Winston the Mascot and Other News

I’ve been pretty busy in the last few weeks, but even for a smokejumper, things settle down temporarily. Just a few items in between fires. Looks like the name for the new Psychiatry Consult Service mascot is Winston.

I just got back from a walk with Winston. Folks down at the gift shop are used to this by now and happily refuel Winston with the usual gas.

“Winston’s the name; smokejumpin’s my game!”

And the update on the change our specialty’s name so far indicates C-L Psychiatry is what the majority favor.

Too bad it’s not an official poll. No word on the real one yet from the Academy of Psychosomatic Medicine, as far as I know.

I suppose most of you have seen the Viewpoint article on physician burnout in The JAMA Network:

Shanafelt, T. D., et al. (2017). “Addressing physician burnout: The way forward.” JAMA 317(9): 901-902.
The US health care delivery system and the field of medicine have experienced tremendous change over the last decade. At the system level, narrowing of insurance networks, employed physicians, and financial pressures have resulted in greater expectations regarding productivity, increased workload, and reduced physician autonomy. Physicians also have to navigate a rapidly expanding medical knowledge base, more onerous maintenance of certification requirements, increased clerical burden associated with the introduction of electronic health records (EHRs) and patient portals, new regulatory requirements (meaningful use, e-prescribing, medication reconciliation), and an unprecedented level of scrutiny (quality metrics, patient satisfaction scores, measures of cost).

I like to emphasize what I consider one of the highlights of the paper:

At the national and state level, a number of reforms are needed. The current burden of documentation related to the clinical encounter required to meet billing requirements, quality reporting, and separate justification for each test ordered individually is unsustainable. Required documentation needs to be reduced and streamlined. Clarification and guidance regarding which tasks (eg, computerized order entry), forms, and documentation elements may be completed by appropriately trained nonphysicians is needed. More input from physicians practicing in diverse settings and specialties should be sought regarding how to improve current and future regulations. Future regulations related to documentation, meaningful use of EHRs, and workflow should be thoroughly vetted with all stakeholders (including physicians) and evaluated for workforce implications prior to their enactment. Requirements by insurers that physicians perform and document unnecessary elements of care to justify billing codes but that do not contribute to good medical care should be eliminated. Payers must also develop a more efficient preapproval process for tests, medications, and procedures. Similarly, maintenance of certification requirements need to be better integrated with standard continuing medical education requirements. State licensing boards should eliminate questions on licensing applications regarding diagnosis or treatment for mental health conditions (which may dissuade some physicians from seeking help for burnout, depression, or other conditions) and replace them with questions regarding current impairment. The National Institutes of Health should allocate funds to support further research evaluating the implications of clinician well-being for the care delivery system and determining how to improve the work-life of health care professionals. (bold face type mine–J.A.).

My friend and colleague, Dr. George Dawson, also has something to say about this in his recent post:

Physician evaluations are often set up to not recognize the unique contribution of the physician to the department and to insist instead on some kind of meaningless corporatized individual improvement plan.  The maintenance of certification (MOC) and maintenance of licensure (MOL) in some states is way to send the message that individual physicians don’t have any particular expertise and in fact have to pass an arbitrary general exam in order to maintain certification – even if they have specialized in the area for 20 years, are recognized for their expertise, and know more about it than the physicians who designed the exam.–Dr. George Dawson, blog post “Managed for Mediocrity–Corporate Medicine in the 21st Century” posted March 4, 2017.

I’ve been trying to read Paul Starr’s book, “The Social Transformation of American Medicine,” which says a lot about the corporatization of medicine in the U.S. If I weren’t so busy putting out fires all over the hospital, I could get somewhere with it.

Hospital census is higher than I can remember it ever being in the time I’ve been here. I suggested considering hiring psychiatric hospitalists, which is essentially what I am:

Muskin, P. R., et al. (2016). “Co-managed Care for Medical Inpatients, C-L vs C/L Psychiatry.” Psychosomatics 57(3): 258-263.
OBJECTIVE: We report on a quality improvement program to co-manage patients with co-morbid medical and psychiatric disorders in the general hospital. A philanthropic donation allowed a high volume, high-acuity urban hospital to hire a co-managing inpatient psychiatrist. The expectation was that facilitating psychiatric evaluation/treatment of medical patients would result in fewer patients staying beyond the expected length of stay (LOS). METHOD: The psychiatrist became a member of a general medical team working with a group of internists and actively co-managing medical patients. After one year, we compared time-to-consultation request and LOS for patients seen through the traditional Consultation-Liaison model and patients seen through the co-managed care model. A second co-managing psychiatrist was hired. A new QI project investigated reduction in lost days. RESULTS: There was a decrease in LOS for patients seen in the co-managed care model when compared with those seen via the traditional Consultation-Liaison model. Co-managed patients were seen earlier in the hospitalization. Excluding very-long-stay outliers, there was a reduction in LOS of 1.19 days (p < 0.003). There was an estimated annualized saving to the hospital of 2889 patient days. CONCLUSIONS: A program of co-managed care reduced both LOS and lost days to the hospital. This resulted in an increase in hospital support to hire 2.5 full-time equivalent psychiatrists and 1.0 full-time equivalent social worker for the Consultation-Liaison service. Such programs may permit the return of modernized psychiatric liaison programs to medical and surgical services.

However, the model is apparently not sustainable and there is no money in the budget for them in most medical centers. On the other hand, the growth of the hospitalists in general has been steady over the last 20 years (Wachter, R. M. and L. Goldman (2016). “Zero to 50,000 — The 20th Anniversary of the Hospitalist.” New England Journal of Medicine 375(11): 1009-1011).

I was just notified by the American Board of Psychiatry and Neurology (ABPN) that I owe them money for their Continuous-Maintenance of Certification (C-MOC) program. I had a look at their list of approved CME and Self-Assessment activities and most of them are not applicable to my practice, many cost $500-$1200 for content irrelevant to my work as a C-L Psychiatrist, and many are expired or otherwise not at all convenient or available. I have just asked them how much I owe them. I’m an inch away from dropping MOC. I’m too busy for MOC busywork. I’ve considered certifying with the National Board of Physicians and Surgeons (NBPAS). I’m getting close enough to retirement that I wonder if it’s even worth doing that now.

Pretty soon I’ll be moving on. The rest of medicine can move on down the line without me. Of course, Winston might want to stick around…

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