Unveiling Medical Heuristics: Beyond Clicking the Boxes

            I think and feel I have a lot to say about how detrimentally medicine is practiced in our fast-paced business of ours these days. I've seen it in my own career and in many other colleagues' careers too. In this commentary, I'm going to do something I've never done before or at least didn’t think about it on a deeper level. I'm going to pull back the curtain, and, I'm going to show you where we have erred and continue to do so in our daily practices. More specifically, what we have become--Robotic box checkers-- as modern-day clinicians. 

Moreover, why what we or you're doing isn't working as well as you'd like to admit, and what to do instead? I'll show you not one, but 2 root causes where we have unconsciously abdicated our very own thinking selves. As medicine pushes for profits, we too have been pushed to become super “fast thinkers” when providing medical services to the patient community. In many respects, we have become too automated, even protocolized in many instances. Do not misunderstand me, I am not against abiding by following practice or clinical guidelines, or even abiding by organizational protocols. Obviously, they have a role in standardizing medical care. However, be that as it may, be, I feel, we have relinquished our clinical thinking to a robotic mode, or simply to the activity of “checking boxes” in our minds. Luckily, Psychologists have looked into this phenomenon.

Interestingly enough, Cognitive Psychology proves this very clearly. This is when we all practice Medical Heuristics (aka, rules of thumb applied as they say it). Unfortunately, this mindset–although very convenient–oftentimes leads us astray in our medical decision-making activities. Sadly and tragically, this leads us to medically misdiagnose, or delay the appropriate treatment, therefore the increasing plethora of potential medical errors and adverse outcomes we see occurring across the continuum of medical care. See, this is where we are all doing it all WRONG! Not slowing down to pause & think and look beyond the immediacy or even look at the big picture when making clinical decisions in our daily busy practices. In essence and sadly that has become our Achilles heel in many legal instances.

I know to some that statement might come across as a bit sanctimonious. But know this, and rest assured I know this firsthand & better than most. Why? Because I have seen this issue occur over and over. Furthermore, from a different lens than yours: that of a medical-legal consultant perspective. Mostly when I have served as an expert reviewer in alleged PA med-mal claims, but sadly…there it is--the elephant in the middle of the room. Perhaps we should start being more open about this problem.

            However, in the spirit of sharing, I just had to remind you of this. And from a Risk Management perspective, I'm telling you, that knowing this body of knowledge helps mitigate your clinical risks. In other words, this stuff works if you familiarize yourself with these inherent biases (Medical Heuristics) and understand how to consciously sidestep them in your everyday patient encounters, whether it is in the office, ED or urgent care settings, or hospital. At the very least, it's worth taking a few minutes more of your time to see for yourself what I'm talking about when you put these techniques into practice. It will give you a better understanding of the legal landmines lurking in the background. 

Start practicing safely and confidently...don’t take chances by being or becoming an automated provider. Better yet, don't sabotage your own career. Stay present, become an engaged provider, and allow your fast (unconscious) and slow thinking (conscious) to coexist harmoniously when making your final clinical decisions. Your patients will be less inclined to raise any potential medical malpractice claims knowing that you balanced your options before making a rash decision. You owe it to them...you owe it to yourself.

Will I ever get over The Impostor Syndrome?

        As a PA, as you mature and grow professionally you will eventually come to a point where you stop seeking professional validation from your colleagues or supervising physician(s). Moreover, many mid-career or senior PAs can’t recall exactly when this occurred in their career, but suffice it to say that level of clinical comfort comes to fruition around your 3rd or even 5th year of clinical practice--maybe a little sooner or a little bit later. Everyone learns and assimilates differently. Just ask your peers.

        You may still feel like a fraud ( aka The Impostor Syndrome ) even with many years of experience under your belt. In fact, even despite the years of CMEs, conferences, and practice skillset refinement & continual enhancement of your knowledge base, it is not uncommon to still feel that you don't measure up in the eyes of others including yourself.

