Season 1: Episode 8 – Burnout: Insurance Coding & Psychological Corrosion

Dear Healthcare It’s You: Episode 8

Elisha Yaghmai

You can do certain findings. They'll say you have congestive heart failure. Why did they document the congestive heart failure? Because that's a high dollar code. Right. Now, did you actually have congestive heart failure? No, you didn't. Right. Now, I'm not saying here again, it's very important to say they're not outright lying.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

You had the coding criteria for congestive heart failure. Now, did they actually think in medical terms that you had to just part of it didn't? Right. But did they code it? They sure did. Why? Because they treated you for it. Because you met the code and criteria for it. Right. Now, where do you see this play out is down the line.

Elisha Yaghmai

Five years later, you come in. Somebody sees you. They look at your diagnosis and they say, yeah, you know, you have congestive heart failure. Yeah, you don't.

Jo O’Hanlon

Welcome back to your health care. It's you. Welcome back to health care. It's you where we're talking about the broken American health care system. We've got Dr. Leslie Hagman with us. And I am Joe O'Hanlon. Last time we were talking about you being in Seattle, and we didn't fully cover that story, but we were talking about how there was just an overuse of admitting to the hospital from the E.R. and then this debate that you were kind of faced with about how far you should treat someone before it becomes unkind, basically, in that situation.

Jo O’Hanlon

But I know there's more to that story in terms of especially your last year in Seattle. So that we can pick up the story there. What was so different about or what happened in your last year that was so formation for you?

Elisha Yaghmai

It was really more a crystallization of a lot of things that had gone on before. So when I go back, when I go back and look, I started making notes after I finished residency and just went out notes about patient encounters, random things that I experienced just so I would have some memory of them as I went on.

Elisha Yaghmai

And it's really interesting, actually. I went back and reviewed those notes recently, and I saw that in the first few years actually out of residency, I was very excited. I was trying to I wanted to explore new subjects. I wanted to research things, I wanted to ask new questions and I saw that by the third year out start to erode.

Elisha Yaghmai

And instead, what I was recording was negative experiences. I didn't I didn't have nearly as many positive thoughts in terms of here's a here's a thing I want to create. Here's a thing I want to do. Instead, it was this is really sort of wearing me down. And here's negative case after negative case. And I don't mean necessarily bad outcomes.

Elisha Yaghmai

Yeah, I mean, like a I have been described before, other physicians have used the term moral injury, but something like that, I think, meaning going on.

Jo O’Hanlon

Moral injury.

Elisha Yaghmai

To moral injury to me, Yeah. Yeah. To me. And many physicians have have articulated this, you know, and it comes from it's just a variety of different sources. But, you know, here again, the I think the key emphasis is that everything I saw there, I have since seen lots of other places. So it's not it's not that that that place was uniquely bad or uniquely burnout prone.

Elisha Yaghmai

They were just doing what everybody does. So what I thought at the time was unusual. As I went out into the world and worked in more places and saw more places, what I realized was this is this is pretty normal. This is how it is.

Jo O’Hanlon

Were you experiencing new things there in terms of like you were at first thinking it was just there and you're talking about having looked back at these notes and seeing that transition in yourself. Was that just having dealt with the same things again and again over time and then it wearing on you, or was it new things that you were seeing in those later years in Seattle that were making you more jaded or overworked or things like that?

Elisha Yaghmai

Yeah, what I saw was so Seattle was ahead of Kansas in terms of billing maximization.

Jo O’Hanlon

Okay?

Elisha Yaghmai

And Kansas was further behind at the time. And bear in mind, I had in Kansas, I was in a training environment, right? I wasn't responsible for the billing. I was responsible for trying to learn medicine and trying to care for the patient right. But I wasn't the one who was ultimately in charge of how does all this get billed and paid for?

Elisha Yaghmai

Right.

Jo O’Hanlon

Which is once you're out of residency, that's exactly.

Elisha Yaghmai

You know, so this was this was the difference. And Seattle was just the hospital system. There was just better at it. They're better at everything. They were better at hitting their quality metrics. So call their in better making the documentation look better. They were they were better at finding ways to, you know, make the make the coding look as high as possible to collect the highest payments from insurance.

Elisha Yaghmai

These are all things that they did. And then on top of that, the volume of people was higher, right? So the number of cases coming in is higher. The level of complexity also was in many cases, at least equivalent, if not higher. Right. So all of these things were happening simultaneously. And I think I think a problem my assumption, I should say, is that a lot of a lot of physicians sort of go through this transition.

Elisha Yaghmai

Yeah. You know, but but there's there's multiple things going on. So when we talk about, you know, I think our intent in this episode was kind of talk about how how did I get burned out on this system.

Jo O’Hanlon

Right.

Elisha Yaghmai

And hospital systems have spent money on this has been research on this right. Probably the most effective phrasing that I have heard about it actually came when I was driving around rural Kansas one night and I heard a guy talking on the radio who said Burnout is not working too hard. It's when you're working too hard on the wrong things, you know.

Jo O’Hanlon

And which in Seattle, when you started there, if I recall correctly, you were excited by how much there was in terms of just access to people who knew more than you. I mean, there was so it was such a robust system in terms of the care available. And so in these latter years, you started to have this burnout from those same very like the other side of that same coin sort of.

