- Email: [email protected]
Path to leadership in medicine: Advocacy and evidence-based medicine
G Model JOGOH 101680 No. of Pages 3
Journal of Gynecology Obstetrics and Human Reproduction xxx (2019) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Editorial
Path to leadership in medicine: Advocacy and evidence-based medicine$ A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 December 2019 Available online xxx
Physicians are experiencing overwhelming demands to generate revenue and complete ever-increasing administrative tasks. Whether employed by large health systems, academic centers or still struggling in small private practices, the autonomy so valued by medical professionals, and our ability to influence policies impacting our patients and the public, has diminished. In order to regain the joy in practicing medicine and overcome the sense of “burn-out” and frustration so many of us experience, it is essential to dedicate ourselves to becoming leaders in our communities, in our institutions and in our medical schools. We must apply the triad of evidence-based medicine – the data derived from randomized clinical trials, our learned experience, and our patients’ values – to become leaders in the path towards reasoned public policy and institutional procedures that improve the care for individual patients and the community. Through advocacy and leadership, we can re-engage with the passion that drove us to our profession and renew our commitment to the patients we serve. The energy and time required for these activities will be more than repaid with joy and passion in our daily work and a sense of purpose in our lives. © 2020 Published by Elsevier Masson SAS.
Keywords: Professionalism Evidence-based medicine Advocacy Leadership Burn-out
Professionals generally have degrees of “freedom to exercise their independent, professional judgment,” with “a high degree of control over their own affairs.” All professions have privileged status used to influence the conduct of their own members, as well as “exercise a dominating influence over the entire field . . . .” A profession is characterized by the power and high prestige it has in society. It is the power, prestige and value that society confers upon a profession that more clearly defines it. Physicians have long been revered in society as a profession centered not only on the art and science of medicine but on the health and well-being of society at large. Our task has been to focus on the patient before us, while our status depended upon engagement and trust within our communities. A cornerstone of the esteem we enjoyed was the notion that we took responsibility for ensuring that our conduct was in the best interest of the patient. We stand up for doing “what’s right” independent of payment for our services. A series of changes in the delivery of health (or illness) care in the US and abroad have accumulated to threaten the role physicians have traditionally played in consistently working to relieve suffering and improve the health of our patients. We are losing our status as champions for public health and our ability to drive changes that result in benefit to our patients and the public. Many of these changes are the result of unintended consequences
$
Presented at the AAGL annual meeting, November 2019, Vancouver BC.
related to the high cost of care and the desire to “modernize” health care delivery. The corporatization of medicine has stripped physicians of our revered and powerful status. We can and we must regain leadership positions and the skills and voices necessary to drive better quality; safer care at lower cost. The grueling path to becoming a physician, coupled with the increased demands for “through put” and the requirement for standardized documentation are driving many physicians towards an apathetic state where we struggle to get through the day and accomplish all the tasks required of us. Efforts to drive revenue have resulted in a series of check boxes and burdensome tasks; there is decreased autonomy in medical decision-making and a sense that we are simply mechanics going through the motions. Over the past 25 years these changes have occurred insidiously, sneaking up on many physicians. Focus on getting through the day and a reluctance to take on additional responsibilities, as well as a general lack of training in the “business” of medicine have diminished our position within the hospital and health system structure. C-Suite executives find it easy to ignore our input. It is imperative that we regain our focus on the patient; renew our commitment to serving the needs of the people we care for; and back away from the optimization of corporate profit in the health system. We must regain our role as serving leaders who drive our systems to create high standards of performance, remove obstacles to success and encourage every member of the health care team to contribute what they do best.
http://dx.doi.org/10.1016/j.jogoh.2020.101680 2468-7847/© 2020 Published by Elsevier Masson SAS.