        But rest assured,  as you grow and continue your professional development in your career journey, you will find out you no longer feel like you're a clinical fraud and know nothing at all! In fact, it will all come together and those insecure professional emotions and self-felt insecurities will vanish away. I have precepted numerous PA students during their second-year rotations over the years. All of my students have gone on and done well and I am proud to call them colleagues. While working with these students for 8-week rotations, I have made great friendships. Many have shared their concerns and uncertainty in their readiness to practice. I have also seen their triumphs and watched many grow in their skills and become great PAs. I have also heard their fears. 

        Eventually, you will realize that little nervousness and apprehension you felt and experienced almost daily immediately post-PA school during your early career while going it "alone” or without any mentoring will come to pass too. This is not to say you will never have your fair share of trying times, or difficult patients, nor toxic colleagues/workplaces,  or changing employers several times early on, etc.

        Remember, as the old saying goes: pace yourself; is not a sprint! I now find myself approaching my retirement after 35 years as a surgical PA. Naturally, I feel more comfortable in many areas of medicine than I ever did before; but truth be told, I still feel like I don’t know enough at times. Why? Because medicine is always evolving at a dizzying pace--we all know that. And among the PAs or physicians who have practiced longer than myself, I am sure they would attest to that or feel the same way.

        So, will you ever get over the Impostor Syndrome? Yes, and no. You might not feel any longer nervous or apprehensive about your knowledge base or skill set; rather, more self-aware of what you need to continue learning, and know that learning is a life-long endeavor. Yet, we must recognize and accept many of us in practice tend to see other experienced providers as “experts” in their careers. And in my view that’s okay! Again, Medicine is too vast to be an expert in everything. A PA wanting to be successful (and sane) knows when to ask for help or where to look for the answers.

      Reflecting back at my career thus far, I have concluded that we never really get over The Impostor Syndrome,  but instead, we slowly can become better providers by self-validating our clinical selves knowing that your “training” to be a PA did not end at graduation. The first several years in practice and thereafter will help mold you into the PA you will become thus giving you your very own and unique PA identity. 

 

The Dark Side of Medicine: Profits... their Bottomline

            In recent years, a new phenomenon known as assembly-line medicine seems to have spread throughout an entire industry in a very short time. But more significantly (IMHO), from what I’ve seen, heard, and/or read this new practice mindset can be one of the biggest root causes leading to the demise of Primary care as a specialty. The complaints, frustrations, and/or disappointments of primary care providers seem to have reached an all-time new-level highs given the massive exodus of healthcare givers into medical/surgical specialties.

            The old nice, relaxed pace of practicing the medicine of years gone by are now just a distant memory for many. Back then student graduates were guided and nurtured. They were transitioned easily into their roles by more senior peers or employing supervising physicians. Today  & sadly, that’s not the case nor the reality of this business; everyone is now required to see a higher number of patients regardless of the acuity listed for that encounter visit.

            The pressure to see increased patient numbers (i.e., 10-minute time slots for patient encounters) has not only strained working relationships but also compromised patient care in so many instances. Moreover, is no surprise why many veteran providers retire early, others simply burn out, and others move on to other specialties and/or careers as well. This new practice mindset is not what many students expected nor were they prepared for during their training. Similarly, this very same situation raises another ugly question: are we sacrificing guided professional development with this fast-paced reality? (a topic of discussion for another time)

            Sure, I realize we live & practice in a different economic world order where “lean” operational practices supposedly enhance work productivity & safeguard the (financial) bottom line. I for one, have nothing against this reasoning or belief, yet what I truly oppose is the element of dehumanization this industry philosophy brings to the patient-provider delicate relationship: a mixed message at its core… if not a conflicting one. Isn’t somewhat hypocritical when we try to come across as a very patient-centric industry but all we truly worry/care is about the “numbers” we can keep up, or dare I say it… profits?  

PAs a new breed of Executive Healthcare Administrators -- Why not?