Elisha Yaghmai

Yeah, it started, I think initially it started with the other side of high expertise, right, is kind of what we had alluded to in the previous episode, right? No one knows how to shut it off. Right? So the initial problems were patient comes in with clearly terminal illness. Right. And we are forced to continue providing care, even though it's obvious that it's going to be terminal.

Elisha Yaghmai

Right. And what we're doing is in terms of personal ethics is not obviously the right thing to do, but it is the expedient thing to do. It gets everybody paid and it avoids any uncomfortable conversations that we may have to have about the fact that your life is coming to an end. Right. Or your loved one's life is at its end and it's time to acknowledge and accept that fact easier.

Elisha Yaghmai

Instead to say, look, we can we can do this, we can do that. And by the way, it pays us $20,000 when we do that. Right?

Jo O’Hanlon

Right.

Elisha Yaghmai

All that gets a little muddy, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

So we had, you know, episode. Does that fit into that particularly well? And I think I described one in the previous episode. I still remember there was here again talking about how the health care system works. There is a patient that we had that was probably 30 years old who had had pneumococcal meningitis. That's a bacterial infection of the brain.

Elisha Yaghmai

As a child, it had left her blind. And if I recall, death and as a result of various illnesses that she'd had after that very severe illness, over time, she'd had her arms and legs amputated. So, she had stumps for legs and stumps for arms, and she was blind and deaf. So she was a blind and deaf torso in a bed.

Elisha Yaghmai

Right. And she would periodically decompensated and her father was providing her care. The family had long since broken out. They're divorced. And this happens to a lot of families that care for chronically ill children and others. And so he would periodically bring her into the hospital for whatever the thing was and disappear. He would just disappear. And in fact, what we learned later was that this is how we would take a vacation, really, because there was no way to care for her.

Elisha Yaghmai

You couldn't hear against the American healthcare system, right? So it's like he could afford in-home care, Right? So, the solution to this was to come up with the reason that she needs to go to the E.R., get her hospitalized, disappear for a week or two or whatever it was, turn off his phone, completely unreachable. Wow. So, you would bring her in and you'd fix the problem in 12 hours, Or if there even was a problem, whatever it was.

Elisha Yaghmai

Right. And then and then the patient would sit there. Right. And you would be sitting there looking at a person that is in every way nonfunctional, is not able to interact with the was unable to do anything. And on top of that, I said one day it wasn't like it wasn't like someone was home cognitively. Like cognitively she was destroyed by that infection.

Elisha Yaghmai

And so you look at that and say, okay, so at age three, I think it was age two or three when this happened, right? This is this is when this person's life effectively ended. Yeah, here we are at 30 still going, right? Why are we still going?

Jo O’Hanlon

Yeah. What is the alternative? Those just to deny care and let her deteriorate.

Elisha Yaghmai

Well, the alternative would be to have a I think on some level it's like it's, you know, as a culture, our culture is terrified of death. Right? Absolutely terrified of it. Who do anything to prevent it because it represents the unknown. Right. And people assume that if it's unknown, therefore it's bad. Right? Obviously, nobody really knows. Right. But people have theories.

Elisha Yaghmai

And obviously, this whole religious structures and philosophy.

Jo O’Hanlon

Will control and. Yeah, yeah.

Elisha Yaghmai

So, this is an area you don't have any. Right. Yeah. So for for many people, death is viewed as the ultimate evil and therefore anything should be done to prevent that from ever happening. But when you work long enough in clinical medicine, you realize in some ways there are things that may actually be worth maybe worse than death.

Elisha Yaghmai

They may be worse than death. Now, I will say.

Jo O’Hanlon

There's speaking to like the quality of life.

Elisha Yaghmai

So, yeah, you have you have no quality of life whatsoever. That said, I mean, I think I should also acknowledge there have been research papers that have been published on this that said medical professionals have a much more dismal view of this than the general public. Like the people the general public that were interviewed said, yeah, you've never had a terrible deficit.

Elisha Yaghmai

I would still want to be alive. It's still better than being dead, right? Whereas the medical professionals were like, If I have a deficit, I'd put me down. Right? It's is just a totally different like to say something about that culture. Yeah. You know, now some of that maybe.

Jo O’Hanlon

Know too many times.

Elisha Yaghmai

That that's the opposite right? That the health care professionals see it to agree see what that really entails. Right. Whereas the general public you know they're imagining a thing that they in many cases they may not have seen. But there is still some disconnection between how health care professionals feel about death and dying and disability and how the general public may feel right, wrong on what their their individual experience has been.

Elisha Yaghmai

Right. But the point is that in that environment, so what I'm seeing this right, I'm seeing things like and then let's get even more pernicious. There was a guy that was addicted to heroin came and he had a stroke. The reason he had a stroke was because he had an infection in his heart valve. But the problem with his stroke was that it left him like he was he was gone like he was what we call intended.

Elisha Yaghmai

Right. He was just basically unresponsive. Okay. So when we when we figured out that he was not waking up and he had an infection of a heart valve, which in turn had he had gotten due to his heroin addiction. Right. Yeah. To inject drugs, bacteria get in there. They can, they can land in your heart valve. Right. And they can set up an infection there.

Jo O’Hanlon

Okay.

Elisha Yaghmai

Right. So when we learn this. Right. The obvious assumption was, well, you know, we're probably done right? We have an infected valve and there's nobody home currently. And he had obviously a very severe addiction at baseline.

