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Join us for an insightful podcast episode featuring Shideh Shafie, an emergency physician. We’ll delve into the profound values that drive physicians to serve humanity and alleviate suffering, and discuss the impact of corporate-driven metrics on the medical field. Shideh shares her experiences and strategies for balancing institutional pressures with a commitment to providing high-quality, patient-centered care.

Shideh Shafie is an emergency physician.

She discusses the KevinMD article, “Navigating profit-driven metrics: Upholding core values in medicine.”

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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 Shideh Shafie. She’s an emergency physician. Today’s KevinMD article is “Navigating profit-driven metrics: Upholding core values in medicine.” Shideh, welcome back to the show.

Shideh Shafie: Thank you, thanks for having me again.

Kevin Pho: So Shideh’s been on in the past. Go to KevinMD.com/podcast to search for her name and hear her story. But today let’s go into your most recent KevinMD article, “Navigating profit-driven metrics: Upholding core values in medicine.” What’s this article about?

Shideh Shafie: So you know, I think we live in this society that’s getting a lot of metrics, and in health care we see tons of metrics coming in. And this came for me as I see so many physicians that struggle when their metrics don’t look great. And it can be confusing, because we get two kinds of metrics, or we get multiple kinds of metrics.

But in the article I talk about, there’s some metrics that are driven by our core values as physicians, which is really like patient care, patient safety, maybe teaching metrics, that we want to teach our young. Well, everyone’s are a little bit different, but they’re often rooted in service of the patients, and if you’re in academic medicine, often your learner. And some of the metrics we get really speak to that. And then there’s other metrics we get from our administrative teams that are really more about the hospital bottom line.

And I don’t mean that you need to ignore either set of metrics. It just means that they will sometimes come into conflict with each other. And so, you know, I talk about one of the geriatric researchers who used to work with me, who was lovely, and she would send us metrics quarterly about if you were prescribing benzodiazepines or diphenhydramine or other medications that increase the risk of fall in elderly patients over 65. You just get like a little alert, and then you get like a graph of how many you had prescribed compared to the rest of the group and compared to your past prescribing patterns, with a little bit of education of why you were being taught that.

And so for myself, I saw that number go down over time and I was proud of that, because yeah, you know, maybe that person doesn’t need the Benadryl, like maybe we can do something different, or whatever it is. And so it really was a metric geared to protecting patients.

Then you get all these other metrics also, and they can be on, you know, length of stay. Or this one that Maran Wilbur is writing a book, and I think it’s coming out quite soon, it’s like around now, where she just interviewed a lot about how she was getting metrics about like the length of stay in the hospital in ovarian cancer surgery, where open surgery actually is the gold standard, because your chance of survival is higher, because the tactile component is very important in that surgery, versus laparoscopic surgery where you lose that component. And so she was being sort of told not to do that open surgery because the length of stay increases. And so if you’re getting compensated the same for the surgery and one is like at a five or six day length of stay, of course, and one is like a same day or next day thing, that changes, that metric really feeds to the bottom line of the hospital. And of course the bottom line of hospitals matter, but they actually are not where our duty as physicians matter.

And so really understanding how to navigate that, and it’s a balance, right? So you know, we get metrics about Tylenol prescription, IV, oral. And so like in places, IV is much more expensive, and so obviously that’s a metric that has to do with bottom line. In places where it doesn’t matter, right, like there’s people like, it doesn’t matter, they might want an IV, but oral is much cheaper and almost equally as effective, right? Like it’s OK to choose the metric that doesn’t harm the patient but is also serving the bottom line of the hospital, because that does matter.

But in places where it does matter, and even in individual cases it might matter, right, like let’s say you have this patient who just had a hip fracture, as an old lady in a C-collar, can barely swallow anything, maybe that’s an OK place to use the IV Tylenol, because in the service of that one patient IV Tylenol might make more sense. And you will get dinged, you get dinged on every single IV in the emergency room. And it’s OK to be dinged, because what you are as a physician, as an expert in patient care and serving patients, you are not an expert in the billing and the bottom line. And that friction that exists is a natural friction that should exist.

