Stop Physician Burnout: Is blanket genetic testing the straw that breaks the doctor's back?
Today's sign that the end is near ...
Or the legitimate future of healthcare??
Will the doctors survive to see it through?
One of the reasons for the modern epidemic of physician burnout is the leadership habit of piling more and more and more on the backs of the doctors. We survived residency. We can take almost anything. And even the most well conditioned baby boomer workaholic physician has their limits.
- The thousands of clicks and key strokes of the modern EMR, text messages, emails and other InBox work. Maybe you even deal with 2 or three different EMRs each week.
- The various quality indicators and patient satisfaction requirements, HCAPS, MOC and more
- Dealing with the chaos in the insurance markets and continuous mergers and acquisitions
The default setting for any new task is always, "let the doctors take care of it". No one appears to be asking the Quadruple Aim Question: "What effect will this have on the health and wellbeing of the providers."
I believe we just got a peek at what our collective Last Straw might look like just this week - and it is a sneaky one for sure. This would appear to be a good thing on the surface - good for the patients. And you are going to have to convince me this is not a legitimate Last Straw for the doctors. Ready? Drum roll please ...
This Week the Geisinger healthcare system decided they would provide free DNA sequencing for all patients !!
Sounds good on the surface, right? How generous. How cool. How cutting edge and progressive.
Here is the press release quote:
“The way we look at it, that’s millions of Geisinger family members who no longer have to rely on the law of averages to forecast their health and make plans about their life and how they live it.” Who could argue with that?
Hang on just a minute. Take a breath and put yourself in the doctor's shoes.
You thought patients with Google printouts were bad. Now they are going to look up at you when you walk in the room, lines of worry on their face, WITH THEIR ABNORMAL GENOME IN THEIR HAND. What in the world are you qualified to do next. What will you do or say to this patient?
Are the Geisinger physicians and APP's going to be capable of handling the extra work this initiative entails? The Geisinger MyCode Community Health Initiative is finding treatable abnormalities in 3.5% of people screened so far and estimates 10 - 15% will need counseling and/or intervention because of this new test.
Just how big a Can of Worms will this turn out to be For The Doctors ?
You sit there trying to figure out the difference between genotype and phenotype. You wonder why YOU are being asked to deal with this and why Geisinger didn't hire 100 genetic counselors to handle the incoming questions and take them off the doctor's plates.
BTW, that is the only reasonable way to deal with what is a massive expansion of the scope of medical practice.
Completely new areas of practice demand a new department, staffed with capable consultants. I personally can't imagine dealing with this blowing up my practice day. [If you are experiencing this in your practice, please leave a comment below!]
In their defense, here is what Geisinger is doing for the doctors
"if a mutation is found, the patient will be notified within five days and physicians will take a CME course on the diagnosed disease"
Does that sound adequate to you? Are they monitoring the additional stress on their primary care doctors? Is anyone asking: "What effect will this have on the health and wellbeing of the providers."
On the Geisinger My Code Community Health Initiative website, the procedure is described to the public like this:
"In a small percentage of cases – about 3.5% – we will discover that you have a genetic change that puts you at a higher risk for one of the known genetic conditions which can be medically treated or managed, mostly cancers and cardiovascular risk.
In these cases, this information will be confirmed in a certified clinical laboratory before we inform you and your medical provider about the finding and place the information into your medical record.
If you have a result returned, you will be afforded the opportunity to speak with a member of our genetics team and/or your medical provider about your result."
So my patient comes in with a genetic mutation (genotype) which may never manifest (phenotype) although they are scared to death about the printout they hold in their hand right now. Then I am supposed to take a single CME course on the abnormality - I just have oodles of spare time lying around for that for sure - and THEN WHAT?
And I will need to repeat this 300 times.
That's 15% of the 2000 patient panel of a busy family doctor.
- Is the doctor, with one CME course under their belt, supposed to now effectively counsel this patient if they don't want to talk to a genetic counselor?
- What is the "standard of care"?
- What about the concept of false positives when we know not all genotype abnormalities are actually expressed in real life?
- What about patient satisfaction in a situation where they are mortified and no one can tell them what it means?
- Is this really the best care for the patient? An overwhelmed PCP with a CME course knowledge base, doles out a medicine or referral based on predicted risk from DNA analysis?
- What is the payment mechanism for the genetic analysis and the resulting counseling and treatment? Is it FFS?
- Do we know if a program like this is solvent in a capitated payment environment?
- Are you paying the primary care doctors for these counseling visits?
- What are the wait times to get a visit with my PCP when my genome is flagged?
So many questions.
Is anyone watching out for the doctors in this scenario?
The system could be set up to route each and every patient directly and automatically to a qualified genetic counselor to teach both the doctor and the patient and family what to expect and what to do now. The genetic counselor pool and the My Code team could be staffed up to minimize wait times for a consult. The patient could be given a treatment plan that the doctors simply execute on. It could be designed to put zero additional stress on the doctors. Is that how the program is structured? I have a healthy level of doubt.
Heavens to Murgatroid
If you were waiting for the Last Straw that will break the backs of the poor physicians at Geisinger - this is a really good candidate. This just may qualify as a sign the end is near. Is anyone watching the doctors here?
Or is this a preview of the standard of care of the future?
- Genome on your cord blood
- Treatment plan for all identified abnormalities
- and our work is done ... right?
I just want to make sure the doctors survive to see this future. Someone please tell me this is no big deal.
I sincerely hope Geisinger is monitoring stress and burnout in their physicians and APP's during the roll out as we all adapt to this brave new world of precision medicine. I hope someone, somewhere is indeed asking the Quadruple Aim question: "What effect will this have on the health and wellbeing of the providers?"
PLEASE LEAVE A COMMENT - Especially if you are a Geisinger provider
Is this genomic-medicine-for-all initiative a good thing?
What kinds of conversations can you imagine when an asymptomatic patient with no family history comes in with a genetic abnormality and you are being asked to deal with the situation???