Jo O’Hanlon

Right.

Elisha Yaghmai

They did it. They did a valve replacement on him. Right. They did a surgery to replace his valve. And I was left.

Jo O’Hanlon

Saying, did he have any family? They're like two concentric.

Elisha Yaghmai

If I recall correctly. I don't think he did. I don't think he did.

Jo O’Hanlon

Is that a factor in that when it's like you don't have somebody to ask?

Elisha Yaghmai

Well, it works both ways, actually, right? So when there's no family around and it usually comes down to the opinion of the treating physicians, that's what wins the day. If the family is not there to register an opinion. Right. If the family is there to register an opinion, the patient can't speak for themselves, then it's a discussion. Right?

Elisha Yaghmai

Right. Physicians. But in this situation, if I recall correctly, there wasn't necessarily a great push, right? It was just this again, we can't turn this off. Right. And so the question you had to ask was, what's the long term play?

Jo O’Hanlon

Yeah. Like, was there hope for this patient that he would come back on? Well, I think, like you're getting consciousness.

Elisha Yaghmai

I think that was the that was the way it was sold.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

Maybe his brain will come back at some point.

Jo O’Hanlon

Right. But realistically, that was not a high price.

Elisha Yaghmai

It was not a high probability. It was not a high probability, but this was done anyway. Right. And it was very much again, we discussed last time kind of forest and trees. Right. Okay. I know how to fix heart valves that are bad, right? Yeah. I can take this one out and I can fix it. Right. Right. This is what this is what was done.

Elisha Yaghmai

And yet again, it's at least worth a question.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

Is that the right decision?

Jo O’Hanlon

Is that patient's insurance is known and brought into the equation when these decisions are being.

Elisha Yaghmai

Absolutely. Yeah. If they have insurance that will pay for a thing. The thing is more likely to happen. That's actually more likely to happen.

Jo O’Hanlon

Is that part of what like you mentioned, the billing side of things before or having more of that on your plate and in your view, is that the main thing that made a big difference for you in terms of seeing these situations play out? Or was it already that you were seeing these situations in your first couple of years there and like that they were sitting wrongly with you?

Jo O’Hanlon

Was it more about understanding that connection, about the payment being such a factor?

Elisha Yaghmai

Yeah, I think well, no. So I understood it. I already had a concept of that. Right. But at that time I thought this insurance stuff is basically a game, right? We have to play this game, right? Because this is how America has decided to set up its system, right? So if we want to care for our patients and we want to be able to keep providing care for future patients, yeah, we have to generate revenue.

Elisha Yaghmai

How do we generate revenue by billing insurance companies, Right. And to build insurance companies, there's a whole game of compensation. There's rules about how you do everything right and you try to optimize your function and documentation relative to those rules to seek the maximum reimbursement and the way that's justified is what we have to do this right. We have to do this to continue to pay people to be able to do the work.

Jo O’Hanlon

Right. Right.

Elisha Yaghmai

That's what it is, where it where it goes wrong is when that becomes a priority in treatment.

Jo O’Hanlon

Over the deciding factor of what's best.

Elisha Yaghmai

That's the reason of why this is down or why this is not done right.

Jo O’Hanlon

Would you say that you've seen that happen elsewhere? Like is that part of what you were saying? So seen all over the.

Elisha Yaghmai

Years later, years later in rural Kansas, there was a patient that was brought in. He was severely developmentally delayed cognitively extremely challenged, like basically and I can't now remember what all that happened, but what his life was was sitting in a chair and drooling this is what he would do. I mean, that's not an exaggeration. That's what he would do.

Elisha Yaghmai

Yeah, there was no way to interact. There was really no meaningful, no obvious, meaningful interaction, really, in any way. So he at some point passed out and I think he passed out, got brought in to the emergency room. Long story short, he got transferred to a specialty hospital where they put a $35,000 defibrillator device in his chest.

Jo O’Hanlon

In his chest?

Elisha Yaghmai

Yeah. They'd do a procedure to stick it in there right. So, they did they stuck it in at that time, I think it was building out at about $35,000 in research. Correct me. You know, And again. Right. You looked at that and said, why don't why did we do that?

Jo O’Hanlon

So, in terms of someone like this where insurance would pay for them for their treatment, it's not going to land on them in terms of debt or their family or whatever, but they don't have a high quality of life. Now, you would feel like that's unethical to do in your in your shoes with what your experience has been and the things that you've seen you feel like that would be unethical to to keep doing that, even if it's not detrimental to the patient?

Elisha Yaghmai

Well, it's I would say for one, it's detrimental. Detrimental in the sense that you are exposing them to the risk of a procedure. Right. Nolan? No medical procedure is risk free. Yes, almost none. There's just so so there is some risk associated. So there's that. There's the cost, right? So we as you indicated, Okay, so maybe they've got various types of public insurance.

Elisha Yaghmai

Maybe they get Medicare and Medicaid, for example. Right. So in the end, they're not going to get a bill out of it because of the special needs that they have. Fine. But who is paying for that? We are society is paying for that, right, Because they don't get their money from nowhere. Right. It comes from taxes. Here again, you can say, well, in this one off situation, you know, maybe there is.

Elisha Yaghmai

Right. But this one off situation is not a one off situation. Right. This is happening hundreds or thousands of times across the country on a regular basis.

