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Join Archana Reddy Shrestha, an emergency physician. In this episode, we explore her personal journey through the highs and lows of her medical career, addressing the challenges of metric-driven evaluations and the impact on a physician’s sense of self-worth. Archana shares valuable insights and three key mindset shifts that can help health care professionals navigate these issues.

Archana Reddy Shrestha is an emergency physician.

She discusses the KevinMD article, “Metric shaming in medicine and 3 ways to overcome it.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Archana Reddy Shrestha. She’s an emergency physician. Today’s KevinMD article is titled “Metric shaming in medicine and 3 ways to overcome it.” Archana, welcome back to the show.

Archana Reddy Shrestha: Hey, Kevin, it’s so good to be here. Thanks for having me.

Kevin Pho: So we were talking offline, and I think it’s been two and a half years since you were last on. Thank you so much for coming back. Now, for people who may not remember you, just briefly share your story and journey.

Archana Reddy Shrestha: Yeah, my name is Dr. Archana Shrestha. I’m a board-certified emergency physician, I’m a life and weight coach, and I’m also an author. And I’m the founder and chief wellness officer of the MamaDocs School, where I empower women in medicine and health care to achieve improved wellness and also overcome burnout or moral injury.

Kevin Pho: All right, so in today’s article we talk about metric shaming. So first off, before you talk about that, tell us what that is.

Archana Reddy Shrestha: Yeah, so metric shaming is a term that I coined. I think we’ve all heard of the term fat shaming, right? I started to realize that there was this phenomenon happening in my experience as a physician practicing in the emergency department of a community hospital, and also to other physicians and clinicians. We were being held to a lot of different metrics at work. I’m sure you can completely relate, Kevin: things like RVU bonuses, patient satisfaction scores, the rate at which we’re prescribing things like antibiotics or controlled substances, door-to-doctor times, all sorts of metrics.

What I started to notice is that these were being posted in various ways. Sometimes they were sent out as an email to the entire practice, to all your colleagues, and sometimes they were posted in very public places in the doctors’ lounge: These are all the surgeons and these are their infection rates, or these are all the OB doctors, with their names next to it, and here are their C-section rates. It started to feel like a public shaming: Well, this is where so-and-so is at. And amongst colleagues there was sometimes discussion like, “Oh, did you see so-and-so’s RVU bonus? This person got the highest, and this person got the lowest, and this person isn’t producing enough.” It became almost like playground chatter.

Kevin Pho: Yeah, so just to be clear, I think that almost sounds like high school, right? So you’ve literally seen charts of doctors and their various metrics publicly posted? For instance, surgeons will have their post-op infection rates posted and ranked in order based on infection rate. Is that literally true?

Archana Reddy Shrestha: That is literally true. I have seen that in doctors’ lounges. I also have colleagues: I have an OB friend at a completely different hospital, in a different part of the country, who said, “Oh yeah, our C-section rates are posted with our names there.” And in my own personal experience, we would get emails sent out: OK, here are the RVU bonuses, here are the patient satisfaction scores. Nothing was anonymized, right? Just names next to all the data.

Kevin Pho: And why do you think administration would post it so publicly? Do you have any speculation as to what their motives could be?

Archana Reddy Shrestha: Well, it would all just be speculation, right? I obviously don’t know specifically what their thoughts or intentions were. I think it was most likely very innocuous, that they were just putting the information out there. These are now metrics on so many levels. With Medicare, Medicaid, CMS, we are all being held to these metrics, and it’s very easy to capture these things now with the EMR, right? So we can collect this data. I think the intentions most likely were benign. They weren’t trying to shame anyone intentionally, but I think they just wanted to hold people accountable: This is what the rates are and this is what the goal is. And usually that was how it was posted: Here’s where everyone stands, here’s what the goal is and what we’re trying to aim for. I don’t think it was ever really meant to harm anyone, most likely, although I don’t know for sure. Maybe there was, maybe there wasn’t. I can’t really say. I’ve never been an administrator, I’ve never been the one posting any of these things, so I can’t say for sure what it was.

But what it led to is what I can speak to. It basically started to erode confidence. In my particular case it was eroding my confidence, and I felt like, wow, these are the only important things? What about the fact that I did a great job with my patients, that I have really great outcomes, that I have incredible rapport with my patients, that many patients actually asked if I could be their private physician even though I don’t have a private practice? To me that was always the ultimate compliment. I’m a hospital-based physician, and these patients were saying, “I wish I could come see you in a private practice.”