Please cite this article in press as: B. Levy, Path to leadership in medicine: Advocacy and evidence-based medicine, J Gynecol Obstet Hum Reprod (2020), https://doi.org/10.1016/j.jogoh.2020.101680
G Model JOGOH 101680 No. of Pages 3
2
B. Levy / J Gynecol Obstet Hum Reprod xxx (2019) 101680
Senator Barbara Boxer of California has said, “Medical professionals, not insurance company bureaucrats, should be making health care decisions [1].” The same may be said about hospital and health system executives. Their role, despite many fancy mission and vision statements to the contrary, is profit margin. Politicians, too, must be made to defer to health care professionals as they craft legislation and regulation that impacts the access to, and quality of, care available to the public. It may be that their role is to get re-elected. Our role is patient care and public health. So, how do we regain our sense of purpose, earn the public trust and impact the system as it is today? We can and we must engage, participate, and use our hard-fought knowledge and judgment to implement patient-centered, evidence-based, innovative approaches to improving the health of our patients and our society. We are living in an age of “pseudo-science” and “fake news”. Blatantly false statements and marketing by industry and celebrity “influencers” are pervasive. As physicians and professionals, it is our duty to use the best possible evidence to inform our advice to, and care for, our patients and the public. Where do we find that reliable evidence and how do we choose to translate it into meaningful messages? Our first task is to understand the basis of evidence-based medicine. It is more than clinical trials. Sackett defined evidencebased medicine as a triad, “ . . . the integration of best research evidence with clinical expertise and patient values [2].” Randomized trials are expensive and may be fraught with limitations created by practicality or funding source. For example, researchers for the Women’s Health Initiative, a massive randomized trial to study the potential benefit of menopausal hormone therapy in preventing cardiovascular disease, made a choice to aim their enrollment at older menopausal women in order to target a population at higher risk for cardiac disease (and thereby reducing the number of enrollees needed to achieve study power). In addition, women had to agree to randomization. Women with significant menopausal symptoms were unwilling to be randomized. Is it any wonder, then, that the results of the trial demonstrated no improvement in quality of life for women on hormone therapy? The women enrolled, for the most part, were not symptomatic. How could an intervention make them better? Cost, scientific rigor and practicality limit the inclusion criteria for many clinical trials. So, can and should we extrapolate the results to a general population? Researchers, journal reviewers and editors have an obligation to provide greater transparency in the discussion of the funding sources and limitations of such studies. We, as readers, must always look for the unasked questions, the unstudied population cohort or the stakeholders who might stand to gain from the results of a trial. As physicians we must integrate our clinical expertise with the outcomes of clinical trials, and the values and desires of our patients to arrive at the right intervention for the right patient at the right time and place. The results of clinical trials will help to inform that analysis, BUT evidence-based medicine is far more than adopting a formula for distinguishing levels of evidence and determining confidence in the results. Are they statistically AND clinically meaningful? Is this the outcome my patient is concerned about, and is my patient represented in the study population? If not, extrapolating the results to her may not be appropriate. Unfortunately, there are inherent barriers that make identifying and incorporating “truth” in clinical evidence difficult. Biases, both conscious and unconscious, are pervasive. Funding for high quality studies is limited and not infrequently based on the potential for study findings to be provocative - generating publicity - or directly lucrative for the funder. Large data sets are now being mined to
find correlations between exposures and certain outcomes. The larger the population, the more likely a meaningless but nevertheless statistically significant association may be found. We must constantly ask ourselves whether such findings deserve the publicity and public angst they frequently generate. The statistical analysis of studies can impart bias, and there is certainly inherent bias among reviewers and editors to publish positive results AND results that confirm our underlying beliefs. The discovery of H. Pylori as the infectious cause of duodenal ulcers and the barriers to publication of properly designed studies that did not conform to longstanding medical and cultural beliefs is a cautionary tale to remind us that bias in selection for publication may exist. Finally, the publicity afforded medical research may be biased. Media outlets are motivated to sell advertising and create interest and controversy. Their choice of studies, and the editorials they chose to publicize, add to biases in public and