How to Treat Compassion Fatigue

Like the oxygen masks on an airplane,  you put your mask on first

 Bryan Mingle  /  Rise Health Contributing Blogger

One of my favorite modules in a year-long classroom certification program for Alcohol and Drug Counseling addressed "burnout." The instructor, who was at the top of her license in Orange County, Calif., treatment centers overseeing SAMHSA services, told the future counselors that it was the No. 1 enemy for the new and the experienced. 
 While many jobs and professions bring on burnout, health-care fields involving contact with patients carry the highest risks -- and the lowest tolerance. Can you imagine being a frightened patient in need of empathy and an even-keeled delivery and facing a doctor whose manner and energy said "shell-shot."
Luckily, burnout precautions and preventative plans often are provided for counselors, nurses, physicians and other providers in health-care settings. But not always.  
  I learned during  my first year as a chemical dependency counselor in a chaotic detox unit in Jacksonville, Fla.  that the greatest teacher is experience itself.  In other words, the old adage of no pain, no change, proved very true.
While self-care was reviewed during evaluations by my supervisors, practicing it when 12-hour days were piling up was a challenge and a reality that myself and  fellow social workers knew too well. I had one or two role models where I worked, but for the most part staffers around me were drowning in work and documentation of that work. At some point, the return on such workaholism showed up negatively. I'll never forget one evening, after several days in a row of  12-hour shifts, I was scouring the nurses station for a missing chart and one of my patients, watching and waiting in his nearby med line, shouted out: "Bryan, are you OK? You look like you really need a drink." Good insight.
Other therapists and I began to engage in "process sessions" on van rides to the parking lot before and after our shifts, or during gobble-down lunches on a picnic table roped off from the milieu. We vented about work. About patients. We basically had big complaint sessions, which, as it turns out, is one of the top tell-tale signs of  compassion fatigue and burnout.
Real patient-centered care mandates that the providers walk their talk and center some care around their own lives. I left the detox unit after a year and began working at Rise Health in a practice support center that was a virtual extension of primary care practices for a safety-net hospital in Boston.
Call volume was high from the start,  and many of the patients on the other end of the phone had a low tolerance for frustration and were demanding of their needs. What I learned as a counselor applied to all of our patients on the other end of the phone at Rise: Offer unconditional positive regard and genuine empathy; do no harm. Listen, reflect back and offer options/solutions.
To do that on a consistent basis requires the self-care that my instructor in California relentlessly taught about.
Today I came across a column and a web site that are echoes of my concerned teacher, who frequently told  us that she wanted each of us to be the counselor who would treat her daughter the same way we would our own family member. I am publishing it here to remind myself and others in the health-care field about a very basic component of any treatment plan: self-care. If you never leave the basics, you don't have to return to them.

Cynicism and sarcasm are among the first signs of burnout

Physician Burnout and Physician Stress – Find Solutions Now

Patients Are Our Best Teachers

by Michael Kirsch, MD | in Physician

There are some patients we doctors never forget. They linger in our memories for various reasons. Often, it is their serious or unusual medical condition that stays with us. On other occasions, it is a zany or unique personality that we recall, even years later. Rarely, when the doctor-patient relationship becomes injured, then the patient may become unforgettable.
I remember a particular patient from 20 years ago for a very different reason. I recall him clearly because he rejected my medical advice to him with aplomb. Although I haven’t seen him for two decades, I will never forget him. He taught me a lesson, which is not surprising since patients are our best teachers. There are no CME credits for these lessons, but I’ve learned more from them than I have at many medical conferences or from medical journals.
It was July 1991, a month after I completed my fellowship in gastroenterology. I had jointed a multispecialty group, and I was the only gastroenterologist in this particular site of the clinic. There was no senior gastroenterologist to supervise me. What a comfort it was during fellowship training to have seasoned clinicians nod affirmatively to my diagnostic plan, or point out what I overlooked. To this day, I wish I had one of these master clinicians sitting quietly in the back corner of my exam rooms to mentor me. In July 1991, I was now responsible for my own advice. Despite excellent training, I was anxious that it was my finger on the trigger.
I performed a screening colonoscopy on this man and discovered a large, flat lesion in the upper part of the large intestine. A biopsy indicated that this was a pre-cancerous polyp, although it was possible that there was cancer present that was not sampled by my biopsy instrument. (Biopsies only obtain tiny pieces of tissue, which may not be representative of the entire lesion. Physicians call this phenomenon sampling error.)
This concerning lesion could not be removed with the scope, so I recommended that he consult with a surgeon to discuss an operation. He listened and calmly declined my advice. More accurately, he offered a conditional decline. He stated that he would see the surgeon, but not until 4 months had passed. This was unexpected as most patients want their surgeries to occur yesterday. The patient made clear that there was no earthly force that would alter his decision. This mystery entered the theater of the absurd when I learned his reason for the delay. Here are some choices. Take your best guess.

