“It’s all because of the system.”
“The system is terrible!”
“The hospital only cares about making money; the system is so broken.”
As a medical student, I can’t get through a week on the wards without hearing lamentations like these from physicians and other trainees. We often see ourselves in an endless battle against the so-called system, and I am taught that advocating for my patients means “fighting” or “pushing” against the system’s barriers. And that is true to a certain degree. Sometimes the health care system puts constraints on the good we can do for patients. But that’s not the whole story.
This “system” eventually becomes our scapegoat for all the things that don’t work the way we would like them to. And the trouble with this viewpoint is that it creates a sense of helplessness. Yet, what put the system there in the first place? What sustains it? Or more importantly, perhaps, who sustains it?
Prior to medical school, I was a business student. I learned to think about the economy as a sum of transactions between people. In other words, the combination of everyone’s choices and actions—manifested in forces known as supply and demand—work together to create and sustain the environment we all live in.
In the same way, the health care system is the product of individuals’ choices and actions, including those of physicians and trainees both past and present. We all collectively contribute to creating and sustaining the system as it is. Directly or indirectly, we are the system.
In my previous experience as a project manager in a hospital, one of the most memorable quality improvement projects I was a part of aimed to reduce wait times for MRIs. While capacity was undoubtedly an issue, the more pressing one was how to triage requests. It turns out that physicians were writing “STAT”—meaning, emergency, must be done ASAP—on almost all the requisitions. It was impossible to distinguish signal from noise. Today, having been on the front line seeing patients myself, I sympathize with this impulse on a physician’s part. Every patient feels that their own case is an emergency, even when it isn’t. It is often out of a desire to comfort or appease the patient that the physician feels the need to help rush things along. And yet these actions, taken as a whole, clog up the system and make it impossible for the true emergencies to be triaged as such.
In the quest to provide the best care possible, physicians can become caught up with the patient in front of them. It is the way we are trained. To us, patient-centeredness means doing everything we can for the patient we can see. We often forget that we are participants in a broader system which is invariably shaped by our actions as well.
The good news however, is that we are most certainly part of the solution.
For example, in 2010, American bioethicist and family doctor Howard Brody helped identify the top five treatments and tests that were ordered unnecessarily with minimal benefit for patients. This work developed into the Choosing Wisely campaign by the ABIM Foundation, and by 2014 it had also reached Canada.
Medsafer, an electronic tool that rapidly identifies opportunities to safely de-prescribe, was also the result of physicians working to improve patient care, this time in collaboration with pharmacists, researchers and other health care professionals. More than 30 percent of adults age 65 and older in Canada take at least five medications, which is known as polypharmacy. Polypharmacy is a risk for adverse drug events, and not all prescribed medications are appropriate or necessary. MedSafer drives home the importance of judicious prescribing to minimize harm to patients. It also helps take some pressure off emergency departments, where the number of visits is associated with the number of prescription medications patients are taking, even after adjusting for age and number of chronic conditions. A single visit to the ED can cost up to $333, and a single hospitalization $7,528. This amounts to $13.6 million per year in Ontario, with an estimate of $35.7 million in Canada.
These initiatives help trim back unnecessary tests and prescriptions, freeing up critical resources for the health care system which can be re-invested. Everybody wins.
All physicians can find ways to contribute to quality improvement. Many hospitals have ongoing initiatives to improve the delivery of care by improving work flow or by implementing much-needed new projects (e.g. electronic medical records). In my experience leading these projects in the past, physician attendance was always an essential ingredient for success. Physicians order the vast majority of medications and tests, and admit and discharge patients. Without their buy-in, the work of the entire team to make improvements could go to waste. Although it is never easy to tear ourselves away from the demanding task of managing large patient loads, our participation is critical to improving the environment we all work in.
It is time for more physicians and trainees to participate in initiatives such as these. We are not helpless victims of a flawed system; we can rise to the occasion and embrace our roles as stewards of that system, despite its finite resources and complex issues.
As a medical trainee, I look to staff physicians to teach us not only to denounce the barriers in health care, but to do good in the system despite the barriers, and where possible, to step up and make change.
We have the power, and we have the responsibility. Let’s embrace that.