professional perception. It is helpful to think through what stimulates us as doctors and people to do what we do. Unconsciously we all want to feel good. We want to do things that enhance our sense of wellbeing, our professional stature and our influence. We want to be valued for our contributions – both financially and within our work and community cultures. We tend to gravitate towards innovative approaches and strategies because they are fun, interesting and may distinguish us from our colleagues. In our current environment, something new seems to be accepted far more readily than in times past. Endorsements by key opinion leaders, be they famous physicians or celebrities, drive the public to seek the newest, best (although perhaps minimally tested) interventions. To appear up to date, modern and competitive many of us quickly adopt new technology without insisting on a solid evidence foundation. “First, do no harm” has become – don’t miss out on the latest, greatest . . . laser, robot, device, medicine or supplement. There are typically seven steps in the assessment of innovative techniques or treatments: 1) 2) 3) 4) 5) 6) 7)
The promising report Adoption by leaders Public acceptance without critical evaluation Acceptance as “a standard of care” Investment in research – the randomized clinical trial Results of the trial result in denunciation or promotion Creation or Erosion of support
As leaders and dedicated professionals, it is our obligation to use our extensive training and experience to strive to do “what’s right”, to critically assess and evaluate marketing materials, early promising reports, and pressure from our employers and patients to adopt innovative tools before their value has been established. In the specialty of Obstetrics and Gynecology, we are far too aware of the expensive and devastating consequences. How would obstetrical care be different today if we had not incorporated electronic fetal monitoring into standard care before its value had been properly ascertained? We certainly have not realized universal benefits in terms of improved perinatal outcomes for mothers and infants. It is our responsibility to our patients, the public, and to ourselves as professionals, to be accountable for what we do. We need to measure, analyze and continuously improve the care we deliver. The Electronic Medical Record was sold to the public as the mechanism to do that. However, it was designed and sold to our employers – the large hospital and health systems – as a mechanism to increase revenue. It has become a source of frustration, “note bloat”, and medical error. To regain joy in our work and renew our sense of purpose in what we do, we will
Please cite this article in press as: B. Levy, Path to leadership in medicine: Advocacy and evidence-based medicine, J Gynecol Obstet Hum Reprod (2020), https://doi.org/10.1016/j.jogoh.2020.101680
G Model JOGOH 101680 No. of Pages 3
B. Levy / J Gynecol Obstet Hum Reprod xxx (2019) 101680
have to engage with administrators, vendors and professional associations to drive innovative, creative solutions to clinical documentation. The status quo is unacceptable for good care. We must be able to use real world evidence, as documented in, and automatically abstracted from, the clinical record to find optimal interventions for broad patient populations. The results of randomized trials must be analyzed in conjunction with that real-world evidence to help us determine the best care for our patients. Professionalism and leadership demand: that we do right for both our patients and our communities; we be good stewards of resources; that we critically review the literature; and we remember that shiny new technology and marketing doesn’t substitute for therapeutic appropriateness. In the end, satisfaction and joy in the practice of medicine will require us to re-engage, to find a purpose in our work so big and meaningful that it motivates everyone’s best effort. We must challenge ourselves and each other to raise the bar, to create a high standard of performance, to work collaboratively to remove obstacles to success, and to build on the strength of our training and experience to contribute meaningfully to the well-being of our patients and our communities. That is advocacy. It is fighting for what’s right – for our patients, our communities and ourselves as caregivers. It is using the triad of evidence-based medicine to drive genuine improvement in health outcomes that are meaningful to those we serve. The path is not straightforward to regain what we’ve lost, but the road to professional satisfaction and joy is a road paved with commitment
3
to truth, advocacy, and remembering that we went into medicine because we care. Doctors are teachers; we are leaders, and we are professionals dedicated to caring for our patients and our communities. When we rekindle that focus on caring we will find our voices, our passion and our joy in the privilege of serving our patients. References [1] Barbara Boxer Quotes. BrainyQuote.com. Retrieved December 26, 2019, from BrainyQuote.com Web site: https://www.brainyquote.com/quotes/ barbara_boxer_167645. [2] Sackett David L, Rosenberg William MC, Muir Gray JA, Brian Haynes R, Scott Richardson W. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71.