• He and his family were about to leave on a 4 month cruise.
• November was his lucky month and he wanted surgery then.
• It was golf season, which was sacred.
• His medical insurance coverage would become active November 1st.
• He intended to travel to Mexico for alternative medical care.

I surmise that most readers did not select the correct answer. This man was a golf fanatic, and even the possibility that he harbored a colon cancer, would not coax him off the fairways. Interesting priorities. We physicians need to remind ourselves that patients make the decisions, even though we often believe that we have the right answers.
The denouement? Months later, he underwent surgery and a large benign lesion was removed. I think I was more relieved than he was.
If this guy’s appendix or gallbladder were to go bad, I hope it happens during wintertime. Surgery can occur in any season. But, golf …
Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

There Will Not Be a Test

... but there will be risk-rewards




How does an ACO make health care more patient-centered?
How does an ACO provide health-care services that are more effective?
How does an ACO encourage providers to start to address health rather than just sickness?


This blog hopes to explore these questions and more by publishing the writings of health-care professionals and thought leaders who possess valuable insight into the future of their industry. These insights are largely developed through the authors' past experiences.
Here is a collection of thoughts by Dr. Ben Miller, who holds a doctorate in clinical psychology and is an assistant professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine, where he is the Director of the Office of Integrated Health-Care Research and Policy. His "Looking at What's to Come: Accountable Care Organizations" blog entry first appeared in  Occupy Healthcare.
Accountable Care Organizations (ACO) take up only seven pages of the massive new health law, yet have become one hot topic in health-care circles. What are ACOs and what implications do they have on the community?
Well first, let’s define an ACO:
Accountable Care Organizations are partnerships between health-care providers designed to be accountable for the quality and cost of the health care they provide in return for financial incentives. How these partnerships are implemented may vary, with some focused purely on primary care, while others include sub-specialists and hospitals. In all cases, primary care is expected to form the core of these organizations, the center of the wheel, and base for the ACO.
As we have discussed before on this blog, primary care is so central to many health redesign efforts because it can help the system attain the triple aim (improve health-care quality and patient experience, as well as reduce overall health-care costs).
The promotion of ACOs is an exciting and innovative aspect of the Patient Protection and Affordable Care Act (PPACA). However, as with many things in health care, the devil is in the details. Much of the benefit and potential benefit for ACOs be found primarily through the Medicare Shared Savings Program (MSSP). MSSP is described in proposed regulations published by the Centers for Medicare & Medicaid Services (CMS) on April 7, 2011; however, the influence of the ACO regulations on the nation’s health system will extend beyond the MSSP.
ACOs are risk-bearing entities and require capitalization. To this end, hospitals and other health-care professionals like physician groups are partnering with insurers and company ventures associated with insurers (e.g., Rise Health, www.risehealth.com)  to form these entities. The partnerships that participate in the MSSP will likely cross over into commercial plans, and Medicare will not be the only health insurer to benefit from the cost reductions realized by ACOs.
There appear to be some interesting opportunities within ACOs to deliver unique health-care innovation. It is important, as with most health-care initiatives, that the community be aware of what is happening at a macro level in order to be best informed on how to engage their health-care community. While ACOs can be confusing, the better we as a community understand the opportunities and implications, the more likely we are to have our voice heard. After all, someone outside of CMS is also going to need to say if this is working or not.
And of course, with any effort to change how health care is delivered, we must examine the payment mechanism.
There are three financial incentives models for ACOs: shared savings, savings bonus plus penalty, and capitation. Each of these tiers are characterized by increasing risk and benefit while decreasing the system and provider’s dependence on fee for service and with capitation, ultimately eliminated. This is a major step for health care as we can start to move away from fee for service.
Shared savings allows for organizations to receive a portion of the amount saved compared to predicted costs in addition to regular fee for service payments.
The savings bonus plus penalty model is similar to the shared savings model, with the addition that the organization must take responsibility for any excesses in spending, therefore increasing risk and potential reward.
What’s potentially very exciting is what happens when these savings are shared back into the community? Many interesting opportunities may unfold at this juncture, but how this will play out remains to be seen.
Dr. Miller has his doctorate in clinical psychology and is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Health-Care Research and Policy. His core task is to integrate mental health across all three of the department’s core mission areas: clinical, education, and research. Opinions expressed here are his own and not those of his employer.

