Posted on

There are a lot of things wrong with medicine today. A lot. But they aren’t the things most people typically focus on. I genuinely believe that the number one problem with our healthcare system is the people in it and how they are compelled to behave. I started down this somewhat offensive pathway here in this post about physician ethics.

People (doctors, nurses, healthcare executives, etc.) will typically behave in whatever way suits their best interests. It’s human nature. We all want to be happy, secure, safe, and make a couple of dollars for ourselves and our families. Any system that we create, whether it’s related to healthcare or anything else, must appreciate and promote this reality or it will inevitably fail.

What goals would the ideal healthcare system promote? For many years, health policy wonks have focused on three things (called The Triple Aim):

  1. Improved population health
  2. Lower cost of care
  3. Better patient experience

These three areas are intricately related and are synergistic. What does the Triple Aim look like in a real-world example? Let’s consider an average woman’s obstetric experience.

Today, in many clinics, an average-risk woman who becomes pregnant will have 11-13 doctor’s visits for prenatal care. Each of those visits will consume well over an hour, with most of that time spent waiting. During those visits, she will undergo a battery of tests and ultrasounds, most of which are unnecessary and whose importance (or lack thereof) goes unexplained to the patient. She will receive a litany of incorrect advice (both from her doctor and from society) and spend a lot of time worrying about things that she need not worry about during her pregnancy. Eventually, her doctor may recommend an induction of labor, and this induction will likely not be medically indicated. Then, there is a good chance she will undergo an unnecessary cesarean, increasing her pregnancy risks now and in the future. She isn’t likely to breastfeed for more than a couple of weeks, and when she has postpartum depression, it is likely to go unnoticed and untreated. Most of this poor care that she receives will come in a fragmented form, seeing a variety of different providers and nurses, most of whom don’t know anything about her or her life. All of this care will cost many thousands of dollars.

Does this sound like a good healthcare system? Is it how you would want to have a baby?

Of course not.

The Triple Aim helps bring focus on the best way to reform this broken system. How can we make women and children have better outcomes, lower the cost of care, and improve the overall patient experience? I’ll give just a few ideas to think about that apply to this obstetric example.

  • Reduce the number of visits and wait times. The current system could be replaced with perhaps 6 or 7 visits and 2 or 3 dedicated educational group visits, for low-risk women.
  • Don’t perform unindicated tests and ultrasounds. Industry drives the majority of genetic and aneuploidy screening tests and patients often do not understand their choices or the implications of doing these tests. Most patients I meet don’t even know they had the tests done (like carrier screenings, first-trimester screening, NIPS, etc.) Many (if not most) would decline this testing if fully-informed. A whole ecosystem of unnecessary ultrasounds and fetal well-being tests now exist that have not been shown to benefit patients (like antenatal testing for women who are AMA or have diet-controlled GDM).
  • Recommend only evidence-based interventions and advice.
  • Don’t induce women without a medical necessity if it increases their risk of Cesarean or an unnecessarily long-labor.
  • Simplify breastfeeding advice and recommendations.
  • Screen women by phone early and often for breastfeeding difficulties and evidence of mood disorders.
  • Encourage continuity of care with a provider or a very small team of providers.

We could go on and on about ways to improve prenatal care (or any other aspect of medicine for that matter). Each of the items I mentioned does something to improve the patient experience, improve the population health, and lower the cost of healthcare. Yet, we are not incentivized to make these changes. Why not?

First and foremost, the answer is money. In obstetrics, we are told that we have a shortage of physicians and that this shortage will grow to become a crisis in a few years. Physicians always talk about there being a shortage of physicians because it is a good negotiation tactic with employers and payers who hold them hostage every year. If there were indeed a shortage, then cutting the number of prenatal visits and encouraging group visits would improve physicians’ availability, patient satisfaction, as well as the quality of care. Group visits (with an educational focus) are a good thing for patients and free up physician time if done appropriately. Doing fewer unindicated tests and ultrasounds would take away more than half of the business model that currently sustains the entire subspecialty of Maternal-Fetal Medicine and would severely cut into the revenue of many general practices as well. Fewer inductions of labor would be mean fewer Cesareans which would mean less money to hospitals. It also would mean shorter lengths of stay which would mean more available beds and less demand for obstetrics nurses. In short, doctors, nurses, and hospitals all stand to make less money. Yet, patients would have greater access to care, lower costs, and better outcomes.