Barbara Levya,b,* George Washington University School of Medicine and Health Sciences, Washington, DC, United States
a
b
The Levy Group LLC, Arlington, VA, United States
* Correspondence to: George Washington University School of Medicine and Health Sciences, Washington, DC, United States. E-mail address: [email protected] (B. Levy). Received 30 December 2019 Available online xxx
Please cite this article in press as: B. Levy, Path to leadership in medicine: Advocacy and evidence-based medicine, J Gynecol Obstet Hum Reprod (2020), https://doi.org/10.1016/j.jogoh.2020.101680
Journal of Gynecology Obstetrics and Human Reproduction xxx (2019) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Editorial
Path to leadership in medicine: Advocacy and evidence-based medicine$ A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 December 2019 Available online xxx
Physicians are experiencing overwhelming demands to generate revenue and complete ever-increasing administrative tasks. Whether employed by large health systems, academic centers or still struggling in small private practices, the autonomy so valued by medical professionals, and our ability to influence policies impacting our patients and the public, has diminished. In order to regain the joy in practicing medicine and overcome the sense of “burn-out” and frustration so many of us experience, it is essential to dedicate ourselves to becoming leaders in our communities, in our institutions and in our medical schools. We must apply the triad of evidence-based medicine – the data derived from randomized clinical trials, our learned experience, and our patients’ values – to become leaders in the path towards reasoned public policy and institutional procedures that improve the care for individual patients and the community. Through advocacy and leadership, we can re-engage with the passion that drove us to our profession and renew our commitment to the patients we serve. The energy and time required for these activities will be more than repaid with joy and passion in our daily work and a sense of purpose in our lives. © 2020 Published by Elsevier Masson SAS.
Keywords: Professionalism Evidence-based medicine Advocacy Leadership Burn-out
Professionals generally have degrees of “freedom to exercise their independent, professional judgment,” with “a high degree of control over their own affairs.” All professions have privileged status used to influence the conduct of their own members, as well as “exercise a dominating influence over the entire field . . . .” A profession is characterized by the power and high prestige it has in society. It is the power, prestige and value that society confers upon a profession that more clearly defines it. Physicians have long been revered in society as a profession centered not only on the art and science of medicine but on the health and well-being of society at large. Our task has been to focus on the patient before us, while our status depended upon engagement and trust within our communities. A cornerstone of the esteem we enjoyed was the notion that we took responsibility for ensuring that our conduct was in the best interest of the patient. We stand up for doing “what’s right” independent of payment for our services. A series of changes in the delivery of health (or illness) care in the US and abroad have accumulated to threaten the role physicians have traditionally played in consistently working to relieve suffering and improve the health of our patients. We are losing our status as champions for public health and our ability to drive changes that result in benefit to our patients and the public. Many of these changes are the result of unintended consequences
$
Presented at the AAGL annual meeting, November 2019, Vancouver BC.
related to the high cost of care and the desire to “modernize” health care delivery. The corporatization of medicine has stripped physicians of our revered and powerful status. We can and we must regain leadership positions and the skills and voices necessary to drive better quality; safer care at lower cost. The grueling path to becoming a physician, coupled with the increased demands for “through put” and the requirement for standardized documentation are driving many physicians towards an apathetic state where we struggle to get through the day and accomplish all the tasks required of us. Efforts to drive revenue have resulted in a series of check boxes and burdensome tasks; there is decreased autonomy in medical decision-making and a sense that we are simply mechanics going through the motions. Over the past 25 years these changes have occurred insidiously, sneaking up on many physicians. Focus on getting through the day and a reluctance to take on additional responsibilities, as well as a general lack of training in the “business” of medicine have diminished our position within the hospital and health system structure. C-Suite executives find it easy to ignore our input. It is imperative that we regain our focus on the patient; renew our commitment to serving the needs of the people we care for; and back away from the optimization of corporate profit in the health system. We must regain our role as serving leaders who drive our systems to create high standards of performance, remove obstacles to success and encourage every member of the health care team to contribute what they do best.
http://dx.doi.org/10.1016/j.jogoh.2020.101680 2468-7847/© 2020 Published by Elsevier Masson SAS.