Jo O’Hanlon

Is it happening more so with people who have like Marketplace? Now it's marketplace. But, you know, government funded health care.

Elisha Yaghmai

That that I could not answer only in as much as people that have severe cognitive problems often end up on public insurance because they cannot be employed right. So I would say that probably does occur in that context more, but not necessarily because of that, not because they're on public insurance, if that makes sense. But they just happen to be I see.

Elisha Yaghmai

On public insurance. Right. And all of this, you know, here again, it Why is this possible, Right? That's possible because the whole system really runs on documentation, not reality. What you write, if you write the right thing, then you're justified to do whatever you did. As long as you write the proper thing in the box. Right? So the analysis of the actual case may never actually even go on.

Elisha Yaghmai

As long as you write the proper words, then this will be paid for, right? That's a very tempting such situation for a lot of people. We see a lot of fraud in medicine as a result of this. Right. Because all you have to do is write the right words and make check. It's good.

Jo O’Hanlon

And like that. Ultimately, it just will go like, does it go to your superiors or just goes to insurance?

Elisha Yaghmai

Goes to insurance. Yeah. Yeah. I mean here in this kind of takes me so that's sort of second point in this right which was the focus again was on things like documentation, not necessarily on how good of a job are we doing or are we doing the right thing. It was on that condition. So, there's another story that comes to mind with this where you got to remember, at this point, I'm two or three years out of business.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

So, what I want to know what I very badly want to know is am I any good at this?

Jo O’Hanlon

Right?

Elisha Yaghmai

Like, you know, I'm.

Jo O’Hanlon

Just like, you were getting better. Yeah.

Elisha Yaghmai

I mean, I.

Jo O’Hanlon

Feel exposed to a ton.

Elisha Yaghmai

I thought I was good at it, right? I hope I was. But in objective terms, am I any good at this or not? Right. Right. How does my work compare with that of my colleagues in any way? Right.

Jo O’Hanlon

Is there any way at all?

Elisha Yaghmai

Very little. Not very little. It's not a focus. It's not an emphasis. Right. And usually the answer given, if anyone even thinks about it, which they rarely do, is, it's that's hard to determine. Right. And I'm like, yeah, I mean, it's hard to determine, but there are some things that we could measure that are objective, right? That at least give us the beginning of some clues, right?

Jo O’Hanlon

That are not measured.

Elisha Yaghmai

That are not measured. Yeah. In general, they're not measured, right. Or if they are measured, they're not shared with anybody. Right. Right. So so and I was learning this right as I went along. I was like, okay, so we see variations in practice. I'm like, well, okay, so let's you do it this way. I do it that way.

Elisha Yaghmai

Which way is better, right? Are they the same? Is one way better. Do we know? Does anybody care? The answer is no, right? Yeah. Yeah. But what was cared about was what you wrote in that note.

Jo O’Hanlon

For insurance.

Elisha Yaghmai

For insurance purposes. So, in one case, I had a patient that had been hospitalized for 60 days and all kinds of things happened. I came on to service on the 60th day of her hospitalization. This is when I picked this patient up. Right. And I had to write the discharge summary. So, it's a discharge summary. And most people are in hospitals now.

Elisha Yaghmai

It's an incredibly annoying thing you have to do. It's a summary and especially when you're coming out at the very end, I'm going to go back through all this stuff and figure out what all happened, make sure everything is accurately reported. So I go through I did this discharge summary and I fire it off and move on to the next patient.

Elisha Yaghmai

So, week and a half, two weeks later, whatever it is I get or I get a response saying, Hey, new discharge summary you forgot to document hyponatremia, which is low sodium, you forgot to document this. And I was like, Well, that's interesting because I don't even remember there being any hyponatremia in this case. It certainly wasn't significant. It was there.

Elisha Yaghmai

Yeah. So, I went back and looked right, and on day 29 of 60 there was a low sodium documented. The low sodium was 134. The bottom limit of normal was 135. The next day it was lab, but it was just lab radiation. That's just the next day. The sodium is back to normal. Right? Well, so this was number one, probably not real elaboration.

Elisha Yaghmai

Number two, irrelevant. Clinical.

Jo O’Hanlon

It wasn't treated.

Elisha Yaghmai

Clinton wasn't treated. It wasn't treated. Nothing was done. Nobody even commented on it because it was irrelevant. Right. However, for billing purposes at that time, hyponatremia was a so-called high value code. Putting it in the chart raises the payment that the hospital receives.

Jo O’Hanlon

Even though there's nothing that was treated about it.

Elisha Yaghmai

Correct. The final diagnosis, the diagnoses that are shipped off to insurance right there, they're put together a package called the diagnosis related group are. And the more of these high level diagnoses you can slam into the package, right, the more money you get coming back to pay for the hospitalization.

Jo O’Hanlon

So you're getting payment for not just treatments, but for actual diagnoses. You're getting.

Elisha Yaghmai

Payment for what diagnoses you document.

Jo O’Hanlon

Right? interesting.

Elisha Yaghmai

So, Americans at this point are, for example, very familiar with sepsis. People start to hear about sepsis. And it's such an epidemic of sepsis. Right? There's so much fake coding sepsis in charts because it reimburse as well. Right. So everyone's always looking for it. Now, to some degree, it's clinical. They're looking for actual clinical evidence of sepsis so they can catch it early.

