Change doesn’t have to be a bad thing for doctors

Editor’s Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Monya De, MD MPH, who practices internal medicine and integrative medicine in the Los Angeles area. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

A week ago, I received a succinct e-mail from the CEO of the house call startup that employs me. The group message stated that some doctors had been having problems with patient information not being loaded into the electronic health record (EHR) software at the time of the visit. 

Monya De, MD, MPH"Solution,” wrote the CEO, "we're switching our EHR system."

What a difference Silicon Beach makes--and what a lesson it teaches. In many of my previous hospitals and clinics, the administration seemed hopelessly chained to inefficient, doctor-unfriendly EHR systems.

Who is ruining the healthcare system?

Doctors and nurses would complain on a daily basis, but the damage had been done. The holder of the purse strings had dropped some serious cash on the Apple Newton of medical data entry, and we were stuck with it. The worst offender was my medical school. The medical order entry system had a convincingly 1980s DOS-like appearance and interface. But in a startup world, with Mark Zuckerberg telling us to move fast and break things, stultifying technology just won't do. 

Reexamining the 80-hour medical resident workweek

Of course, I had a tiny, instinctive twinge when I read her e-mail (I just memorized my password! I already made templates in the old EHR!), but it dissolved quickly. I admired her completely unemotional decision-making. Sorry, old sales rep. Deal with the change, and doctors and nurses, you'll get over it. Granted, our old EHR was free, but I believe she would have done it even if it wasn’t. 

Change is usually good, and change can save a medical institution, no matter how big or small. 

But the decision to make a change in practice management or logistics isn't always straightforward, particularly for doctors.

Next: New guidelines don't have to be the end of the world

Doctors spend seven to 10 years getting rewarded for doing things just like their superiors do. The adage of medical learning is. "see one, do one, teach one", not, "see one, do one, hack it and make it better."

Even when new medical guidelines are issued that should trigger immediate change in how doctors practice, doctors can be slow to adapt. How many pediatricians "finally got around to" ordering and administering the HPV vaccine? 

MOC, recertifications are ‘cancers’ doctors should rally against

Administrators and practice-owning doctors alike have a bottom line to worry about, and must worry about the costs; fixed costs like training employees to use new software, or variable costs like the possible failure of a new risk, like investing in a medspa attached to the office. 

Cultural norms can sometimes stymie institutions. There's even sociological theory to explain it: the slow-to-change, mired-in-tradition medical school conjures up institutionalism. The nurse has been here for so many years, we forgive her rude behavior. The ordering system is what administration ordered, so we keep it.

A cost-benefit analysis can help make such decisions. One family physician I know actually hired a management consultant to go over her financials, after years of ignoring the consultancy's solicitations via fax. 

The consultant found that she would make more money if she kept only full-time physicians at her practice, as opposed to her multiple independent contractors--even accounting for the added expenses of paying employee taxes. The objective outsider helped her to feel confident in her decision to change her practice. 

Why are we wasting money on healthcare with poor outcomes?

In changes that result in negative consequences, a retroactive cost-benefit analysis can help to illustrate the reasons for those consequences. For example, when the United Kingdom's National Health Service put medical residents under the rules of the European Working Time initiative, an effort to restrict shift lengths for workers to allow time for rest, no one accounted for the consequences to attending doctors' time with students and residents. A report concluded that teaching had suffered as a result.

Next: Throw out 'the way we've always done it'

That doesn't mean that the change was inherently bad. A full analysis prior to the change could have raised the issue of teaching time. The hospitals could have planned for the attending doctors to create video lectures of clinical cases, for example, to simulate the experience of teaching at the bedside. The change itself (giving young doctors more time to sleep) was inherently good; the hospitals just needed a workaround. 

Young doctors are jumping ship to non-clinical roles

What if a practice hesitates to change because of potential discord among employees? In my experience, change at any workplace-be it a department store, hospital, or bank-meets resistance and indignant yowling from employees used to another way, unless it's a pure benefit with no learning curve or downside, like free food.

But employees are resilient and can bounce back. In the case of the startup's decision to "break things," the CEO determined that the temporary pain and costs associated with training employees on a new system paled in comparison to greater future doctor and patient satisfaction with a smoother EHR experience. 

The experiment may fail. Everything carries risk. But, by employing rational choice over just going with "the way we've always done it," the practice stands a chance to grow and improve.