Reframing Contemporary Physician Leadership

We Started as Heroes

Grace E. Terrell

• Éditeur: American Association for Physician Leadership
• Année: 2022
• ISBN:
  9780996663243
• Édition: 1
• Sujet: Medicine
• Sous-sujet: Health Care Delivery

The practice of medicine, today, requires transformational skills. Healthcare challenges are no longer adequately addressed by the traditional paternalistic physician role. Healthcare must be physician-led, but patient-centered. Effective leadership must be collaborative rather than authoritarian, proactive rather than reactive.

• Most physicians work in environments where current cultural paradigms, such as physician as hero, lead to burnout.
• Physicians have not been adequately trained in many of the skills necessary for leadership competence and therefore lose agency with respect to important decisions.
• The pace of technological change impacts physician work in ways traditional workflows cannot accommodate.

This book is a broad analysis into the history, limitations, and possibilities of the healthcare delivery system. Reframing Contemporary Physician Leadership: We Started as Heroes readies physicians for making the necessary changes to transform a system of accelerating cultural and technical changes. Dr. Grace Terrell jumpstarts the conversation about how physicians need to prepare to lead in this complex adaptive system.

You'll learn about the transformation that helps physicians strengthen their ability to lead. You'll take a historical journey through the medical profession and the transitions that brought it to where it is today. You'll gain insight necessary to think through the implications of leadership and current health policy considerations.

Dr. Terrell profiles 11 physician leaders through real-life vignettes to provide concrete examples of physician leaders (and their successes) in the current delivery system. These inspiring vignettes will give the reader a deeper understanding of the historical sources of our current situation and the trajectory of the future state of the healthcare delivery system.

Part I

Condition Red: Situation Today

Chapter 1

Where We Stand

The dogmas of the quiet past are inadequate to the stormy present. The occasion is piled high with difficulty. As our case is new, so we must think anew and act anew. We must disenthrall ourselves, and then we shall save our country.1

President Abraham Lincoln

1862 Address to Congress

So here we are. Two years after the first reported cases of SARS-CoV-2 in the United States, more than 813,000 Americans have died, 57.7 million have been confirmed with the illness, and we have experienced the greatest decline in the economy since the Great Depression. The U.S. healthcare delivery system has reeled under the pressures of the pandemic, from the initial inadequate testing and personal protective equipment capabilities to layoffs resulting from the postponement of elective procedures and inadequate cash flow built upon fee-for-service revenues.

Even as ICUs overflow with COVID-19 patients requiring ventilatory support, death rates in patients without a COVID diagnosis have substantially increased, as people avoid or no longer have access to care for stroke, heart disease, cancer, and the other common serious medical illnesses. Many independent physician groups that were unable to sustain their business during the pandemic have been acquired by larger entities.

The horrifying death rates in long-term care facilities early in the pandemic led to lock-downs with their own horrific consequences, including residents’ extreme depression and loneliness due to isolation from family and the wider community (Figure 1).

Figure 1. U.S. Death Rate 2000–2020. Source: The Centers for Disease Control and Prevention

With the economy in shambles, many employees who depended on employer-sponsored health insurance lost access to healthcare along with their jobs. Children were not in school. Restaurants, sporting events, concerts, and theaters closed, and the airline industry is near bankruptcy. The nation has not experienced this degree of political upheaval since the Civil War.

Amid the existential professional crisis wrought by the COVID-19 pandemic, physician leadership has been on public display as never before. Dr. Anthony Fauci became an icon as the voice of medical authority in the Trump administration’s White House Coronavirus Task Force and now as Chief Medical Advisor to President Joe Biden.2

The astonishingly rapid development of highly effective vaccines by U.S. drugmaker Pfizer with their German partner BioNTech highlighted the scientific work of a husband-wife physician team unseen since the early 20th-century work by Pierre and Marie Curie. As voices of authority from their national platforms, Dr. Robert Redfield of the CDC, Dr. Deborah Birx of the White House Coronavirus Task Force, and Dr. Scott Atlas of Fox News and the White House Coronavirus Task Force have faced public adulation and condemnation. The pandemic led to the projection of physicians in the public eye as “heroes”3 and unprecedented threats to public health officials who provided basic information to the public around pandemic safety practices.4 Physicians around the world have been villainized and threatened by some members of the public.5

Physicians’ identification as heroes has not rung true for many clinicians.6 Even for the decades before the pandemic, physician burnout has been an increasing area of concern, with the physician persona of “superhero” identified as one of the factors leading to increasing levels of burnout. 7 Four hundred physicians die by suicide each year — double that of the general population; physicians have the highest rate of suicide of any profession in the United States.8

As Hartzband and Groopman have so aptly decried, “The unintended consequences of radical alterations in the healthcare system that were supposed to make physicians more efficient and productive, and thus more satisfied, have made them profoundly alienated and disillusioned.”9 These unintended consequences include electronic health records designed for billing rather than clinical ease of use, meaningless check-the-box performance measures, monetary penalties for expanding the length of face-to-face patient time, and reductions in professional authority and autonomy embedded in contemporary health system organizational structures and culture.

Despite the remarkable evidence of healthcare delivery system failure illuminated by the COVID-19 pandemic, the United States continues to spend a disproportionately high amount of money in the healthcare sector relative to other crucial components of our economy.

In 1960, U.S. federal government spending for education as a percentage of gross domestic product (GDP) was 3.7%; for defense, it was 10.1%; and for healthcare, it was 0.3%. By 2020, federal government spending as a percentage of GDP increased to 5.91% for education; defense spending decreased to 3.5%; and healthcare spending increased to 8.0%.10 However, as a percentage of the overall federal budget, healthcare spending ballooned to 28% and is expected to accelerate to one-third of federal spending within the next eight years.11 12

This degree of spending strains the capacity to invest in important aspects of government spending, including infrastructure, defense, education, and crucial challenges like climate change. The amount of money spent in the U.S. on healthcare privately is accelerating even more rapidly than governmental spending. Since 1960, the federal, state, and private expenditures for healthcare services and goods in the U.S. accelerated from 5.2% in 1960 to 18.0% in 2020 (Figure 2).

Figure 2. U.S. National Expenditures as Percentage of Gross Domestic Product, 1960–2020.

The passage of the Affordable Care Act in 2009 significantly reduced the percentage of uninsured Americans. While the uninsured segment of the American population stood at 49.7 million in 2010, the projected impact of insurance market reform that was forecast to bring this number down to 24.4 million by 2019 began to unravel with policy changes instituted during the Trump administration (Figure 3).13

Figure 3. U.S. Nonelderly Uninsured Population, 2010–2020. Source: Centers for Disease Control and Prevention National Center for Health Statistics

The uninsured population reached a nadir of 26.7 million Americans in 2016 (10.0% of the population) with gradual increases since,14 substantially worsening during the pandemic due to loss of employer-sponsored insurance by the newly unemployed.15 This uninsured population segment will continue to challenge healthcare providers when their lack of access to basic healthcare services inevitably leads them to the emergency departments of our overburdened hospitals or to reduced access to any healthcare at all.

More than two decades have passed since the release of the Institute of Medicine’s (IOM) landmark report To Err Is Human16 that spotlighted the high number of medical errors occurring throughout our health system. Even today, with significant resources having been dedicated by healthcare organizations, government agencies, not-for-profit organizations, and physician practices across the country to conduct major quality improvement initiatives, our nation’s health system continues to face significant challenges with eliminating medical errors.

Medical errors remain a leading cause of death in the United States, costing $20 billion a year and resulting in 100,000 lives lost.17 Prior to the pandemic, one study suggested medical errors may be the third-leading cause of death in...