HJNO May/Jun 2022

did not dominate the culture of NASA, nor do they dominate my current organization. But, we must first confront the reality of the present while acknowledging the mistakes of the past. CONFRONTING THE REALITY OF THE PRESENT Since we successfully put a man on the moon, the world of healthcare has changed, much of it quite favorably. But with progress comes un- expected challenges. Though many of the epi- demics of the past — like yellow fever, small- pox, and polio — have been conquered, new challenges have replaced them. And although pandemics will continue to recur as they have throughout history, they will evolve and have dif- ferent impacts. In the 1918 influenza pandemic, the demographic that suffered the highest mortality were young, healthy people between the ages of 20 and 30. They died from a hy- peraggressive immune response that induced severe lung injury in the days prior to mechani- cal ventilation. This most recent pandemic tar- geted the weakened immune systems of the elderly and people suffering from chronic con- ditions like obesity and diabetes, which in turn correlated strongly with socioeconomic factors. Once we extended life expectancy by ef- fectively curing or preventing the infections of childhood and young adulthood, people began to live long enough to develop chronic conditions. Diseases of lifestyle and aging have replaced many of the acute illnesses that were so prevalent several decades ago. Obesity, diabetes, high blood pressure, chronic kidney disease, degenerative joint disease, and other chronic conditions now dominate the health- care landscape, requiring vastly different man- agement approaches than acute conditions, and healthcare spending on these chronic conditions makes up a disproportionately high share of medical expenditures. Yet the models for care delivery and the economic models that fund them have remained largely unchanged. Furthermore, the metrics we use to track our progress in healthcare are largely predicated around measures of volume, throughput, and efficiency, reflecting our reliance on the same economic model upon which current finan- cial viability depends. But this reliance on the economic and delivery models of the past have led to the consequences and seemingly insurmountable challenges of the present. Let’s take provider burnout as an example. The 2020 Medscape National Physician Burn- out and Suicide Report reported a burnout rate of about 43%, which is consistent with the 46% reported in 2015. Furthermore, according to the nationwide Future of Healthcare survey, 70% of physicians are unwilling to recommend their chosen profession to their children or oth- er family members. And more than half of phy- sicians say they’re contemplating retirement in a few years, including an alarming number of those younger than 50. These statistics are not just disconcerting, they are heartbreak- ing. Can you imagine not recommending the healthcare profession — this most sacred and noble of professions — where we have the po- tential not only to make a good living, but to engage in meaningful, purpose-driven work every day? Something is dreadfully wrong here. The term “burnout” can be insulting or at the very least may impugn our sense of resil- ience. A better term is “moral injury.” Although first applied during wartime, the moral injury of healthcare is not the offense of killing an- other human in the context of war. It is being unable to provide high-quality care and heal- ing within the context of our profession. Fail- ing to consistently meet patients’ needs has a profound impact on physician well-being, and therein lies the crux of moral injury. I am a primary care physician, which means that I relish creating collaborative, trusting relation- ships with patients. I love the challenge of solving complex clinical problems, of spend- ing time with and listening to patients, and of helping them manage chronic conditions so that they can avoid future problems that might impair their quality or quantity of life. However, in our current healthcare system, primary care has essentially become mission impossible. Primary care physicians manage a “panel” of patients — meaning the number of people who call them “their doctor” — typi- cally averaging around 2500 patients. Stud- ies from over a decade ago put the amount of time necessary to deliver high quality pri- mary care into proper perspective. One study showed that for a panel of 2500 patients, the amount of time necessary to adequately man- age their proportion of chronic conditions would be about 10.6 hours per day. Another study showed that to perform all of the recom- mended preventive health for that same size panel would take 7.4 hours per day. Presum- ably, the remaining 8 hours of that 24-hour day could be spent seeing sick patients. Is it any wonder then, why access to care is a problem or that, despite the best of intentions, experi- ence of care for patients and providers is less than ideal? Morrison and Smith labeled it ham- ster healthcare, citing that doctors “feel like hamsters on a treadmill” ... they are miserable because they have to keep running faster and faster just to stay in place. The typical 15-min- ute office visit afforded by current financing mechanisms for primary care is simply not enough time to sort through the myriad signs, symptoms, and complexity to enable excellent medical decision-making. Is it any surprise that 10 to 15% of patients are reportedly misdiag- nosed, resulting in adverse clinical outcomes 17% of the time? It’s enough to cause moral injury to providers and actual injury to patients! In addition to epidemic rates of provider burnout, people leaving the profession in droves, problems with access to care, variable patient experience, and unacceptably high rates of misdiagnosis, healthcare in the U.S. is also not exactly known for being universally affordable. Indeed, about the only category where the U.S. healthcare system clearly leads the way compared to the rest of the world is that we are the most expensive. The cost of healthcare is a major concern for nearly all Americans, and healthcare costs are the lead- ing cause of bankruptcy, with one study find- ing 66.5% of all bankruptcies tied to medical issues. The exorbitant cost of healthcare might be a price worth paying if we were the high- est performing health system in the world, but there is no objective evidence of that. According to the Commonwealth Fund re- port, “Mirror, Mirror 2021: Reflecting Poorly,” compared to other high-income countries, U.S. health system performance is woefully lacking. Out of the 11 countries featured in the report, we rank last in health outcomes. The report builds upon many prior studies that highlight the discordance between the price we pay for healthcare and the quality of health outcomes we get in return. This relationship between price and outcomes denotes value. Although many healthcare definitions of value exist, I think the best one comes from the co-author of the book “Redefining Healthcare: Creating Value-Based Competition on Results,” Eliza- beth Teisberg, PhD. She defines healthcare value as the health outcomes that matter most to patients divided by the cost of delivering those outcomes across a full cycle of care. We are in desperate need of changes that create value. The good news is that it is pos- HEALTHCARE JOURNAL OF NEW ORLEANS I  MAY / JUN 2022 17