Incivility Disabling Primary Care and Possibly You

With rudeness, discrimination, and violence on the rise, how do we take care of our patients while protecting ourselves? - From Incivility in Health Care: Strategies for De-escalating Troubling Encounters by Amaryllis Sánchez Wohlever, MD in Fam Pract Manag. 2019 Sep-Oct;26(5):8-12.

 KEY POINTS From the Author/Physician

• Studies have shown that six in 10 physicians have been subjected to offensive remarks about their race, gender, ethnicity, age, or weight, and health care workers commonly face verbal abuse, physical threats, or worse by patients and others.
• De-escalation strategies, such as taking a timeout and responding instead of reacting, can help in some situations.
• When incivility escalates, physicians must discern when it is time to get help or remove themselves from the situation.
• Health care institutions have a responsibility to create a culture in which physicians feel protected.

There are Limits of Empathy and the Need for Healthy Boundaries that involve Protecting our safety and Protecting our hearts

Please read this article. https://www.aafp.org/fpm/2019/0900/p8.html?cmpid=em_FPM_20190911

This is one of the best articles that I have seen in some time. Daily I see information about how patients are treated poorly, but rarely do we see the other side or explore interactions with patients to see what went wrong, or why, and what to do.

There are more patients/family who are preloaded to react poorly during and after an encounter. There is clearly less trust in physicians.

Shattered Trust - What used to be a given now is a strain to obtain with a patient or family - if it can be gained at all.

There are systemic and other reasons....

• Patient assumptions and expectations
• Patients may blindside you – they may not express that they are upset and instead ventilate to social media, friends, family, or those higher than your supervisors
• Pressures to avoid certain medications or low value care. This may involve prescribing pain medication, or ordering xrays that mean little, or prescribing antibiotics. Patients expect pain medicine, narcotic cough medicine, antibiotics, and many types of xrays that do not help to guide care. Physicians and designers may understand evidence based movements and low value care, but patients do not.
• Employers do little objective evaluation or preventive assessment of the employees or the workplace. Best function is a two way street - you want good health professionals and team members but you also need best support for their functioning.
• Patients and families are suffering more due to poorer health and because of health care design. Their situations are worsening and health care design made add to their financial and other strains
• Misinformation by insurance companies, government, hotlines
• Declining primary care delivery capacity and support for the primary care team members. Frustrations due to access barriers will continue to mount. The distractions of the various design changes can impact care and caring.
• Less and less experienced primary care team members due to massive expansions of MD DO NP and PA (each year more with less experience enter) and due to high turnover taking primary care experience out of the primary care workforce pool

The Blindside Encounter - Remember that the past is past, this is now.

In the past you could often tell when patients were upset and focus on what might modify the situation and consequences. People are less likely to indicate that they expected a xray for a knee or shoulder or neck. They can and do ventilate to social media, to websites, to journalists, or to your corporate bosses.... 

What If You Have a Series of Adverse Encounters

You might have this

• by chance, or
• because your employers or team members are looking for this, or
• because the population you see is changing or
• because you need to make a change.

There are always improvements to be done, but where? There is little diagnostic or evaluative process. And more situations are coming your way.

High Risk Encounters - Protect Yourself

As the prevalence increases of unidentified or unpreventable adverse encounters, the probability of having a series of such encounters increases. The more years that you work, the more patients that you see, the more you are pushed to do, and the higher the risk of such patients all increase the risk to your job.

High risk patients include those with chronic problems, past poor encounters, or those who do not communicate well. Many people are having a prolonged illness for the first time - a cough or pain that has not improved after weeks. There may not be a test or evaluation that can specifically determine the reason despite multiple previous visits.

High risk patients may include those who are health professionals or who work for your employer. More and more patients are trying to avoid an emergency room or hospital cost. They may be in the wrong place such as urgent or retail or primary care.

Recent Encounters That Could Be High Risk

• I am having headache, neck pain, fever, and feel awful - I want to rule out meningitis (probably the flu or similar infection, but a potential high risk situation as most sites are not set up for such an evaluation)
• I have been more short of breath and was sent here because of possible pneumonia (despite no fever and improvement of breathing with albuterol). She expected a chest xray and lab tests - an expectation from the one who referred her. You want to listen to a patient to tell their story for the first minutes of the encounter, but you need to move them to talk about their symptoms and their impact so that you can actually progress in their care.
• I have had a fall with rib pain/tailbone/pelvic pain that is not better after a week. (The pain will last weeks if not months, the xrays do little in evaluation, the pain involves most of what a patient does, likely never had such a lasting pain).
• I heard a pop and my knee swelled. (Same employer as you, works in health care, not happy unless xray).
• I have had cold, cough, congestion, and green sputum for 2 days (a viral URI but expects antibiotics and some even want a chest Xray).
• And then there are period of a few months with really bad viral illnesses - GI or respiratory - and people are more ill and do not get better in the usual time.

Do You Know Math and Statistics? Does Your Supervisor?

Your supervisors may not understand the probability of having a string of adverse encounters. After all, CMS has implemented numerous policies that fail to understand this (Star Ratings, Readmissions, MACRA, Value Based).

The probability of being an outlier increases with more years of practice, higher risk patients, difficult patients, and certain conditions. If you trigger as an outlier, your chance at some level of awareness and understanding of this is poor. It is easier to believe that an employee has a string of events because of something that they are doing – rather than doing more investigation

Objective Investigation could do 6 things

1. ...reassure the employer
2. ....reassure the employee and reduce stress levels elevated to the maximum with threat to job/career
3. ...provide documentation protecting the employer (if there is litigation or someone powerful feels they have been wronged)
4. ...improve the future encounters of the physician
5. ...improve the future encounters of the site of care, including addressing any supervisor issues or lack of support for the team members delivering the care
6. ...prevent future adverse encounters and events 

Proactive Efforts Rather than Reactive

It is common now for employers to require multiple yearly "tests and seminars" to document that they are protecting the public and informing you. The intent of employers and government is to increase your "quality" or your "safety on the job." But these are repetitive, they waste time, and discussions about important areas may not go further than the conference room.