Please cite this article in press as: B. Levy, Path to leadership in medicine: Advocacy and evidence-based medicine, J Gynecol Obstet Hum Reprod (2020), https://doi.org/10.1016/j.jogoh.2020.101680
G Model JOGOH 101680 No. of Pages 3
2
B. Levy / J Gynecol Obstet Hum Reprod xxx (2019) 101680
Senator Barbara Boxer of California has said, “Medical professionals, not insurance company bureaucrats, should be making health care decisions [1].” The same may be said about hospital and health system executives. Their role, despite many fancy mission and vision statements to the contrary, is profit margin. Politicians, too, must be made to defer to health care professionals as they craft legislation and regulation that impacts the access to, and quality of, care available to the public. It may be that their role is to get re-elected. Our role is patient care and public health. So, how do we regain our sense of purpose, earn the public trust and impact the system as it is today? We can and we must engage, participate, and use our hard-fought knowledge and judgment to implement patient-centered, evidence-based, innovative approaches to improving the health of our patients and our society. We are living in an age of “pseudo-science” and “fake news”. Blatantly false statements and marketing by industry and celebrity “influencers” are pervasive. As physicians and professionals, it is our duty to use the best possible evidence to inform our advice to, and care for, our patients and the public. Where do we find that reliable evidence and how do we choose to translate it into meaningful messages? Our first task is to understand the basis of evidence-based medicine. It is more than clinical trials. Sackett defined evidencebased medicine as a triad, “ . . . the integration of best research evidence with clinical expertise and patient values [2].” Randomized trials are expensive and may be fraught with limitations created by practicality or funding source. For example, researchers for the Women’s Health Initiative, a massive randomized trial to study the potential benefit of menopausal hormone therapy in preventing cardiovascular disease, made a choice to aim their enrollment at older menopausal women in order to target a population at higher risk for cardiac disease (and thereby reducing the number of enrollees needed to achieve study power). In addition, women had to agree to randomization. Women with significant menopausal symptoms were unwilling to be randomized. Is it any wonder, then, that the results of the trial demonstrated no improvement in quality of life for women on hormone therapy? The women enrolled, for the most part, were not symptomatic. How could an intervention make them better? Cost, scientific rigor and practicality limit the inclusion criteria for many clinical trials. So, can and should we extrapolate the results to a general population? Researchers, journal reviewers and editors have an obligation to provide greater transparency in the discussion of the funding sources and limitations of such studies. We, as readers, must always look for the unasked questions, the unstudied population cohort or the stakeholders who might stand to gain from the results of a trial. As physicians we must integrate our clinical expertise with the outcomes of clinical trials, and the values and desires of our patients to arrive at the right intervention for the right patient at the right time and place. The results of clinical trials will help to inform that analysis, BUT evidence-based medicine is far more than adopting a formula for distinguishing levels of evidence and determining confidence in the results. Are they statistically AND clinically meaningful? Is this the outcome my patient is concerned about, and is my patient represented in the study population? If not, extrapolating the results to her may not be appropriate. Unfortunately, there are inherent barriers that make identifying and incorporating “truth” in clinical evidence difficult. Biases, both conscious and unconscious, are pervasive. Funding for high quality studies is limited and not infrequently based on the potential for study findings to be provocative - generating publicity - or directly lucrative for the funder. Large data sets are now being mined to
find correlations between exposures and certain outcomes. The larger the population, the more likely a meaningless but nevertheless statistically significant association may be found. We must constantly ask ourselves whether such findings deserve the publicity and public angst they frequently generate. The statistical analysis of studies can impart bias, and there is certainly inherent bias among reviewers and editors to publish positive results AND results that confirm our underlying beliefs. The discovery of H. Pylori as the infectious cause of duodenal ulcers and the barriers to publication of properly designed studies that did not conform to longstanding medical and cultural beliefs is a cautionary tale to remind us that bias in selection for publication may exist. Finally, the publicity afforded medical research may be biased. Media outlets are motivated to sell advertising and create interest and controversy. Their choice of studies, and the editorials they chose to publicize, add to biases in public and professional perception. It is helpful to think through what stimulates us as doctors and people to do what we do. Unconsciously we all want to feel good. We want to do things that enhance our sense of wellbeing, our professional stature and our influence. We want to be valued for our