Elisha Yaghmai

Right. But to a larger degree, a lot of the sepsis, everyone knows that's not real, but you can bet they're going to document it. And the reason they document it is because it pushes that total payment up.

Jo O’Hanlon

Wow.

Elisha Yaghmai

Right now, the question is, imagine this. You're a researcher or you want to know something. It's just you want to know something about sepsis. How much is there? Right. What's the prevalence of this this disease? What happens now? You are, generally speaking, using data that is based on that coding. And that coding is is motivated by financial compensation, not reality.

Elisha Yaghmai

Right.

Jo O’Hanlon

So, sepsis results are going to be skewed.

Elisha Yaghmai

It's the problem, right.

Jo O’Hanlon

And there's no back like that. Those researchers wouldn't be able to go very high.

Elisha Yaghmai

Right? They'd have to actually go back to the chart itself and be like, was there actually sepsis here? Yeah, right. Or was there not? Was this coding what we call coding sepsis? Right. Coding sepsis is there's certain criteria you use, you meet certain criteria. And if you do and you have these combination of factors, right, you call it sepsis and you treat it that way.

Elisha Yaghmai

Right. And then because you did that right, then you get to tell the insurance it was sepsis and there's certain charges associated with it is all this mumbo jumbo that goes on. But again, the question was, what are we doing here? Are we doing medicine in science or are we doing, you know, kind of documentation games, right, to maximize our billing?

Elisha Yaghmai

Yeah, well, the answer is documentation games to to maximize the billing. Right. But this was but again, it's not just that's just a this just a thing we do right. To play the game.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

You're like, no, this has actual this has real life downstream effects in terms of our actual knowledge.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

Because you are mis categorizing the diagnosis of things.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

For the sake of being paid.

Jo O’Hanlon

Right. Which also would go into I'm just personally learning about how private insurance is. Still. I didn't realize that the ACA doesn't go over to them, but in terms of your preexisting conditions. So then if you had a preexisting condition that wasn't even accurate just because of a prior ability, then it affects you down the list. No, this actually happens.

Elisha Yaghmai

So this but what you're describing happens for real, right? They will say you'll come in, let's see what you can with certain findings. They'll say you have congestive heart failure. Why did they document the congestive heart failure? Because that's a high dollar code right now. Did you actually have congestive heart failure? No, you didn't. Right now, I'm not saying here again, it's very important to make sure they're not outright lying.

Elisha Yaghmai

Yeah, you had the coding criteria for congestive heart failure. Now, did they actually think in medical terms that you had congestive heart failure? You didn't. Right. But did they code it? they sure did. Why? Because they treated you for it. Because you met the coding criteria for it Right now. Where do you see this play out is down the line.

Elisha Yaghmai

Five years later, you come in, somebody sees you, they look at your diagnosis and they say, yeah, you know, you have congestive heart failure. You don't.

Jo O’Hanlon

And you never did.

Elisha Yaghmai

But you never did. Right. But it got stuck in your diagnoses because that's a high reimbursing code. And so then then that new person is looking at this and saying that how they view you is changed, right? Because they think you if they think you have that diagnosis, how they think about your problem is different than if they do not think you have that diagnosis.

Elisha Yaghmai

Right. This is a real.

Jo O’Hanlon

Thing, right? So if you're doing good medicine and you're actually trying to look at all the factors from the past nine uses. Yes. Yeah. And then you're getting skewed data.

Elisha Yaghmai

Exactly.

Jo O’Hanlon

Missing forms. Your current possible for diagnosis. That's accurate.

Elisha Yaghmai

That's correct. Yeah. Because I think you have diagnosis A, B and C, but you don't have any of those things. So that was never right.

Jo O’Hanlon

Wow.

Elisha Yaghmai

That was never right. Right. It was just coded that way to maximize payment.

Jo O’Hanlon

So in terms of how you learned this, yeah. Is this something that like was just from being called out on not having included certain things from the billing department once you had written these like discharge things and so you learned like what's high coded or not or.

Elisha Yaghmai

Well, the first place I learned it, the first place I learned actually was we had an attending physician. This is back when I was an intern right now is back in Kansas, right? He said, Yeah. So you all got to learn how to code properly. And the reason you have to learn how to code properly is to accurately reflect the acuity of what you're seeing, right?

Elisha Yaghmai

Because they have they have things called case mix indexes and other things that are basically supposed to tell you how sick are these patients that are being treated this okay. Right. Okay. So he gave us as an example, he said there are two hospitals in town. One of them gets really low ratings because what I should say, historically, they had gotten lower ratings in these hospital rating systems because they appeared to be taking care of patients of lower acuity.

Elisha Yaghmai

They were not if they were taking care of the same kind of patients as everybody else, they appeared. So so what happened was this place realized this. They brought in some coding experts to teach everybody how to write about it properly.

Jo O’Hanlon

Right.

Elisha Yaghmai

And then all of a sudden, this hospital went from worst to first in a very short period of time because everybody learned how to properly describe what they were doing. Right. There's a huge problem of error. So we all learned this lesson. Okay? You've got to you've got to reflect your acuity properly, which means you've got to code all those things that they meet criteria for it.

Elisha Yaghmai

Right? Right. That is true. But fundamentally, as a as a physician, as a kind of physicians aren't really scientists in most cases, but sort of a technician pseudo scientist. You know, you ask.

Jo O’Hanlon

Them.