The Triple Aim is a lot like medical ethics because it is based on medical ethics. Justice demands that we don’t waste scarce health resources (lower cost of care). Beneficence and nonmaleficence require us to work to improve population health (remove, prevent, and do no harm to patients). Autonomy requires us to value and respect our patients’ wishes, and they will have a better experience if we strive to do so.

Today, though, we are starting to finally talk about the Quadruple Aim. This added aim may, at first, seem out of place:

  1. Improved population health
  2. Lower cost of care
  3. Better patient experience
  4. Improved physician experience

Yet, the first three Aims are facilitated by the last one. Let me explain. The ideal patient encounter involves a patient receiving exactly the care she needs (no more and no less) at the exact time she needs it (right day, short wait) from a clinician of their choice who is caring, not rushed, evidence-based, and available to them over time (continuity of care).

But physicians today (and yes, I mean physicians to the exclusion of NPs and PAs) face a litany of challenges and adversities that make this problematic.

Burnout. Half of US physicians suffer from burnout, with EM and OB/GYN at the top of the list. The majority of physicians in a majority of the specialties report that they wouldn’t go into the specialty again if given the choice (or even into medicine). They feel cynical, unenthusiastic, unaccomplished, unappreciated, and unrewarded.

Burnout is accelerated by frustration with time spent on paperwork, administrative burdens, stress, liability burdens, and non-face-to-face activities like refill requests, etc. Physicians today spend more time charting in the EHR and taking care of these indirect activities than they do actually taking care of patients. Many of these activities are conceived of by non-clinicians for a variety of reasons, some of which are excellent and promote good patient care, some of which are excellent but poorly communicated, and others of which serve no useful purpose that supports the Triple Aim (let alone the Quadruple Aim). Some are even harmful.

An example of the latter is documentation of patient pain scores: this activity required physician time, wasn’t based on science, and contributed to the development of the opioid crisis today. It has resulted in patient deaths. How many other “good ideas” are implemented into medicine by payors or regulatory agencies that increase the burdens of our job but contribute little or nothing to our ultimate Aims? That’s a subject for another time.

Physician burnout is worsening in the last few years, not improving. This is an ominous sign for the US Healthcare system. We’ll think about why that is true in a moment.

Suicide and early retirement. Both of these outcomes rob patients of their physicians. Both are increasing. Higher rates of burnout encourage early retirement; many who don’t retire feel stuck doing a job that they’d rather not do but must for financial reasons (especially with student loans of $300,000 or more). Suicide among physicians, including medical students and residents, occurs at an alarming rate. High burnout rates, high debt levels, and an increasingly abusive and bureaucratic system contribute to this. Physicians today, plagued by record burnout, have the highest suicide rate among any profession in the US. The rate is more than twice as high as the average rate in the population. Worse, this high rate of suicide occurs among the community of people who are most educated on how to treat mental health problems, how to prevent suicide, and who have nearly universal and easy access to high-quality healthcare. It occurs in a population that generally doesn’t suffer from poverty or other conditions of low socioeconomic status which might be viewed as risk factors for depression, substance abuse, and suicide. Yet, rates of suicidal ideation, depression, and drug and alcohol abuse are excessively high among physicians as compared to the general population.

Even when physicians don’t retire, destroy their ability to work with substance abuse, or kill themselves, the low morale and despair that accompany depression and burnout can have significant adverse effects on the organization and patient care. Frontline staff, nurses, and everyone involved in delivering care become burnout and cynical as well when the physician loses her way.

So, let’s tie this all back to the Quadruple Aim. Physicians report a lot of reasons for burnout and dissatisfaction at work, and the reasons you hear depend on how you ask the question. Here’s one survey:

This list is interesting and paints a picture of physicians who are frustrated by meaningless paperwork and other tasks, long hours, declining pay, frustration with insurance companies, frustration with other burnout colleagues, etc. But hidden in these data is a more significant message: physicians are increasingly burnt out because they don’t feel like they can take care of patients in the way they should and provide high-quality care to them. Maybe it’s because their time is stolen by computers and paperwork and more hoops to jump through each year. Perhaps it’s because they don’t have time to stay up-to-date with the latest evidence. Maybe it’s because they spend more time worrying about whether they will be fired, have their pay cut, get sued, or be replaced by a nurse practitioner than they do actually worrying about patients.

In fact, a 2013 study commissioned by the RAND Corporation found precisely this: the primary driver of physician satisfaction is not money, status, or work hours, it is the ability to provide quality care to patients. A higher rate of physician burnout is a warning sign that our healthcare system is putting up more obstacles to delivering quality care to patients. This excellent review article of the Quadruple Aim relates the following quote from a physician:

I can’t tell you how defeated I feel … The feeling of being punished for delivering good care is nerve-racking.