contributions – both financially and within our work and community cultures. We tend to gravitate towards innovative approaches and strategies because they are fun, interesting and may distinguish us from our colleagues. In our current environment, something new seems to be accepted far more readily than in times past. Endorsements by key opinion leaders, be they famous physicians or celebrities, drive the public to seek the newest, best (although perhaps minimally tested) interventions. To appear up to date, modern and competitive many of us quickly adopt new technology without insisting on a solid evidence foundation. “First, do no harm” has become – don’t miss out on the latest, greatest . . . laser, robot, device, medicine or supplement. There are typically seven steps in the assessment of innovative techniques or treatments: 1) 2) 3) 4) 5) 6) 7)
The promising report Adoption by leaders Public acceptance without critical evaluation Acceptance as “a standard of care” Investment in research – the randomized clinical trial Results of the trial result in denunciation or promotion Creation or Erosion of support
As leaders and dedicated professionals, it is our obligation to use our extensive training and experience to strive to do “what’s right”, to critically assess and evaluate marketing materials, early promising reports, and pressure from our employers and patients to adopt innovative tools before their value has been established. In the specialty of Obstetrics and Gynecology, we are far too aware of the expensive and devastating consequences. How would obstetrical care be different today if we had not incorporated electronic fetal monitoring into standard care before its value had been properly ascertained? We certainly have not realized universal benefits in terms of improved perinatal outcomes for mothers and infants. It is our responsibility to our patients, the public, and to ourselves as professionals, to be accountable for what we do. We need to measure, analyze and continuously improve the care we deliver. The Electronic Medical Record was sold to the public as the mechanism to do that. However, it was designed and sold to our employers – the large hospital and health systems – as a mechanism to increase revenue. It has become a source of frustration, “note bloat”, and medical error. To regain joy in our work and renew our sense of purpose in what we do, we will
Please cite this article in press as: B. Levy, Path to leadership in medicine: Advocacy and evidence-based medicine, J Gynecol Obstet Hum Reprod (2020), https://doi.org/10.1016/j.jogoh.2020.101680
G Model JOGOH 101680 No. of Pages 3
B. Levy / J Gynecol Obstet Hum Reprod xxx (2019) 101680
have to engage with administrators, vendors and professional associations to drive innovative, creative solutions to clinical documentation. The status quo is unacceptable for good care. We must be able to use real world evidence, as documented in, and automatically abstracted from, the clinical record to find optimal interventions for broad patient populations. The results of randomized trials must be analyzed in conjunction with that real-world evidence to help us determine the best care for our patients. Professionalism and leadership demand: that we do right for both our patients and our communities; we be good stewards of resources; that we critically review the literature; and we remember that shiny new technology and marketing doesn’t substitute for therapeutic appropriateness. In the end, satisfaction and joy in the practice of medicine will require us to re-engage, to find a purpose in our work so big and meaningful that it motivates everyone’s best effort. We must challenge ourselves and each other to raise the bar, to create a high standard of performance, to work collaboratively to remove obstacles to success, and to build on the strength of our training and experience to contribute meaningfully to the well-being of our patients and our communities. That is advocacy. It is fighting for what’s right – for our patients, our communities and ourselves as caregivers. It is using the triad of evidence-based medicine to drive genuine improvement in health outcomes that are meaningful to those we serve. The path is not straightforward to regain what we’ve lost, but the road to professional satisfaction and joy is a road paved with commitment
3
to truth, advocacy, and remembering that we went into medicine because we care. Doctors are teachers; we are leaders, and we are professionals dedicated to caring for our patients and our communities. When we rekindle that focus on caring we will find our voices, our passion and our joy in the privilege of serving our patients. References [1] Barbara Boxer Quotes. BrainyQuote.com. Retrieved December 26, 2019, from BrainyQuote.com Web site: https://www.brainyquote.com/quotes/ barbara_boxer_167645. [2] Sackett David L, Rosenberg William MC, Muir Gray JA, Brian Haynes R, Scott Richardson W. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71.
Barbara Levya,b,* George Washington University School of Medicine and Health Sciences, Washington, DC, United States
a
b
The Levy Group LLC, Arlington, VA, United States
* Correspondence to: George Washington University School of Medicine and Health Sciences, Washington, DC, United States. E-mail address: [email protected] (B. Levy). Received 30 December 2019 Available online xxx
Please cite this article in press as: B. Levy, Path to leadership in medicine: Advocacy and evidence-based medicine, J Gynecol Obstet Hum Reprod (2020), https://doi.org/10.1016/j.jogoh.2020.101680