Autonomy, mastery, respect, and fulfillment are key to avoiding moral injury in physicians

Simon G Talbot and Wendy Dean
BMJ blogs
Originally posted 16 Jan 20

Here is an excerpt:

We believe that distress is a clinician’s response to multiple competing allegiances—when they are forced to make a choice that transgresses a long standing, deeply held commitment to healing. Doctors today are caught in a double bind between making patients’ needs the top priority (thereby upholding our Hippocratic Oath) and giving precedence to the business and financial frameworks of the healthcare system (insurance, hospital, and health system mandates).

Since our initial publication, we have come to believe that burnout is the end stage of moral injury, when clinicians are physically and emotionally exhausted with battling a broken system in their efforts to provide good care; when they feel ineffective because too often they have met with immovable barriers to good care; and when they depersonalize patients because emotional investment is intolerable when patient suffering is inevitable as a result of system dysfunction. Reconfiguring the healthcare system to focus on healing patients, rebuilding a sense of community and respect among doctors, and demonstrating the alignment of doctors’ goals with those of our patients may be the best way to address the crisis of distress and, potentially, find a way to prevent burnout. But how do we focus the restructuring this involves?

“Moral injury” has been widely adopted by doctors as a description for their distress, as evidenced by its use on social media and in non-academic publications. But what is at the heart of it? We believe that moral injury occurs when the basic elements of the medical profession are eroded. These are autonomy, mastery, respect, and fulfillment, which are all focused around the central principle of purpose.

The info is here.

Insurance companies aren’t doctors. So why do we keep letting them practice medicine?

William E. Bennett Jr.
The Washington Post
Originally posted October 22, 2019

Here are two excerpts:

Here’s the thing: After a few minutes of pleasant chat with a doctor or pharmacist working for the insurance company, they almost always approve coverage and give me an approval number. There’s almost never a back-and-forth discussion; it’s just me saying a few key words to make sure the denial is reversed.

Because it ends up with the desired outcome, you might think this is reasonable. It’s not. On most occasions the “peer” reviewer is unqualified to make an assessment about the specific services.

They usually have minimal or incorrect information about the patient.

Not one has examined or spoken with the patient, as I have.

None of them have a long-term relationship with the patient and family, as I have.

The insurance company will say this system makes sure patients get the right medications. It doesn’t. It exists so that many patients will fail to get the medications they need.

(cut)

This is a system that saves insurance companies money by reflexively denying medical care that has been determined necessary by a physician.

And it should come as no surprise that denials have a disproportionate effect on vulnerable patient populations, such as sexual-minority youths and cancer patients.

We can do better. If physicians order too many expensive tests or drugs, there are better ways to improve their performance and practice, such as quality-improvement initiatives through electronic medical records.

When an insurance company reflexively denies care and then makes it difficult to appeal that denial, it is making health-care decisions for patients.

The info is here.

First do no harm: the impossible oath

Kamran Abbasi

BMJ 2019; 366
doi: https://doi.org/10.1136/bmj.l4734

Here is the beginning:

Discussions about patient safety describe healthcare as an industry. If that’s the case then what is healthcare’s business? What does it manufacture? Health and wellbeing? Possibly. But we know for certain that healthcare manufactures harm. Look at the data from our new research paper on the prevalence, severity, and nature of preventable harm (doi:10.1136/bmj.l4185). Maria Panagioti and colleagues find that the prevalence of overall harm, preventable and non-preventable, is 12% across medical care settings. Around half of this is preventable.

These data make something of a mockery of our principal professional oath to first do no harm. Working in clinical practice, we do harm that we cannot prevent or avoid, such as by appropriately prescribing a drug that causes an adverse drug reaction. As our experience, evidence, and knowledge improve, what isn’t preventable today may well be preventable in the future.

The argument, then, isn’t over whether healthcare causes harm but about the exact estimates of harm and how much of it is preventable. The answer that Panagioti and colleagues deliver from their systematic review of the available evidence is the best we have at the moment, though it isn’t perfect. The definitions of preventable harm differ. Existing studies are heterogeneous and focused more on overall rather than preventable harm. The standard method is the retrospective case record review. The need, say the authors, is for better research in all fields and more research on preventable harms in primary care, psychiatry, and developing countries, and among children and older adults.