And there it is. As a general rule, providing better care to patients means fewer profits for the healthcare industry. Fewer labs, fewer imaging studies, shorter lengths of stay, fewer surgeries, fewer prescriptions, etc. It has been estimated that we spend as much money on unnecessary tests in the US Healthcare system each year as we do on the entirety of K-12 education. So, why don’t physicians just order only the appropriate tests? Perverse incentives.

These perverse incentives come in the form of fears of liability, fears of decreased economic security if the organization that they work for (which is seemingly already struggling to stay afloat) has declining revenue, etc. Everything tells physicians to do more to patients, not less. We are incentivized to squeeze every dollar out of each insured patient while ignoring uninsured patients – then we wonder why population health outcomes don’t improve while insurance premiums go up. It is, all told, a harrowing experience.

Healthcare has become a business. But it is the worst sort of business – one that claims that everything it does is morally necessary. It is highway robbery cloaked in the white coats of physicians, and those physicians have had enough.

The Quadruple Aim.

So, if we genuinely want to achieve better population health and better patient experiences at a lower cost, we much improve the physician experience as well. Many authors have referred to this as the missing aim. Not only is it missing, it is essential.

Here are some tips:

  • Reduce paperwork and charting burdens. A decade ago, we spent 1/3 of our time on these things; now, it is 2/3 of our time. Computers were supposed to make life easier, not harder.
  • Reform our tort system. Physicians shouldn’t fear a lawsuit in every interaction they have with patients.
  • Reduce regulatory burdens. Many, if not most, regulations in healthcare today don’t help patients; they help consultants who charge large fees ensuring compliance. No regulation should exist unless there is clear and referencable evidence that it improves patient outcomes.
  • Promote income stability. Physicians waste a great deal of energy and effort wondering when the next cut in Medicare or Medicaid reimbursement will occur (and fighting against it). Cutting physician reimbursement doesn’t lower the cost of healthcare; in fact, it may increase utilization as physicians feel compelled to do more surgeries and more procedures to maintain the same income level. Read here for some effective ideas of what can reduce the cost of healthcare (and take note of who gets hurt when these ideas are implemented).
  • Restore respect to physicians. Physicians trained for a long time and gave up years of their lives to be able to do one thing: be an expert in delivering high-quality healthcare to patients. Yet, increasingly, physicians feel like just a cog in a wheel, replaceable by anyone (including non-physicians) who will take less money. I love nurse practitioners and physician assistants. I genuinely do. I train them and work with them. But no physician should feel like their job and expertise is at risk to someone with 1/5 of the training. NPs and PAs can dramatically help improve the work satisfaction of physicians by allowing them to see patients of higher acuity who would more benefit from their highly specialized training and procedural skills. Physicians need to be involved in every level of decision making in healthcare organizations, and they need to be trusted and not overruled by someone with less or no healthcare experience.

Physicians are the key to the Triple Aim; we are the experts who know how to reduce cost and provide better satisfaction at a lower cost. I described some ideas about routine prenatal care at the beginning of this article that would do just that. But I can’t implement those ideas in a system that penalizes me for it. In fact, many physicians would be fired for even suggesting these sorts of changes.

A lot of people talk about the Quadruple Aim, and most get some critical concepts about it wrong. Let me demonstrate this graphically and make a couple of points.

This fourth aim, improved physician experience, was, indeed, always the missing aim. It is physicians who drive the next two aims: lower cost of care and better patient experience. We know how to do it; we just need to be freed to do so. When those two goals are met, improved population health will result. Some authors and speakers represent ‘better patient experience’ as the ultimate goal, but it shouldn’t be. All of the goals are interrelated, of course; but what we all want is to improve the health of our population. It’s why we spend our tax dollars on it. Another mistake often made is how the Aims are labeled. For example, ‘better patient experience’ is sometimes labeled as ‘better patient health;’ but this wrong. We can’t achieve the Quadruple Aim by thinking on an individual patient level, we must think on a population level. Only by considering the effects on a population, for example, might one realize why it is best not to do yearly pap smears or yearly mammograms.

Lastly, ‘improved physician experience’ is sometimes labeled as ‘improved provider experience.’ Physicians want NPs and PAs and others who deliver healthcare (PTs, RTs, pharmacists, nurses, etc) to all have improved experiences. Everyone in healthcare will have an improved experience if we work towards these aims. But physicians are the key. We have the training and expertise to drive these needed changes and we are the ones who currently have historically high rates of burnout, depression, cynicism, early retirement, and suicide.