Doctors are like hamsters running on an exercise wheel to nowhere [PODCAST]

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“No wonder doctors feel like hamsters running on an exercise wheel to nowhere. And this sense of futility is driving burnout. How much patient care will you get out of docs who have moved on to nonclinical jobs, retired early, or committed suicide due to burnout? The time for rumination and hand-wringing is over! It is time for medical organizations to cooperate, take prompt action, and avert a health care crisis by protecting one of their most precious health care resources.”

Banu Symington is a hematology-oncology physician.

She shares her story and discusses her KevinMD article, “No wonder doctors feel like hamsters running on an exercise wheel to nowhere.”

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Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at kevinmd.com/rate. Subscribe at kevinmd.com/podcast. Today on the show we have Banu Symington. She is a hematology-oncology physician, and we’re going to talk about her KevinMD article, “No wonder doctors feel like hamsters running on an exercise wheel to nowhere.” Welcome to the show.

Banu Symington: Thank you, Kevin. Thank you.

Kevin Pho: So we’ll get into your article in a little bit. First off, briefly share your story and journey to where you are today.

Banu Symington: I’m a hematologist-oncologist, as you mentioned. I also am the medical director of the Sweetwater Regional Cancer Center in the very frontier area of Wyoming. We’re 200 miles, 300 miles from any other facility. I’m a big-city girl. I grew up in Philadelphia, went to school there, and transplanted into increasingly rural communities as I became more mature.

Kevin Pho: So you mentioned that you practiced in a rural environment. You’re a solo practitioner as a hematologist-oncologist. Tell me some of the challenges that you face.

Banu Symington: First, we have a dearth of subspecialty support: infectious disease. We just recently got a pulmonologist. We don’t have a rheumatologist, and as therapies for cancer expand, we need a rheumatologist close by. Patients are relatively medically unsophisticated. There are a lot of uninsured patients. We don’t have easy access to the internet, for example. The Wi-Fi is unstable even in this community.

Kevin Pho: Give us an example, a case study of one of your patients that can really illustrate some of the obstacles that you just mentioned.

Banu Symington: So I have patients from 150 miles away. They have time-sensitive therapies. The highways will be closed because of winter conditions. They can’t get in, or their medicine cannot be FedExed to them because weather is closing the roads, and there are no alternative ways for them to get their medications.

Kevin Pho: So in situations like those, what options do patients have?

Banu Symington: Delay. We just delay therapy. I’ve been on national conference calls when the internet has gone down, and all they get is a blank screen instead of me. So for that reason, even telemedicine is a challenge for this community. We can’t necessarily call into a patient when the internet is down because of wind or weather conditions.

Kevin Pho: All right. So let’s talk more about your KevinMD article. It’s titled “No wonder doctors feel like hamsters running on an exercise wheel to nowhere.” Now, for those who didn’t get a chance to read your article, just walk my audience through it. Share the story of why you decided to write it.

Banu Symington: I decided to write it one day about a year ago when I was looking at my quality report card. I was digging deep into it and noticing that the measures that I was being assessed for were not measures that I was responsible for.

I’ll talk about a quality measure, OP-35, in oncology. It’s a grade that’s given to you for any patient who ends up in the emergency room or hospitalized within 30 days of treatment. I got my report card yesterday. I’ll use yesterday’s example, but the same thing woke me up a year ago. I had two emergency room visits after treatment in my last report card.

One emergency room visit was for a patient who was quadriplegic, with a decubitus ulcer, when she presented to me. In fact, she presented with her cancer because of the decubitus ulcer. She periodically goes to the ER because the decubitus ulcer needs care. She did so after treatment, and I was dinged for that. It had nothing to do with her treatment. It was a pre-existing condition.

The second patient on my report card: The report card is for visits to the ER within 30 days of treatment. She had not had treatment for eight weeks, and she had actually been seen in the cancer center the day of her ER visit and deemed to be too sick to have her condition treated in the cancer center. But that was still viewed as an ER visit within 30 days, erroneous on two counts: timing and the fact that she had already been seen in the cancer center.

The goal of this quality measure is to reduce unnecessary ER visits and hospitalizations due to chemotherapy, but both of my outliers didn’t fit. So I felt like I was trying harder and harder to achieve a perfect score, but it was impossible to achieve because of the nature of data collection. They were sorting through the EMR for chemotherapy and ER visits and not necessarily excluding factors that should have been excluded.

Kevin Pho: So in these outstanding circumstances that you just mentioned, do you have any recourse to contest these results?

Banu Symington: Very good question. I’ve tried. The quality committee for the hospital is fearful of demerits from CMS. Demerits from CMS come with financial consequences to hospitals, so they don’t want to appear to be overlooking any potential adverse outcome, and they are unwilling to change their screening protocols.

The doctor is caught between the Titanic, which is CMS, and the iceberg, which is hospital administrators, and they’re just getting crushed between these two immutable forces. I actually had a conference call with CMS about these quality measures, and they said, “We can’t help it if hospital administrators are overzealous in applying these screening factors. That’s their decision.” But they do actually play a role in that, because the hospital administrators are overzealous because they fear the large financial consequences that come with poor scores.

So the physician, who is at the front line between the patient and the score, is held responsible. In some cases, not my case, physicians are financially punished for these scores, these poor scores. And if you can’t fix it, if you can’t change it, if the score is based on erroneous data, you feel hopeless and you give up.