And I think sometimes as physicians, you know, we’ve been really cultured to get an A in everything, we’ve gotten A-pluses all over our life, we love the A+. And so when we’re getting like a demerit or like a demotion of some sort, even if it’s a metric that is in conflict of our other value, which is serving patients, and sometimes those metrics come into conflict, and there’s no right answer for any particular scenario. Just being aware of that framework I think really helps physicians and other health care providers not feel so bad, because I see a lot of physicians and NPs and PAs, all of them suffering from like, oh my God, I got a bad report card. Let’s hold on, is it a bad report card, or what is it pointing out to you?

Kevin Pho: Sure. So it sounds like what I’m hearing from you is that of course all metrics are not created equal, and it’s really to that individual physician perhaps to tease out and discern which metrics really will improve patient care and which metrics less so. What are some rules of thumb? How can a physician determine, when looking at a metric, which one truly serves the patient and which one is, I’m not going to say less important, but I’ll say serves the patient less?

Shideh Shafie: Well, I think is first just like look at the metric. I think that there’s a pre-step before getting to that, is that we just feel bad when we get a bad grade. So like first, like letting yourself, like, these are not grades, these are metrics for you to understand. And so that’s like the first step, is unhooking from that feeling of like, oh, I did bad. Like, OK, well, it’s not bad or good, it’s a metric to understand where you lie.

And then to look at it and say, OK, when I’m looking at this metric, left without being seen is a very common one in the emergency room. And so when you look at that one, is it one that serves patients, and to what degrees does it serve patients? Right, like to some degrees that’s a metric that kind of serves both. It serves patients to think about, we don’t want patients to leave that are sick. So there’s one element. But it’s also a little bit about getting paid, right? Like how are we meeting that metric, and where is there something I could have done differently to meet that metric? And so if I’m running around seeing patients as fast as I can in the ER and a patient left without being seen, that might not have anything to do with me.

And then there’s like personal metrics about like MRI utilization, for example, as one that we will get in the emergency room. And then really deciding that one, because it’s a really hard one, right? Like we live in a society right now where a lot of people are underinsured, may not have access to an MRI, and we know that it is really challenging to get an MRI as an outpatient. And so you know, if I think a patient has something that needs emergent MRI within the next like month, how will I deal with that? Can I go to bed at night knowing that I didn’t order it and this patient probably won’t be able to get it as an outpatient? Like, where’s my duty?

And so really remembering that our duty is actually only to the patient, and that’s also medical-legally where the standard is held as well. And just reminding yourself of that, and that being able to sleep at night factor is like a really good one to check in with yourself on.

You know, it has certainly recently come up in my own personal patient care experience. I was working in a clinic day where sometimes we take care of patients with newly diagnosed HIV, where we’ve screened for it, found it, and we’re going to start them on PrEP, or not on PrEP, on a treatment. And so with those patients we know that they’re coming in and we have slotted other patients, and so we can book them for a time, but we also know a lot more about those patients. And then I’m working in a model where they’re scheduled visits also.

And so this patient was slotted for a 15-minute visit, undocumented, uninsured patient who is HIV positive and needs to start, was scheduled for a 15-minute visit. My NP had done all this pre-work and was seeing that patient, and but of course that’s like a much longer, like everyone knows that visit is going to take longer than 15 minutes. She came out, she felt so bad, it had taken her two hours to do the visit, because there was a partner who was pregnant who was in tears, so they like added that patient on. There was a lot of like social dynamics that had to be navigated in that setting.

And so when that happens she’s feeling so bad about herself. And like, I’m the doctor, like I’m a tank, I can plow through a patient board, not a problem, like we didn’t fall behind, it was fine. But she felt so bad. I was like, why do you feel bad? Like, do you think that you should have been able to wrap up that patient in 15 minutes? Do you think that there is something you did that was wrong, or is that just a visit that takes longer?

And in fact, like maybe the policy should be that if we’re taking on these patients that we know are underresourced, or with a new diagnosis that is scary and has lots of things, that maybe you should have had an hour blocked. Now there’s no way to know about the partner that has all these other things going on, we can maybe not block two hours, but it’s OK to push back on these metrics that make no sense too.

Like, we have to be nuanced. Like, you know, when we think about like our political system, which I’m not saying is like in perfect repair, but it’s a three-tiered system between the executive branch, the judicial branch, and the legislative branch. There’s a push and pull, that’s a power balance. And in hospital systems the power balance is like, we are the experts in patients and patient care, and the financial people and the admin side are the experts in financials. But the real business of medicine, to be honest, we are the only revenue generators, or the people that are seeing the patients. And that’s really important to understand, because the cost of medicine, the more you add middlemen, the cost of medicine goes up.