Elisha Yaghmai

Do we not want to know for real what this person actually has? Do we not really want to know what they have? Right? Do we not want accurate information on which to base research? Right. And all the other things that kind of flow from that. And the answer, I think, is pretty clearly, yes, we would want that to be accurate.

Elisha Yaghmai

Right. But nobody cares about that. They care about. Did you meet the coding criteria so that we can tag another diagnosis on to this chart? Right. And this ultimately downstream skews everything it induces errors, right? It produces over coding and all these other types of things that go on.

Jo O’Hanlon

Is there personal incentive to like, are you receiving more personally as a physician when you code for these hires.

Elisha Yaghmai

Usually.

Jo O’Hanlon

Don't. So there's not personal motivation for it. It's not like you're going to be coding off the wazoo just because you're going to make more in your pocket. No, but your.

Elisha Yaghmai

Motivation.

Jo O’Hanlon

From your pressure from.

Elisha Yaghmai

Correct? Yeah, your organization. Right. Especially working in the hospital.

Jo O’Hanlon

In.

Elisha Yaghmai

Your organization, is getting paid for this. Right. So it affects you indirectly. Sure. But how much money they have and to some degree, it also affects you in the sense of, you know, you work at the place with the highest acuity, Right. So that, you know, it's like a little gold star, right? this is all about getting little gold stars, right?

Elisha Yaghmai

So you get a little gold star. You work at the high end place, right? The highest in place. And you get that because you're coding properly. So you really reflecting, right? What your this is. That's that's how the game is played. Right. So take that now to sort of step three. Right. So step three is what you alluded to a little bit earlier.

Elisha Yaghmai

Right. I have a fake heart failure diagnosis, which was a sign because I met the criteria like last hospitalization or four hospitalizations ago. So I now have this fake diagnosis living in my chart. Right. Which is skewing what I think. Well, the obvious is that from the physicians perspective is, well, okay, I see a part of your diagnosis.

Elisha Yaghmai

I need to go confirm that. Right. Which means you have to go. I have to go into the electronic record and I have to go look and see. They do ultrasounds of the heart. I have to go look and see if anybody ever do an ultrasound of the heart. Right. What was the function? You know, there's various things that we look at, numbers that we look at.

Elisha Yaghmai

Right. I have to go do that, right? Yeah. Well, let's say I'm lazy and I don't do that right. I just decide to treat you in a certain way because you have halfway done this, right? Yeah. So the problem is that when I assigned that, when that when I look at that false diagnosis, the electronic records in general at that time and even up till now though they could though they could present you with the information to tell you this was not actually true.

Elisha Yaghmai

They don't you have to go find that. Yeah, you manually have to go look right. And that's often several clicks down the line. Right. And so you have to find that.

Jo O’Hanlon

Now, I've heard you say that even just in our last episode about it feels like the whole system is so inefficient that it's like I'm hearing from you that it feels like to you to be a good physician, you have to double check everything.

Elisha Yaghmai

Yes, you have to double check. That is absolutely correct.

Jo O’Hanlon

Because there's not continuity across from one to the other of anything.

Elisha Yaghmai

You're your patient rolls in. They've got records in five places you have access to none of them. Right? Right. You know that something occurred. Yeah, I know what it is. You have the patient's story, which may or may not be accurate, especially for diagnoses and things like that. It's not their area of expertise. They may not be correct.

Elisha Yaghmai

You have your own chart, right? Which as time has gone on and these records are voluminous and there's just so much information in there. Right. But you have your own chart, which can be huge, right. And so when the patient comes in, if you're going to do due diligence, you have to check everything.

Jo O’Hanlon

Right.

Elisha Yaghmai

And so the problem is that and here again, why do you have to check everything? Because the software package doesn't do it for you.

Jo O’Hanlon

Right.

Elisha Yaghmai

So a lot of the a lot of the algorithms that you're following, software could do this faster and better than you. Yeah, it doesn't because there's no mandate for it to do so. Gotcha. So the same vendors that sell these, you know, million dollar, $100 million write electronic medical records, these hospitals didn't build a lot of that functionality into it even when they could.

Elisha Yaghmai

Right. So if I wanted, for example, to know something about your alleged heart failure. Right. I have to go click through until I find that particular study, open it up, read it. Yeah, right. And then it gets even worse. Let's just say I just wanted to throw it into a document and document the number. I then have to click all the way back out and manually type that number into a note, even though it lives in the suffered.

Elisha Yaghmai

You see. I mean, the software has the study in it with the number in it, but it can't bring that number from point A to point B, you manually have to do this. Right. And that's just that's just the very beginning of this. Let's say I've got, you know, 15 years worth of labs in there.

Jo O’Hanlon

Right? Right.

Elisha Yaghmai

I got to go back through those labs. I got to look and see. Okay, Well, how are things trending? Like, are we missing anything? Is there something that went on back there that looks been kind of training the wrong way for a while? Maybe nobody's been paying attention to. Right? Very real thing. Was there a was there cancer on a passed CAT scan that nobody bothered to pay any attention to that wasn't flagged anywhere?

Elisha Yaghmai

Right. That's that's real stuff that's happened, right? Yeah.

Jo O’Hanlon

Well, you're literally looking at the images and.

