at their disposal to work with their physicians. At smaller institutions, this is not the case. If one isn’t a big money maker for a hospital/organization, one isn’t on their radar. Your colleagues outside of a children’s hospital really need your help.
• The ABP – American Board of Pediatrics. Please, buy these people out, take over their organization, or give them some smelling salts. Something. Anything. Board certification has become a non-paying, significant part-time job. Yes, proving competency throughout a career is needed. But the pendulum has gone too far in their direction. Action level – national AAP involvement.
• Continuing Medical Education (CME) – This overlaps with board certification. It is no longer acceptable to just further one’s education. The hours have to be in certain areas, and certain types of QI activity are required. If the specifications aren’t troubling enough, the number of hours required are. For example, in Illinois, one needs 150 hours of CME over three years. (On a side note, can you imagine not doing CME for one year, completing one hour in a 2nd year, and then 149 hours at the end of the cycle? Insanity!) But, for those of us near St. Louis, if you practice in Missouri, you need 50 hours over 2 years. I don’t remember much from differential equations in college, but I think that is essentially 50 hours/year in Illinois and 25 hours/year in Missouri. Really? Double the work for crossing the Mississippi River? This really ought to be a uniform, agreed upon number. Action level – National AAP and state chapters.
• There needs to be a discussion about the role of technology as it affects the daily practice of medicine. There are plusses to be sure; however, on cynical days, I stole this line from another physician at a trail race: “My job is data entry for the medical center.” We are more available than ever with patient portals now becoming common. The ability to respond more quickly than ever before is present. The problem is managing expectations. Do I see another two or three add-ons to my schedule now, or do I respond to all the medication requests and patient questions? My healthcare organization says “yes” to both. Technology gives the illusion that we can respond on the spot. With EHR systems, we are now prisoners of “meaningful use.” While we need to demonstrate effective care and that we are doing what we say we are doing, every system that has been developed is cumbersome or requires “clicking more boxes”. All this takes away from one-on-one interactions, which is why most of us went into medicine. The patients don’t like the dynamic, and neither do we. Common ground! Action level – your guess is as good as mine. My solution involves taking a flame-thrower to EHR systems and starting from scratch, but that’s not practical.
• I haven’t even addressed keeping up with every AAP guideline at every single, compact, 15 minute office visit. I would love to see some members of the executive committee try to honor each guideline at every single office visit. If you can get in parental concerns, discussions of nutrition, safety, education, anticipatory guidance, and an exam at every visit while scoring and completing two screening tools, you are better physicians than I ever was. And I’m actually not blaming the AAP on this one. It falls under re-imbursement; if we had more time with each patient, this isn’t as daunting of a task. Action level – national AAP policy combined with working on bullet point #1.
• And then there is the very small issue of not only improving wellness so physicians don’t burn out, but making help available in non-punitive ways for when help is needed. Not every hospital or healthcare organization currently operates in such a manner that self-report of issues is actually possible. There are state medical boards that still deal with you in punitive ways for merely asking for help. And even then, one’s own unique work situation may preclude readily asking for help. The point is: if you want physicians to get help they need, it needs to be available in practical, actionable ways (and not just be available “in theory”). This may even need active participation and guidance on the part of the AAP to help create and grow “centers for wellness.” Action level – state chapters working with similar professional organization and state medical boards. As for setting up “centers for wellness,” you will need to work hard with individual healthcare systems.
I’m sure this is not an exhaustive list. I haven’t addressed specialist needs vs. general pediatrician needs, and then NICU, PICU, and ER needs. This gets messy fast. In the words of our current president, “Nobody knew health care could be so complicated.” (OK, that was a cheap shot.) This is a huge task and undertaking. But since you’ve gone to the trouble of bringing this issue up at the NCE, I figured it was time to 1) lay out the issues and 2) encourage you to keep at it. This will require a large, coordinated effort, involving not just the national AAP, but also state chapters, like professional organizations for other areas of medicine, and persistence. This isn’t as complicated as coming up with a plan for disposing of nuclear waste (that, seriously, was a great “Last Week Tonight with John Oliver”), but it is close.
This is a battle worth fighting. We all know that this is an issue, and if it isn’t addressed, the risk is losing rolls of your pediatricians to other careers. Again, I’m familiar with this. We really don’t want a healthcare system that convinces its physicians, providers, and nurses that they are expendable and replaceable. We are on the verge of de-recruiting people from the profession. That’s not a great place to be.
I hope the AAP has a wonderful, wild and crazy time in Chicago (first World Series parade in 108 years, and now the AAP comes to town? How does Chicago remain standing?). Go to Second City, take a run along the lakefront, and sample some of Chicago’s food (I’m partial to the New Rebozo and Hoosier Mama Pie Company). Don’t go to a Cubs game; that’s just silly. Wrigley Field is a DUMP. And while you’re there, can I please get you to talk to the Illinois Chapter of the AAP? Please? Given the composition of their executive committee, they seem to deny the existence and importance of the rest of the state of Illinois.
Jason Kesselring, MD