Wednesday, April 4, 2012

Measuring Work

The Crush
I aim to bear my burdens gracefully, but I do fall short particularly when it comes to watching my husband working himself to death. Bearing witness to a crushing workload on another person is distressing.

My husband on average leaves home at seven in the morning and returns at ten in the evening sometimes earlier and more often, later. There is no time for dinner together, no time to help our children with reading in English or piano, no time for friends or hobbies. The long hours instead sap his health and deprive him of essential downtime. We each do what we must. My husband feels he has no choice but to work and work and work. The work never stops. The need is great.

Japanese friends have expressed concern that my husband has so much work, interpreting that there must be many sick American children sent by the military to Japan. It is more complicated than this because there is not an equivalent type of care or assessment available in Japan- there are few enough physicians trained to work in mental health with children even in the States. Meanwhile the Japanese answer to some of the garden variety behavioral problems in children is simply that they do not exist- except that my children regale me with tales of children wearing trash cans and entertaining classmates with interruptions and pranks that to perhaps a more trained eye speak volumes on children adrift.

Help is Available
For families that realize that there is help available, they come. Being helpful means, people come, but the helpful help is not so quick or easy to formulate. The way that health care administrative processes review and determine workloads rewards initial visits and office visits and not the process often needed over time.

According to statistics, which no one can clearly explain how they are derived, my husband, despite his monster hours, numerous phone consults, hand holding sessions, and administrative responsibilities, is only working part-time on the admin guru scale. This shortchanges not just him but patients and families as well. It begs the question is your health care best determined by you and your needs with a doctor or an administrative process in an office years before you ever know you have a medical need?

In mental health there can be a fairly long assessment and interview process that requires a detailed write up and then there are ongoing visits and adjustments for medications and treatments. Some of which can be done over the phone particularly when there are long travel distances involved for patients and families except that this penalizes the physician. This patient centered focus doesn't jibe well with the "in and out" and only "one problem at a time" insurance processes which guide both civilian and military medical care.

Mental health write ups take time from collecting the information, to listening to a family and a patient, to reviewing the problems, to doing the actual writing and insuring diagnosis are supported appropriately. Then there is ongoing follow up and consultation such as talking with the schools, families, and patient except that in the administrative world of health care this isn't important- at least in terms of how the physician is encouraged to act by the number of beans put into his doing good pile.

It would help if he didn't care, didn't help, and told everyone to come in for an appointment- meaning no help over the phone- since it takes patients months and months to get an appointment, but he doesn't. He just doesn't eat dinner with us, or have time to himself, or make time for friends, instead he wears himself out working halftime, twiddling his thumbs, and doing all of the things that aren't rewarded in the system. He tends to notice what is and is not helpful to the particular person in front of him.

Those civilian healthcare models that the military strives to emulate usually include staff that are seasoned; stay in the same department and roles over long periods of time; and have support staff that are specialized and dedicated to their area; whereas the military pulls people away for training; shuffles staff constantly; or just lets you do the job of seven people. Someone is sure to stop by and tell you to come to a meeting where they can give you a pep talk and tell you about your numbers too. They are two different sports trying to play by the same rules.

The Impact
Yes, I'm flawed, frustrated, and through, but I have also noticed that when patients or their families do approach me it is to tell me things like, "Your husband is the most wonderful...." His unbearable workload appears to be helpful to patients. The system doesn't care what is happening to him and so it goes on. But me? I'm standing on the sideline witnessing an atrocity, a waste, and I can't keep my mouth shut, but before you dismiss my plight, this is bigger than one doc.

Consider the impact of valuing numbers, widgets, and budgets. The system is promoting care that is responsive not to patients but to metrics. Few providers have the stamina to oppose the flow of bureaucracy. What is measured and how it is measured matters to every single one of us. Plenty of providers look perfect on paper, but annoy patients to no end for not listening, not taking calls, and not taking time to assess more than one problem at a time.

You get what is measured and there is a whole lot of humanity missing from the cup of healthcare metrics being served today.

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