Elisha Yaghmai

Yeah, you're looking at it right where you can. You're looking at the report and you're saying, you know, I think I talked about that in back in residency. Right. But that's that's a real that's a real thing. Right. This happened. So there's a finding that's important that never got flagged. No one knew anything about it. Never made it into the record.

Elisha Yaghmai

Right. Yeah, there sepsis did. But but there, you know, the tumor on their CAT scan never actually did. So to my knowledge, it doesn't exist because it's not anywhere in their diagnosis list. Right. So the only way I can know it's there is to go back into that.

Jo O’Hanlon

Well, I'm sure the patient would even know, though.

Elisha Yaghmai

They don't know. Right. Because here's what happened. The study was done in the last day of their discharge. Nobody quite looked at it. You know, they got discharged home. Nobody looked at it. The primary care doctor didn't see it either. Nobody quite knew it was there. Right. So how do you find it? You have to go back and you have to look it out.

Elisha Yaghmai

And it's not that the electronic record was smart enough to say, hey, there's a tumor, and anybody respond to this, I don't see a diagnosis corresponding to this, you know, CAT scan report. So stuff a software could have done even a few years ago, Suffolk could have done wasn't doing it wasn't doing right. So your your responsibility, your task as a physician in this context is to go back in detail on all of these things.

Elisha Yaghmai

You have to check everything. So down to this point is to double check the diagnoses and confirm if they're true. You have to go back and look through the data to see, was there anything in this that nobody has commented on, no one knows about? Right. Yeah. And you find stuff and the thing is you find stuff and you find stuff with enough frequency that you can't stop doing that.

Jo O’Hanlon

Was everybody looking into stuff like that?

Elisha Yaghmai

No, not everybody was doing that. But this is this is exactly what happens, right? So imagine now you're carrying 15, 16 patients. They're fairly complicated. They have all kinds of all kinds of problems, diagnoses of the things going on right. This puts the here again, this is what leads to the burn up. This puts the physician in an impossible position because what I was doing.

Jo O’Hanlon

What I was doing, it sounds unsustainable.

Elisha Yaghmai

I'm going into seven and I'm going all day, right? I finish up at 7 p.m. or whatever it is. I go home and I chart for four more hours. Easy, right?

Jo O’Hanlon

Charting what you've been working on or going through past both.

Elisha Yaghmai

Both. Yeah, right. So I'm writing down what I did that day, and then I'm also going back to past data, right? And I have to do this at least once an admission for every patient. If I'm if I'm doing my job properly, I have to do this right. And so so I'm putting in all that time. As soon as I say 4 hours, it could be later than that.

Elisha Yaghmai

Right. So so does that. I'm finishing up at 132 in the morning. Right. And then I got to get up and go back in there at 7:00 and then do it again and then do it again and then do it again and then do it again. Right. All this is happening. And if I don't this, I'm doing a disservice to my patient who trusts me to try to provide the best care I can.

Elisha Yaghmai

Right. But providing the best care I can means I have to sort through all of this chaos that's produced by bad deficient software, by misaligned incentives. Right. In terms of accuracy, yeah, right. I have to sort through all of this to try to find what the actual truth is. Right. And so this what you end up with is a situation where you are you are forced to choose between killing yourself or killing your patient.

Elisha Yaghmai

This is the choice you have to make because your every time you don't do diligence, there's a risk, right? I mean, malpractice risk. I mean, there's a risk to a real person, right? You're going to mess something up. You're going to miss something that that dramatically affects their life in a negative way. Right. But the amount of effort and energy you have to put into that, right.

Elisha Yaghmai

Is grinding you down to dust over time. This is the issue.

Jo O’Hanlon

So do most people just not do it?

Elisha Yaghmai

A lot of people don't. I can't speak for most. Right. It's going to vary from physician to physician. But yes, a lot of people cut those corners. They cut the corners because they're like, you know what? My kid's got a baseball game, right? I got to get out of.

Jo O’Hanlon

Here because, I mean, yeah, it sounds it sounds unsustainable in a way. It's it must be such a hard thing to continue to. I mean, it's just burning. Yeah, it's a burn out system.

Elisha Yaghmai

Yeah, it just burns.

Jo O’Hanlon

So were you were you ever influenced or persuaded to miss code, like, intentionally for a higher code?

Elisha Yaghmai

No, I didn't. I had only one episode. So what I would code I would code by criteria. Yeah. If they met the criteria, I would code it. Even if I knew very well that clinically that was not what they had. Okay. And that's because that's the game. That's what you're supposed to do. It's not even like it's illegal.

Elisha Yaghmai

It's just a thing that doctors do, right? They're instructed to do it. You're taught how to do it. This is the thing that you do. I had only one episode where someone asked me to falsify a code and that was where the patient had a post-operative infection. And the surgeon came up and asked me to call it something other than a post-operative infection, because that dings your payment.

Jo O’Hanlon

For the surgery.

Elisha Yaghmai

For the surgeon and for the for the case. Right. The hospital can lose payment. I forget how it all works now, but I think if you get readmitted for a post-op infection, it comes out of their hide in some way or financially. But again, let's go back to get to the question of accuracy. Right. So the purpose of having a penalty assigned to post-operative infections to try to reduce your risk of it, to force people to pay attention to post-operative sex and try to reduce the risk of that.

Jo O’Hanlon

Right. Right.