More objective evaluations would be costly, but could reap more benefits in terms of revenue and less downstream cost from adverse encounters.

Your employer is unlikely to have a plan to evaluate physicians on a regular basis or after reported incidents. They need to use objective methods (such as having a secret shopper visit to evaluate the site, physicians, team, and experience). This could do damage control or prevention. It might also identify sites that were not supporting team members or sites that needed new management.

Why Encounters May Go Poorly

Patients and families are experiencing worsening relationships and worsening finances. Their health and their health care are often reasons. They have had more previous health care interactions gone bad or perceived as going bad.

There is a climate of blame the physician fueled by the media and by misinterpreted research (such as To Err is Human and published medical error research that has serious errors and assumption problems). People know that something is wrong and are looking for someone to blame - and sometimes we get the blame as physicians.

• They do not see the system, but they do see us. And they may treat our staff worse than they treat us.

Patient issues continue to arise from the usual sources such as bias, intolerance, mental health issues, health illiteracy, and chronic pain. But there are more issues arising

Who is the doctor? - Sometimes I have people tell me what they have and even say - "But you are the doctor" - when in fact they have already shaped their impression and have their plan set up already. More patients believe that they know what is wrong and what you should do in terms of evaluation, testing, and treatment.

Ruling in Is Easy, But Ruling Out Is Not - The patient or caregiver may well have the ability to rule in their condition - but they do not have the training and experience to rule out what is not likely. Beware the patient who works in health care or has a family member who does. Also be careful about treating people who may be employed by your employer - they may be high risk (expectations, connections, may blindside you).

Patients are also misdirected by their insurance hotlines, friends, and advisors. This results in wrong expectations, wrong assumptions, and wrong places of care.

The serious systemic problem of the Primary Care Financial Design

The US primary care workforce is grossly underfunded and the dollar distributions assure worsening access barriers. Only 5% of health spending for 50% of encounters has long been abusive, especially where most Americans have half enough due to lowest payments and worsening costs of delivering primary care.

The primary care workforce is about service and provides by far the most services. Primary care delivers half of the patient encounters each year and may shape the expectations of the population substantially - and sadly in a negative way as the primary care delivery capacity is insufficient by design.

Primary care is about people - people interacting with people. The innovations and the financial design interact to reduce our time with patients, our time with other team members, and our time with our families

Designers Fail in Primary Care Awareness - Interestingly those who design health care may not use primary care much or visit primary care offices that are well funded and well supported - because the designers have the best incomes and health plans. Where half of the American population resides with half enough generalists and most access barriers, the situations are quite different. Finances, distance, insurance plan design, and lack of local workforce work to prevent getting primary care at all.

If you live in a place where the local population has concentrations of the worst public and private insurance plans, then you live in a place where those with and without insurance share access problems.

The Systemic Problem of Less Experienced Primary Care Workforce

The primary care workforce is already the least experienced in its history and this is also seen in urgent, retail, and convenience care. Diploma mill expansions of NP, PA, DO, and MD annual graduates are throwing out more and more graduates each class year at 6 to 12 times the annual population growth rate (0.6%). They are pumping out massive increased numbers of the least experienced. If you pump out thousands more each class year, you dilute those most experienced and increase those least experienced.

• Primary care is often an entry level career - but is not the long term result.

The primary care financial design worsens this by moving them to other careers and specialties even faster. Nurse practitioners have the least experience as a primary care clinician due to the greatest overexpansion, the most part time or inactive, fewer years in a career, volume/scope differences, and high turnover rates.

The financial designs plus massive expansions have changed primary care from a permanent primary care workforce with 25 - 30 year careers of higher volume, scope, and intensity to a shorter temporary primary care career - often spent looking for a better paid and better supported job.

You learn best in health care by investing in a lifelong career - not in temp jobs.

The Systemic Problem of Fewer and Lesser Primary Care Team Members

The team members that primary care can hire and retain also have limitations due to the financial design. There is a pecking order. The sites that serve the poor often have least experienced team members. They move on to other primary care that is better supported. These move on to specialty clinics or hospital work which is supported by the best financial design. Primary care used to have RNs working one on one with physicians. Now RNs are far less common and often work doing triage or begging insurance companies to take care of our patients.

Patients also move on when they feel that they are not being treated well by staff.

The team member changes have not been ideal for continuity, for efficient cost of practice, for best patient interactions, and for experience in the primary care workforce.

There are too many that graduated too recently and they have too little experience - by design.

And primary care is being marginalized by design along with general specialty services. Paid too little, usual costs of delivery increasing, and new innovative/regulatory costs disable basic access, primary care delivery capacity, care, and caring.

Patient Beware of the New Primary Care Workforce

Why Not Inside Out Empowerment Rather Than Outside In Abuse

Physicians Are All Alone Together

For Burnout Relief, Focus on the Financial

We Are Not Growing Primary Care, We Are Shrinking It - Not only is primary care delivery capacity declining, we are shrinking primary care from within by compromising team member functions.

Real Health Care Solutions, Not Value Focus

The CMS Contribution to the Demise of Rural Health - CMS leads by example - the wrong way

You're Killing Us Smalls - Small health is being killed off by design.

Bob Bowman

Basic Health Access