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Meaningful Use was recently found to not be correlated with performance on clinical quality measures.[33] Rolled out as purely a financial incentive program, the fact that estimated 75% of US physicians are employed by hospital systems[34] this initiative is mandatory for most US physicians. A new set of current procedural terminology (CPT) codes was released from the American Medical Association and is meant to improve our procedural coding system. International Classification of Diseases-10 (ICD-10) is a new diagnostic schema. The Federation of State Medical Boards (FSMB) is working to mandate new maintenance of certification (MOC) and maintenance of licensure (MOL) requirements. These requirements are additional to the current Category 1 Continuing Medical Education (CME) requirement of 50 hours a year as well as of every 10 year Board Certification examination that requires extensive study and are expenses placed on providers. There is no clear scientific evidence that MOC improves quality of care at the point of clinical service.[35] Newer Electronic Health Record (EHR) systems prioritize capturing as many MU as possible to obtain federal money set aside to reimburse for EHR expenditure. The design trade-off for MU capture priority has led to poorer clinical workflow design, actually interfering with and obstructing normal clinical operations. Daily operational impairment to clinical workflow creates chronic frustration and distress for providers and staff which does not eliminate with time and familiarity with the EHR program. This cognitive strain depletes executive function available which increases the risk of errors. Increased documentation time has cut into productivity, and lengthened the work time in a day further affecting work/life balance. Inadequate risk/benefit analysis occurs if the authoritative mandate source does not account for or coordinate with other sources of mandates, regulations, and laws imposed on physicians. Otherwise it is impossible to reasonably assess total impact and potential unintended consequences of the initiative. These uncoordinated efforts have unknowingly caused reckless endangerment of staff and patients, and the interventions in summation become counterproductive to their intended purpose. Many administrative and regulatory influences begin with good intentions ("friendly fire"), and may include the additive effect of too many uncoordinated "quality" measures and reactive "corrective" policies to events. In summation they may cumulatively paralyze care. Some influences have not-so-good intentions and are purely financial in motivation ("enemy fire"). Examples include purposeful hassles to patients and providers to lessen payments for care that create unreasonably enormous profits. These factors both add up to feeling under siege and are added non-work life stress and daily work stress of being a physician. Being compassionate while dealing with pain, suffering, illness, injury, blood loss, death, and distressed families[21] is what physicians expected when going to medical school. The additional tsunami of insidious stressors they did not expect nor have they been prepared for. 3.2 Non-work life and feeling trapped Physicians have gone to school a minimum of 21 years. The Association of American Medical Colleges (AAMC) reports the median four-year cost for medical school for the class of 2013: $278,455 for private school and $207,868 or public ones.[36] Thirty-six percent of those graduating from medical school have debt of over $200,000, 22% owe $100K-200K, 6% $50-100K, 7% < $7K, and only 25% have no debt.[37, 38] After this much time and financial commitment has been made to become a physician, they are substantially trapped in their profession. Having a daily sense that your work life is under siege from innumerable outside sources creates more demoralization and stress than is currently appreciated. The more outside influences that mandate activity that is beyond their control to influence the more the PFC degenerates in function. Satisfying these mandates is often relegated to "discretionary time" that is not paid for by the employer. This chronic home-life time conflict greatly increases unnecessary stress on them which negatively spills over to their family relationships.
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