You know, we’re seeing in the fashion industry, we’re seeing the opposite trend, right? We’re seeing companies like Italic or like Public Goods, where they go and find the source companies, take off the branding, and so they’re basically getting rid of a whole host of middlemen and bring the cost of a product like a $1,000 cashmere sweater to $200, because all of the steps in between have been removed. And in health care we’re seeing exactly the opposite, right? Like health care used to be like direct patient care much more, with like a cash fee basis, and then the cost of health care keeps escalating because we’re just adding more and more middlemen.

But recognizing that the real relationship there is between you and the patients. And when I say the you, like I’m talking about the big you, right, the nurses, the NPs, the PAs, the physicians, the clinical staff. All of the clinical team is who generates the revenue, and then in between, team is there to help sort out that stuff, but they’re not the experts in it. We have to a little bit claw back our expertise in that sense, and our power in that sense. I think it’s really important for messaging for physicians and health care providers in general to hear that, that you are the meat of the system.

Kevin Pho: Now, when it comes to these metrics, some are more patient focused, others perhaps more bottom line focused. As you know, some of these metrics are tied into a physician’s compensation, right? So there’s an inherent tension. You can’t necessarily tease out which metrics to pay more attention to when some other metrics are tied to how much you’re paid. So tell us how, as a physician, one can reconcile that tension.

Shideh Shafie: Yeah, so I mean, to be very frankly honest about that, is that it’s not super clear-cut, and it depends on your employment structure. That is one thing that I think is the power. You know, there’s so many women out there and men that teach physicians about money, and the physicians teaching physicians about money, I really think that that’s such an incredibly important thing, because you have to become a little bit clear on finances. And remembering that you are the only one who brings money in, that is like a very central tenet of all this, that is a massive negotiation point.

We think of ourselves as super replaceable. We are not as replaceable as we think of ourselves as, right? Like there’s a lot of messaging like, oh, we’re going to be overrun and we’re all going to be replaced. You have to remember that the financials of it, like when you can get clear on your own financials and finances, because that is the key. It’s like understanding that element, you have to really unpack that and understand that.

And then you’re always going to have to pay attention to the ones that are patient-centered, because that is also where your duty lies, not just from a moral duty but also medical-legally, right? Like, and this is the other part that I think is really important for physicians to understand. It’s like if you don’t order that MRI, right, because, well, doesn’t really need to happen today, it should happen within the next two weeks, but this patient has no way to get it, and then they have like a bad outcome, you will be liable. And the hospital doesn’t go down with you. They don’t care about your metrics reporting, because your duty was to the patient, not to the metric. And that’s a really important thing to remember.

And I’m not, I don’t want people to get sued, I don’t want to cause fear for people, that’s not the point of it. Is that that duty exists because that is our job as physicians. And the administrative parts where they’re thinking about the financials, that liability doesn’t really fall on them, it falls on you. Your lost wages in having to take time off to go through that, your incredible moral and psychological stress that comes with going through a lawsuit, all of that goes to you. So I mean, it’s a form of self-preservation, and also stepping into that expert role. You are an expert, you have gone through all the schooling. They may tell you that you need to decrease this, but ultimately you are responsible for your decisions.

It is not unlike your taxes, right? Like you have an accountant and they will give you advice about like, oh, you can make this tax break. But if you decide to take a loophole that you know upsets the IRS, you’re accountable. It’s not your accountant who’s accountable. It is your decisions. And just remembering that, letting that wave through you, and being OK with pushing back a little bit.

I think a lot of times physicians, I think this is something I find really interesting in physicians. My husband’s a lawyer, and he worked at one of these big law firms in New York for a long time.

Kevin Pho: Yeah.

Shideh Shafie: And in law firms there are secretaries and administrators, but the lawyers generate the revenue, and the secretaries and the administrators work for them, because they are the revenue generators.

Kevin Pho: Yeah.