So what about all of those intangibles? To me those were the things that were really important in med school. The whole reason I became a doctor is that I really wanted to take good care of patients and help them in their moments of need. Yet here we were, being held to all sorts of other metrics, which in many ways seemed random. Of course some of them are important in patient care, but many of these things we don’t always have control over.

Kevin Pho: So in the emergency department, and I know emergency medicine is a pretty metric-heavy specialty, what would be examples of such metrics that you don’t feel you have personal control over?

Archana Reddy Shrestha: Yeah, for example, things like door-to-doctor times. The patient would check in at the front of the ER, and if we were really backed up and couldn’t get the patient back to a room quickly, the clock started the second that patient was in the waiting room. Then they would get placed into a patient room, and then we would go see them. Oftentimes we would get into the room to see them within five or 10 minutes of them being placed into a patient room. However, we were held to that whole time, from the moment they hit the door and the waiting room until the time we saw them. So that clock didn’t seem fair. Maybe it should have started from the moment they were placed in the patient room, because that was when we could actually go see them in a private way that respected their privacy, right? So there were things along those lines.

Sometimes even things like patient satisfaction scores felt beyond our control, because some of the questions that were asked had to do with their wait time, which oftentimes we didn’t have control over. And take some of the other questions, like how satisfied are you with your care. If a patient waited three hours, generally they’re not going to be satisfied, no matter how great the care was once they were seen. Even things like, was your pain taken care of or addressed? Sometimes it was appropriate to prescribe strong pain medications such as narcotics, but in other instances it wasn’t, and in some instances patients perhaps had a dependency or addiction to those and were seeking those medications.

So it sometimes felt like an impossible task to try to cover all of that. On the one hand, we needed to be fast and quick and see as many patients per hour as possible, and we were being measured on our RVU productivity. Yet on the other hand, we were being asked to keep our patient satisfaction scores up. And what we do know is that patients are generally more satisfied when they feel that they’ve been heard and listened to, which requires time. We can’t just be in and out of the room in two or three minutes and expect that the patient will feel they’ve been heard and understood and all their concerns were addressed. So it felt like this catch-22.

Kevin Pho: So when you saw all these metrics, did it subtly, or maybe not so subtly, change the way you practice medicine?

Archana Reddy Shrestha: In some ways, yeah. I remember that they brought in a trainer, an outside consultant: OK, here are the things that you can do to improve your patient satisfaction scores. In a community setting, at community hospitals, this was really important, because it determined how well received the hospital was within the community, how many people would possibly go there, depending on whether the patient satisfaction scores were high or low. So they wanted to really improve this metric.

I remember being taught certain scripts to say, things like, “Just so you know, you can expect to be here for X number of minutes,” or “Have we done a good job of addressing your concerns?” There were certain scripts that we were asked to say, or, oh, go get them water, a blanket, get them a snack as long as they’re not NPO. So at times it started to feel like I was becoming a waitress. And there’s no shame in getting a patient a blanket or water or a snack; I don’t feel that is beneath me by any means. It just felt forced when we were doing it with this end goal of raising patient satisfaction scores. So we were trained in ways to try to improve these things, yet there are so many other things going on in a busy emergency department, where you’re just trying to make sure you’re doing all the right clinical things for your patients, let alone these other things like getting blankets and water.

Kevin Pho: So your KevinMD article is “Metric shaming in medicine and 3 ways to overcome it.” Let’s talk about the latter part. What are some ways to overcome metric shaming?

Archana Reddy Shrestha: Yeah, so a lot of these are things that I learned when I became a life coach, right? I think there are many skills that we never learned anywhere along the way. But some of the key things that I learned are these. First of all, we have to make these numbers neutral. We can’t make them mean so much about ourselves. Whether it’s a high number or a low number or something in between, wherever you’re ranking on this leaderboard, at the end of the day the first step is to just make it neutral: not make it mean something good or bad, and just completely neutralize it.

From there, the next step is to realize that you are always 100 percent worthy, and that nothing can change your inherent worth. All humans, right, we’re all born 100 percent worthy, and no number in our life can change our worth, whether that’s our age, the amount of income that we earn, the number on the scale, your Step 1 board scores, a patient satisfaction score or an RVU number. None of these things actually changes your worth. You are 100 percent worthy, always, so none of these things can take away your worth.