            Today’s executive healthcare positions require & in many cases demands more than a business background or the ability to speak “financial-ese”. This new industry paradigm requires a well-rounded leader; one who is conversant with both the business and the clinical side of medicine. It’s no longer sufficient to be an accountant or a trustee to provide fiduciary oversight to the executive management team. Above and beyond that, these leaders need to be familiar with the latest trends in the industry, not to mention the sometimes unforeseeable marketplace changes in this day and age. Let’s not forget the perennial mandate of cost containment so critical for any business enterprise's sustainability and survivability as well.

           When it comes to Executive Healthcare Administrators by and large they all seem to have the same calling card—a business background. Yet when chosen, PAs are seldom at the top of the list of candidate consideration. Instead, oftentimes, they [we] are bypassed for other PA-kindred professional members (e.g., MDs/DOs, RNs/RPhs, etc). Not until recently, Healthcare Organizations began diversifying their boardroom makeup. And for all the progress that has been made recently, PAs inclusion into this mix has been nil for the most par

            This new executive leader—a Physician Assistant---would possess a unique different skill-set compared to the traditional ones, he or she would have the right experiential mix combination of business knowledge, inside healthcare experience, and technical managerial or administrative expertise. If recognized and groomed properly, these clinicians could significantly eliminate the day-to-day operational deficiencies of HCOs and leadership myopia.

            Unlike traditional business executives or board members, a few forward-thinking  HCOs realize they can do well and even better with PAs due to their prudent stewardship of limited or scarce healthcare resources. While PAs can be good and excel with detailed minutiae responsibilities, almost all are just as good at seeing the big picture too, since they bring a myriad of intangible benefits to the table. Hopefully, others too will start seeing that maintaining these myopic views only perpetuates the untoward effect of unintended professional shortsightedness that is very real encountered in the C-suite

          After all, we [PAs] know first-hand experience about patient-centered care teams & what it takes to catapult the success of an enterprise as a whole. So why not Physician  Assistants as Executive Healthcare Administrators?

The "Awoke" AMA: Are they Tone Death?

        We are in the midst of a global social reset. Many countries including the US are trying to become more trans-culturally transparent by attempting to discard institutionalized biases & racism from all fronts of the socioeconomic spectrum. Also, along the same vein, corporations and profit and nonprofit companies & organizations have begun to effectively address workplace inequalities while the healthcare industry is trying to eradicate past healthcare inequities as well.

        So given that premise, we’re all embarking on crucial conversations facilitating change with elevated empathy, sensitivity, and awareness of past poor systemic inequalities perpetuated by our so-called/racist systemic myopic biases infringing on minority &/or marginalized groups (i.e. BIPOC/LGTBQ+).

        Inexcusably, multicultural health disparities & access to care have been long overdue. Naturally, removing these stereotyped attitudinal beliefs and offensive cultural behaviors will require a huge concerted effort from all healthcare industry stakeholders. Therefore, putting into practice this fresh perspective will require the AMA to go beyond their lip service to the patient community & us--the PA community as well.

        If they want to be viewed by an industry and society as an honestly vested leading humble organization as alluded to in their newly embraced & revised organizational diversity policies, then they must openly recognize two current fundamental needs of the PA profession/community as a whole; namely:

1. Recognize OTP (Optimum Team Practice )

2. Recognize our new professional designation–Physician Associate

        Anything short of valuing interprofessional differences or seeking ways to grow and embrace their understanding & support of the PA profession would be hypocritical. Thus, failing to collaborate in building an industry culture where nonphysician providers are not empowered to bring their full, authentic selves to the table, nor increase access to healthcare to vulnerable patient communities is not only disrespectful but downright non-inclusive. And worse yet, an openly exclusionary industry stance if not a flagrant discriminatory practice in the eyes of many non-woke physicians/APPs. 

        Utter hypocrisy at its best...how deaf tone can they really be?