Rise Health CIO Wins Top Leadership Award

Custom Web application creates business value

 

SearchCIO-Midmarket.com recently spoke with Nicole Bradberry (pictured at right),  Chief Information Officer at Rise Health Inc., a Jacksonville, Fla., services company that serves primary health care provider practices. She led the effort to build a custom Web application -- the Patient Relationship Manager -- that Rise Health employees use to handle intake and aftercare procedures for primary care physicians. It reduces unnecessary patient visits and health care costs by centralizing data from multiple sources.  Bradberry won SearchCIO-Midmarket.com's  2012 IT Leadership Award, selected from a pool of 40 IT leaders.

In this interview, Bradberry shares her take on technology innovation, the changing role of the CIO and the ways the Patient Relationship Manager application creates value for her business and for customers.

SearchCIO.com: What technology or technologies are changing the way your business is run or how it serves customers?
Bradberry: Technology and health care are coming together like never before. Right now in the health care space you've got meaningful use, you've got all the mandates coming with health reform. So, everyone out there is trying to figure out how to get an EMR [electronic medical record system] in every physician's office to get rid of all the paper in hospital systems. How do you connect all the hospitals to the physicians, the primary care specialists, labs and pharmacies? That's what's really going on right now in health care. I think you'll see in the next few years amazing strides that have never been seen before in health care, because health care has really kind of lagged behind the rest of the world as far as using technology.

Can you give me an example of how a technology created value for Rise Health or its customers?
Bradberry: Rise Health is an early-stage company. We formed in mid-2009. The project I've been working on is really to build the entire technology platform--either buy or license some of the needed software -- and most of the time was spent on building what we call the Patient Relationship Manager. A Web-based, sits-in-the-cloud application that we think is pretty darn innovative and answers a lot of the problems that are in health care today, as far as how you make data very actionable when the patient is sitting in the office with the physician.

As a finalist for the SearchCIO-Midmarket.com 2012 IT Leadership Awards, how do you see the leadership role of the CIO changing in coming years, and what do you think is influencing these changes?
Bradberry: I think I'm an example of that change, because I'm not the traditional technologist of old, the guys who came up building servers and building data rooms. The CIOs of today are really part of the business. They're part of the team that sets the strategy for the company; and technology is an enablement of the business model of the company, so I think that's what the new CIO looks like.

Is that akin to your leadership style, or what is your leadership style?
Bradberry: I'm a designer, so I spend a lot of time with the designers in front of a whiteboard, and I let them go do the work. Here's the vision, you understand the business processes, and we spend a lot of time talking about the business processes; and then they go and build and come back. I expect really well-thought-through deliverables, whether it's the up-front design, or the development of the code or the testing; and they present back. I give my feedback, but I'm not really a micromanager. I'm more of that whiteboard-design-up-front leader that really talks about the business and what we're trying to accomplish.

As technology innovation has become a mainstay of many of the tools used in business, has the role of the CIO in driving innovation in a company changed?
Bradberry: The CIO traditionally has been more of an order-taker. This is what the business needs, and I'm going to say I can do it or not. I think the CIO is now part of that executive leadership team and hopefully is the person who says this technology is what we need to expand either our market presence, or our capabilities or efficiency and use innovation when you need it. You don't innovate just to innovate. You use it when it is really needed to expand what you're trying to sell and what your business is all about.