And then the third step is to decide with intention what you want to believe about yourself. At the end of the day, the thing that matters most is what we believe about ourselves, right? Of course those first couple of years of being an attending are kind of rocky. You’re trying to get your clinical footing and gain your confidence. But I knew that I was a great doctor, that I had great outcomes and great rapport with my patients, and that I always did what I believed was the right thing for the patient, right? And I was oftentimes staying late, making sure everything was taken care of. So I knew in my heart that I was a good doctor, and I couldn’t let these numbers sway me. They changed day by day, and there were many forces in play that I didn’t have control over. I just intentionally decided that I would let those be what they were, let them be neutral, and not let them sway what I thought about myself, which was that I was a good doctor, always doing the best that I could with the resources I was given.

Kevin Pho: Now, how difficult was that for you? Because, as you know, a lot of doctors, from undergraduate on, or even from high school on, are inherently very metric-focused, right, whether it’s our grades or board scores. So how difficult was that for you?

Archana Reddy Shrestha: Oh my God, it was going against the grain, I’ll tell you that for sure, Kevin. Everything that we had ever been taught was to the contrary. I think we are such high achievers as physicians and clinicians. Any of us who get into the medical field, into health care, have very high standards for ourselves, right? And the stakes can be high. We’re dealing with patients’ lives, and an error could cause injury or potentially even death. So with such high stakes, we hold ourselves to incredibly high standards, and it took a long time to be able to get there.

But I think there are a lot of key skills that we never learned anywhere along the way in medicine, and if we knew these things we would really be able to handle this differently. It took me being coached a lot myself by others, and deciding to become a coach, to really start to embody these things. And now I teach other people these things as well, because they’re really critical skills for us to sustain a career in medicine, especially given all the metrics that we are held to these days.

Kevin Pho: Do you sense that a lot of younger physicians have the training to cope with this onslaught of metrics, or is it something that you feel comes with coaching and experience?

Archana Reddy Shrestha: I don’t think that they do. Sadly, we’re seeing very high rates of burnout even among residents, right? And I think that all of these things play into it. So I think we really do need to make a shift within the culture of medicine. I’ve always described the culture of medicine as being very militaristic, and I think we really need to be more compassionate to one another.

For those people in a position of power, who are administrators, there are three things that I think they can begin to do to stop this pattern of metric shaming. First of all, they can stop posting these kinds of things publicly and make it anonymous. Number two, if there really is an area where you’d like to see improvement, go ahead and give one-on-one feedback. And be compassionate: Understand that the environment plays a huge factor too. As I mentioned, I’m always doing the best I can with the resources I’ve been given, and I think that’s the case for almost everybody who’s in medicine. They are genuinely trying to do the best they can with the resources they’ve been given, at a time of being understaffed, of different medications not even being available. There are so many different factors that come into play. I genuinely believe those of us who go into the health care field really do try our best and are always trying to help as much as we can. I think we need to have a lot more compassion and learn how to give feedback in a different way.

Kevin Pho: We’re talking to Archana Reddy Shrestha. She’s an emergency physician. Her KevinMD article is titled “Metric shaming in medicine and 3 ways to overcome it.” Archana, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Archana Reddy Shrestha: Yeah, so my biggest take-home message would be, first of all, that you are 100 percent worthy. If you are feeling burnt out right now, like I know so many of us are, this is a huge problem right now: 53 percent of physicians and 60 percent of PAs are feeling burnt out, in a Medscape survey. But I want you to know that there’s nothing wrong with you. You’re not broken. I think you should definitely reach out and seek the help of a coach who can help you work through burnout and get you to a better place. I know that so many of us health care workers are feeling overworked and overwhelmed, like we have nothing left to give, but there is a better way, where you can actually sustain yourself and not constantly sacrifice yourself. It really is going to take learning some key skills, some of which I described earlier, but definitely reach out and seek help. We don’t want to lose any more of our colleagues to burnout, and sadly, as you know, Kevin, people do sometimes take their own lives, so we don’t want to see that. There are so many resources and opportunities for help.

And my other big take-home message is really for anybody in a position of leadership: Really examine the ways in which we’re doing things, create some systems to really help ease the workflow for our clinicians, and be intentional about that. Because it is so key that we keep as many of us in this workforce as we can. Otherwise we’re going to have a massive, massive shortage, and patients will suffer at the end of the day. And all of us will be patients at one point too, so we need to make sure we are addressing this problem.

Kevin Pho: Archana, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Archana Reddy Shrestha: Thanks so much, Kevin.