Shideh Shafie: And in medicine it’s very interesting. I think we want to be nice, we want to be deferential, we want to take out of that sense of like we are the authoritarian physician. But what sometimes happens is that there’s a confounding of like who the actual expert is and who the revenue generator is, right? Like physicians are the revenue generator. Physicians, nurses, NPs, like all of those people generate revenue. We are also the experts. And then yet somehow we feel beholden to just like have to fall in line with it.

It would really be like secretaries running a law firm, which would just never, it’s, lawyers are beyond that, they don’t allow that to happen. And there’s actually a lot of structures about how you can set up law firms and buy law firms. That’s also why they’re not being gobbled up by VC firms in the same way that health care is, because they have structures in place to prevent that. But it’s just an interesting way to think about things, recognizing that we need to sort of reclaim our expertise and our power, and push back sometimes when these metrics don’t make sense, because our duty is to care for these people and keep them safe.

Kevin Pho: How long did it take you to really have that mindset? Because as you said, a lot of physicians throughout their lives, they want to get that A+, they’re people pleasers, they probably wouldn’t be physicians if they didn’t have that mindset. How long did it take you to evolve and be more comfortable pushing back, be more comfortable realizing that, hey, maybe not getting an A+ in a metric that doesn’t benefit a patient is OK? How long did it take you to be comfortable with that?

Shideh Shafie: So I was a director like really pretty fresh out of fellowship. So you know, I have played the role of administrator, and so I got to see the workings from the inside, and I got to see the struggle of like my chairman, who was a physician obviously, like liaising, and like seeing that conflict really early upfront in my career. And he was just, and he still is, he’s a CMO now, like a wonderful man who I really saw fight, of like pushing back about patient care and safety.

And I was really actually lucky, my first real job was in this hospital that had been opened as a philanthropic sort of endeavor, and so it really led with that. It was like a very community-oriented hospital system, and so there was room for that. And so I actually got exposed to that kind of thinking very early on, that understanding that that tension exists, that it’s a natural tension, and that our role in that was to take care of patient safety and care.

Not forgoing finances, you have to think about finances, right? Like there’s this big DPC movement, direct primary care movement, from so many physicians. Those physicians obviously care about the bottom line, but they decide how to balance it. They are in control of balancing it.

So I actually was exposed to that kind of thinking pretty early on. And also my father was a real good teacher of finances to me, so I had a lot of financial, I pretty early in my career, within like I guess like being ten years out, I had independent finance streams. So I knew that, and that really gave me the way to push back. Like when you say something to me, like, I am not here to be pushed around by you. You have a leadership position, but I’m not here to just be told to toe the party line. Like I have to, it has to sit well with me morally and ethically. And having this option of other ways to make money makes it easier.

And you know, I know there’s a lot of coaches in the financial space for physicians, and I really think that’s such an important element of it. You can’t divorce that from the topic, because when you feel like you are trapped financially, then you feel like you have to toe the party line, and that’s a really hard place to be stuck in. And I think that’s a lot of where the moral injury that we see and the burnout that we see comes from, is from feeling so stuck.

And I don’t do that work with physicians, but I do know there’s a lot of people who do that. Tell anyone who’s listening, like, you went to medical school, you went through residency. Finances are like way easier. You just need to give yourself some time to figure that out. Like it’s not hard, but it does require work to learn it and to understand the words. And it’s kind of like medical school, we use all these fancy words, but when you’re teaching them to a patient you teach them with easy words, right? Like the finance is not unlike that, and you are totally capable of learning it. So learn that, figure out that aspect for yourself, and then it gives you a little bit more breathing room to understand all of it.

Kevin Pho: We’re talking to Shideh Shafie. She’s an emergency physician. Today’s KevinMD article is “Navigating profit-driven metrics: Upholding core values in medicine.” Shideh, as always, we’ll leave with some of your take-home messages that you want to leave with the KevinMD audience.

Shideh Shafie: Just remember that you are an expert as a physician. You trained so long and so hard to learn what you have learned. It’s an incredible value to society and an incredible body of knowledge, and your duty is to uphold that body of knowledge and that expertise so that we can keep our patients safe and that we can keep them as the center of care.

And so when you feel that push back on metrics, when you feel that you’re doing something wrong, remember to go back to that core value of patient care and patient safety, and push back. Like, you are the expert, nobody else knows that more than you. Even though sometimes it can feel like the administrative end are in charge, you’re actually in charge of that.

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

Shideh Shafie: Thanks for having me.