Disclosure of Financial Relationships. Why Am I So Unhappy? Jeff Wiese, MD, FACP, MHM Professor of Medicine Tulane University Health Sciences Center

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1 Disclosure of Financial Relationships Why Am I So Unhappy? Jeff Wiese, MD, FACP, MHM Professor of Medicine Tulane University Health Sciences Center

2 The Story of Us Hospitalists vs Gen Internists Length of Stay -0.4 days Costs -$268 Same mortality Same re-admit rate

3 The Story of Us. Value= Quality Cost Quality and Patient Safety Quality: Patients receive the highest standard of care such that expected outcomes are routinely achieved. Patient Safety: Adverse consequences of diagnostic and therapeutic interventions, including medical errors, are avoided.

4 The Story of Us. Value= Quality Value= Quality Cost Cost The Story of Us. Value= Quality Value= Quality Value= Quality Cost Cost Cost

5 1. Hospital Value-based Purchasing 2. Physician Quality Reporting Initiative (PQRI) 3. Expansion of Physician Feedback Program (Resource Use) 4. Value-Based Modifier for Physician Payment Formula 5. Reducing Hospital Acquired Conditions 6. Improving Quality 7. Accountable Care Organizations 8. CMS Payment Innovation Center 9. National Pilot Program on Bundling Acute &Post Acute Payments 10. Readmissions 11. Community Care Transitions Program 12. Medicare Physician Payment Update (SGR) 13. Medical Liability Reform 14. Provider Screening 15. Provider Compliance and Penalties (High Risk Referrals) 16. Primary Care Bonus Payment Money= Happiness= Motivation= Effectiveness But are we happier?. And does that matter?

6 Retention & Sustainability Happiness Time Not Happiness

7 Does Money Buy Happiness? Yes Don t have the possession Time Acquire the possession Don t have the possession Time

8 Acquire the possession Don t have the possession Time Worried about the possession Acquire the possession Don t have the possession Storage Shed Time Worried about the possession Acquire the possession Don t have the possession Storage Shed Don t have the next object Time Worried about the possession

9 Matching Incentives Financial Goal Financial Incentive Increase revenue Bonus payment Social Goal Social Incentive Improve teamwork Awards & recognition.. Moral Goal Self-Incentive Patient care Internal drive

10 Finite and Infinite Games Finite Games Defined beginning and end There are defined roles Players are abstractions of themselves What is not explicitly prohibited, is implicitly allowed The goal is to win the game (by any means possible). The value of any action is measured solely by its utility in winning the game. No one who must play, can play Examples of Finite Games - Football games - Semesters in college - Blocks in 1st/2nd year medical school - Clerkships in 3rd/4th year medical school - Rotations in residency - Shifts or night-float assignments

11 Finite Games Infinite Games -Defined beginning and end There is no end -Players are abstractions of themselves Players are themselves -The goal is to exclude other The goal is to recruit new players players -The goal is to win the game The goal is to keep playing - An action has utility only to the An action utility has value in extent that the help you win the it s own right game Examples of Infinite Games - Sportsmanship - Friendship - Cross-specialty colleagues - Spending extra time with patients/teaching when you are measured by RVU s - Doing a talk like this There is nothing wrong with Finite Games

12 Risks of Finite Games to Patient Safety There are defined roles Players are abstractions of themselves What is not explicitly prohibited, is implicitly allowed The goal is to win the game (by any means possible). The value of any action is measured solely by its utility in winning the game. Wachter R, et al., Ann Intern Med. 2008;149: Why Finite Games Make You Unhappy - Is this going to be on the exam? - Why are my medical student always leaving early? - Why do the residents not want to be taught at the bedside? - Why have my third-year residents checked out. - Why can t I get CT surgery to operate on my patients?

13 Risks of Finite Games With Respect to Happiness - Extra time with patients/students/colleagues is a penalty in the RVU finite game. The game discourages interpersonal connectivity. - Because people are playing roles. - Truly professing who they are in their work is impaired. - Sincerely engaging in interpersonal relationships with others is impaired - Expressing pride/mastery in work is impaired, since there is no incentive past merely fulfilling the role. - Given enough time, the soul atrophies to the role. - The finite game might even incentivize burning down a relationship Leadership s Accountability Systems drive function. Every system is perfectly designed to produce the results that it does. The definition of a bad system is that it puts good people in bad positions. Everyone is trying as hard as they can, and if they are not, it s because the system has brought them to their knees. Re-Frame Everything into Infinite Games Get people to acknowledge their finite games, and to see them as such. Acknowledge that you do have to win the finite games, lest you cease to play Acknowledge that finite games can come at the expense of the infinite game. The two must be balanced, lest performance comes at the expense of happiness and eventually, burnout. Sacrificing the finite game for the infinite game is not sellingout the finite game it s sacrificing productivity to ensure production capacity.

14 Re-Frame Everything into Infinite Games Get people to see past their finite games... Force people to identify names vs roles Ask questions to force people to see patients as people outside of their illness. Obey the laws of group dynamics to optimize covalency Create opportunities for people to interact outside of work Re-Frame Everything into Infinite Games Get people to see past their finite games... Couch feedback with a distant focal point. Emphasize education over training. Make assignments for growth vs. filling positions. Interpret the CV as a curriculum vitae (not a resume) Remind them, No one who must play, can play.

15 Intensity, Bandwidth & Burnout

16 Burnout: Work out of proportion to fulfillment 1. Frenetic/Stress/Lack of Control 2. Intensity/Exhaustion/Work load 3. Boredom Before the Work Hours After the Work Hours

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20 Time Thanatos

21 Time