Wednesday, July 13, 2016


You might wonder what this is about. And I, for starting this have a bit of concern too. But this is a story not about the author, Nathaniel Hawthorne of the House of Seven Gables, nor is it about the City in New York. It is about an effect.

Effect, you say, what about it? Actually it is a fascinating insight into the human condition. Let me trace it back to its origins. A town named Cicero in the Chicago burbs, housed a manufacturing plant called Hawthorne Works. 

The Illinois City named after the one in New York, which was named after the Roman statesman Marcus Tullius Cicero . Both the city and the Roman it was named after suffered; the city lost 5/6th of its land due to weak politicians and its manufacturing status and Cicero’s head and hands were displayed in the Rome’s Forum after his assassination for angering Julius Caesar (34 BC).

Hawthorne Works enjoyed prosperity in the early 20th century and there is where it was determined that when observation and positive interest is shown in a worker’s work, productivity goes up and vice versa. Meanwhile the display of Cicero’s body parts in the Roman Forum were of equal force preventing any further threat against Mark Antony’s reign -  a negative feedback. Funny how the ghosts in names play out the future with equal measure gained from their history.

The Hawthorne Effect has been written about and “studies” done on hand washing among physicians and nurses in an effect to reduce the potential for spreading infections. The reality goes this way…if one is being observed to do a job, one is psychologically forced to comply. Thus the rate of hand washing among the observed goes up against the unobserved. It might be called oversight in another document, but in the Hawthorne effect the simple act of observation even via cameras or other digital means conspires to inspire an individual to take action. All well and good. Good actions beget good results.

Extrapolating from this act of “observation” as an “observational interest” and giving that “interest” some term such as “value” might have an identical effect, if not profound, at least above the zero mark in a person’s productivity? Again, don't take this to the bank, because where I am going with this is a hotbed of molten lava created from fire and brimstone. You fall in, you are done! So look, Learn and Understand!

“Moon walking” back to the premise of interest and productivity we find that if an employee feels his worth by the company, he or she tries harder. The idea behind that is simple incentive, create value for the company and be rewarded with promotions and higher salary.

You with me so far? Ok, so what gives in the environment of Medical care then?

Physicians are “burnt out!” Indeed, more and more reports seem to not only suggest, but also correlate that with higher rates of suicides by physicians. The metaphor of “losing a jumbo jet filled with physicians every year.” Or if you prefer, “Losing an “entire year’s worth of medical graduates from medical school” every year. Disabling thought, isn't it?
And you must ask why? Ah there in that three lettered word is the essence of science. 

Why, indeed?

Let me posit a simpler solution; maybe in medicine, there is a negative Hawthorne Effect. with no cheerleaders for the once noble profession, only grim reapers always crying, "foul!" Maybe, physicians are being railed against in the media 365/24/7 and characterized as bad actors. So if you are a physician and work the 12 hour weary days and find the profession maligned on the television and media when you sit down at the table for dinner, something’s got to go "kerplunk!" The negative Hawthorne Effect comes to play - remember Cicero’s head and hands on display as deterrence? When every observation is a negative event, work becomes a chore, the shoulders get slumped, the days get longer, the work becomes weary, soon depressing thoughts arrive, unannounced, the devolving gyre tightens and finally the mind cannot hold.

But don't take me wrong on this, the powers that be seem to have absolutely NO interest in the Medical care of the patients, it seems. The powers that be have an interest in their own interests. For instance, The Insurers are interested in making higher and higher profits (the average Healthcare company CEO salary in 2014 was $11.7 million) and they blame the claims from the physicians and make them go through hoops of the medical Revenue Cycle to collect their reimbursement on behalf of the work completed. The government has an inverse viewpoint; to lower the costs of healthcare as a percentage of GDP (currently 17% of the GDP) and they too blame the physicians as the drivers. To that effect they have the annual CMS “Data Dumps” showing what physicians have received in payments (BTW: in 2012 out of $1.2 Trillion only $70 Billion went to pay the 850,000 physicians that translates to 5.8% of total). They also have a “Sunshine Act” displaying any gifts from pharmaceutical agencies to physicians; citing that $10 lunches invoke a severe Conflict of Interest in prescribing medications. Then there are quasi, not for profit agencies that have their hand in the pot like the ABIM, ABMS (claiming public interest as their only mantra while fleecing the physicians in millions of dollars - NAV as of 2014: $134 million), PWRS, PCORI (Reporting agencies that create pseudo-science on the go to determine efficacy of care) and other shenanigans like SGR, MACRA, MIP, APM (designed to create and maintain an ever-ascending vertical bureaucracy that deems who and how payments are to be made for service rendered). The list goes on...

You still with me?

Consider this; The physician is now a "data logger," a well-educated scribe so to speak, on the computer (EHR) and the computer spits out (based on an algorithm) a defined set of tests to order for compliance. All this cataloging is nothing more than information gleaned by and for other companies to sell data for analysis to insurers and governmental agencies to better control expenses in some cases, raise revenues in others and further the interests of all involved in their Net Asset Values. For instance CERNER an EHR computer company, for the year 2014, revenues were up 16.9% to $3.4 billion from $2.9 billion in 2013. Net income for the 2014 fourth quarter jumped 146% to $147.9 million, up from $60.1 million in the 2013 third quarter. Hmm… Judgment and Reason, need not apply when it comes to patient care anymore. Its about dollars and cents and a large public pot for any company to pull out oodles and oodles of cash. In this “One size fits all,“ for better or worse, EHR world, the actual “fit” is immaterial. So what if the helm shows, the shoulders sag on the jacket, the stitching is subpar. So what? And it will all get worse, I predict, because the non-practicing physicians who have taken on the mantle of “experts” have decided that programs such as “Choosing Wisely” and “Less is More” need to be the bully-pulpit from where to scream down into the trenches, “Do this and Not that, or else…” 

There is a pathological obsession in replicating an idea that is profoundly destabilizing and will ricochet through humanity transecting the tether that binds us all as humans. Ah "disruption" they cry and all fall down to their knees in unison to the lure of the ethereal enriching beast. The capacity to think of the whole and not always the parts in isolation can bring to view the unintended consequences; those things that go "crunch" in the long winter nights are never a part of their thought.

The Mocking Jay

So while this rant appears like a rant and maybe is, it does have the potential of the sound of a “Mocking Jay.” As the people realize what the future holds for them a band of brothers and sisters will finally say, “I’m mad as hell and I’m not going to take this anymore!” The physicians might lead on this and then as care is depleted and noticed, the rest of us will follow suit.

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