Kevin Pho: So give me an example. You mentioned that some physicians are punished financially for poor scores that are sometimes out of their control. Do you have an example of that? How much financial repercussions can they endure?

Banu Symington: My former employer has just instituted that the bonus is based on your score. So if you have a poor score, your bonus is going to be smaller. That’s from my prior employer.

I’ve heard from national colleagues that their base salary is dinged based on their scores on these HCAHPS surveys, OP-35, and the MIPS measure that looks at death within 14 days of treatment, which can be outside of your control if you’re taking care of acute leukemic patients, or you have discussed how futile therapy might be and the patient says, “Doc, I understand, but I don’t want to give up. I want to keep going.” So their salaries are actually docked for these poor scores.

Kevin Pho: Now, you mentioned these outliers. So in general, when you get these report cards, what proportion of your total scores are these outliers? Do they comprise a majority of your metrics? Are they a small portion? Just give me a sense of how commonly these nuanced outliers occur.

Banu Symington: So the only two visits within 30 days of treatment for the last quarter were these two erroneous ones, so 100 percent. I would have had a perfect score had it not been for these two erroneously calculated items.

Kevin Pho: And fair to say that in this most recent report card, you got a zero in this metric?

Banu Symington: They just report ER visits. So the only patients that they reported really should not have counted. I should have had zero ER visits within 30 days of treatment, and the two reports were 100 percent incorrect.

Kevin Pho: So when you get reports like these, and clearly these are nuanced cases and what CMS is measuring is a blunt-force instrument, how does that make you feel? I know all physicians, to get to where we are, we tend to be perfectionists, type A. We always love to do well in report cards. How does that make you personally feel?

Banu Symington: You nailed it. We are competitive. We got where we were by being competitive. CMS and our quality committee have tried to tell me I shouldn’t view it as a report card and I shouldn’t view it as a demerit, but if you’re actually financially penalized, it is a demerit.

I feel frustrated and angry. If I can’t improve myself to achieve a better score, if the score is reliant on something else or a mistake, I feel very frustrated, and I feel like I shouldn’t even look at the report cards anymore, which defeats the purpose of these scorecards. We should look at them with the eye to improving our performance.

Kevin Pho: So tell me about some of the other metrics that you’re being graded on in this report card. Are there metrics that you do particularly

Banu Symington: Oh, yeah. For discussion of fertility preservation before chemotherapy, discussion of the intent of treatment, discussion of goals of care. And there are improvements to these measures that are misleading or misguided that can be made if enacted promptly, but they just are not.

Another particularly frustrating quality measure, which is an ASCO quality measure, American Society of Clinical Oncology, is that we must discuss all pain at every visit for a cancer patient. I totally understand the need to discuss cancer pain at every visit, but I don’t understand the need to discuss chronic back pain at every single cancer visit. It’s a waste of time and resources for a patient who has cancer to have to do that, but the metric is, again, a blunt force. Instead of asking for cancer pain, you’re asking for all pain, because it’s easier to do all pain.

Kevin Pho: So if you were in charge of the quality metrics in your ideal world, how would you fix this?

Banu Symington: I think the intentions are good. I think that we need to be more nimble in reacting to unintended consequences. What I’m objecting to, what I’m describing in the KevinMD article, is the unintended consequences of measures that were intended to improve quality. They were never proven to improve quality, and they’ve had these distressing adverse consequences. So let’s change the measure.

So for the OP-35, the ER visits, let’s actually do what CMS wants, which is look for fever, pain, fever that’s related to treatment, not fever related to an ongoing chronic disease. Remove patients who have been offered a visit in the clinic from the denominator calculations. So if someone’s been offered a visit to the clinic and has refused the visit, or has been assessed in the clinic and has been felt to be too sick to be treated in the clinic, that patient should not be a contributor to your score.

For the end-of-life things, treatment death within 14 days of treatment, instead of measuring that, I think what you should do is document that the physician has recognized the patient is on a downward clinical spiral and has the goals-of-care discussion, perhaps at the first visit, at the first recurrence, and then at the need for third-line therapy. Document that you have had a goals-of-care discussion, and then show that the physician is acting in accordance with the goals-of-care discussion. I think that’s much more compatible with the actual goal of the death-within-14-days measure than what we’re measuring right now.

Kevin Pho: We’re talking to Banu Symington. She’s a hematology-oncology physician. We’re talking about her KevinMD article titled “No wonder doctors feel like hamsters running on an exercise wheel to nowhere.” What kind of recourse do physicians have to change the system and implement some of the changes that you suggested? You obviously wrote in KevinMD. You’re appearing on this podcast. You’re making your voice heard. Any other options physicians have to change the system?

Banu Symington: I think we’re used to being quiet or complaining quietly in the doctors’ lounge, but I think we have to complain at a national level. Get the ear of CMS. Get the ear of your subspecialty society. ASCO has been quite responsive in coordinating meetings with CMS. But do so as a group, because the single individual complaining can be easily ignored. A group of national subspecialists with the same viewpoint is harder to ignore, I think.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Banu Symington: Quality is good. We all want good quality. Just make sure that you’re measuring quality that the physician is responsible for, and if you’re not, change the measure. Don’t needlessly frustrate and burn out physicians. We’ve talked about burnout due to the EMR. We’ve talked about overwork. But this is a focus of burnout that could be easily and rapidly changed to effect a better outcome.

Kevin Pho: Banu, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Banu Symington: Thank you.

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