Elisha Yaghmai

But wouldn't you want to know accurately when they're as opposed to having an infection so you can figure out who your worst offenders may be in terms of post-op infection and investigate what they're doing or for that matter, I say worse, who your best people are. What are they doing right that makes them superior, Right. But you have a strong disincentive to tell the truth because it hurts you financially to tell the truth.

Elisha Yaghmai

Right. So here again, you're patient. You're like, I need a surgery. I want to I want a surgeon has a low post-op infection rate, right? You Have to hope that the surgeon is honest. You have to hope that the hospital was honest when you're looking. If you even if you can even find their post-op infection rate, which I challenge most people to do, it's very challenging to even get that information.

Elisha Yaghmai

But if you could find it, you have to hope that everybody involved in any post-operative care was actually honest about it. Yeah, because it's just a matter of saying, okay, it's not a post-op infection. I won't use that word. I'm just going to say, they're septic due to an infection. They had a they had a soft tissue infection.

Jo O’Hanlon

So in terms of their medical record, it could be similar. But in terms of the actual surgeon's record, correct. Then you have skewed did.

Elisha Yaghmai

Exactly you have skewed data, which makes the makes the post-operative outcome look better than it is by hiding an infection, by naming it something else. Right now, you say, well, that's sick and should be. I'll get away with that. Well, the reality is, do you think anybody's actually looking through the charts regularly to see, yeah, you falsified it here?

Elisha Yaghmai

That wasn't that wasn't just an infection in a soft tissue infection. That was a post-operative infection. Right. It occurred within whatever, you know, one day of a surgery, two days of a surgery at the surgical site. Right. Which is exactly what that case was. Right. So in that situation, I did not do that. But I was like, this is an awkward situation, right?

Elisha Yaghmai

Because what I'm basically having to do is I'm having to take a step which dings one of my colleagues. Right? So now there's a potential for bad feeling, Right? Right. Dings him in some way, dings the hospital in some way. Right.

Jo O’Hanlon

Well, and ultimately, it shouldn't be a potential for bad feeling because ultimately, it's nowhere near your fault except that there's this pressure from there's this.

Elisha Yaghmai

Pressure.

Jo O’Hanlon

Person because they're part of the system. Yeah.

Elisha Yaghmai

There's a pressure to change which you. Right. Not to change your management to change it you right. Because it makes everybody else look better.

Jo O’Hanlon

Right.

Elisha Yaghmai

But the problem is it makes them look better than they are. Right. And all of that, again, you can kind of he drifted back culture, medical education, if you recall correctly. Right. It's all about hiding weakness. Yeah, it's about hiding weakness. Pretending you know everything. Pretending you have no flaws. Right? Here we are again. Right. So rather than saying let's identify the flaws, let's make it non punitive, let's make it non punitive.

Elisha Yaghmai

So let's identify the flaws. Let's figure out why they're occurring and let's improve it. Yeah, We're going to throw you out with the trash, right? We're going to acknowledge that different practitioners are going to have different approaches and therefore different outcomes. But there is something that we can learn from both the ones that are better than average and the ones that are worse.

Elisha Yaghmai

Yeah, we can learn best and worst practices and we can we can all improve from this. Rather than saying You're bad, right? You have this bad outcome, shame on you. We're going to take your money away.

Jo O’Hanlon

Right?

Elisha Yaghmai

Right. Again, what do you what do you want Your system to produce for you? What it produces now is a strong incentive to be dishonest, which I'm not saying everybody does. In fact, most people may be perfectly honest, but you have an incentive to be dishonest, Right? So again, that goes back to that sort of those ethical and moral questions, right.

Elisha Yaghmai

Of what am I here doing and why am I why am I doing this right? So imagine we have all.

Jo O’Hanlon

The best for.

Elisha Yaghmai

This patient. What is best for this patient is, as you notice it, not even really a question, right? Not even a question.

Jo O’Hanlon

Yeah. It's what's best for the hospital, What's best for the surgery? That's right. Yeah.

Elisha Yaghmai

Yeah. This is. This is the situation, right? So we have to have that that element of it that's there while all that is going on right. You're getting just relentlessly pounded with just patients, volume of patients, volume of patients, more and more people coming in. Right. One of the things you learn from that is on average how unhealthy the country is.

Jo O’Hanlon

really?

Elisha Yaghmai

Yeah, You see, because you see people coming in. Huge burden of disease that comes into hospitals is self-inflicted in the sense that it is due to behavioral choices, lifestyle.

Jo O’Hanlon

It's preventable.

Elisha Yaghmai

There's preventable stuff or it's least at least it's stuff where we could have reduced the burden of disease, right? If we had a different food system, if we had more walkable cities, if we had more emphasis on getting rest. Right. You name it, right? Yeah. If we had a different national culture or a different social approach, we not all have to be here dying.

Elisha Yaghmai

Right. But we are.

Jo O’Hanlon

You're privy to seeing probably the outcome of a lot of broken system.

Elisha Yaghmai

That's correct. You see all of that dumping into your hospital all day, every day. Right. And and it's relentless and it just keeps going. And it's high stress because people are sick. And you are expected, as we discussed before, you're expected to fix them and you're expected to do it perfectly. Doesn't matter what time of day it is.

Elisha Yaghmai

Doesn't matter what else is going on in your life. Works perfectly right.

Jo O’Hanlon

While also personally not being able to rest, eat or.

Elisha Yaghmai

All fail.

Jo O’Hanlon

These properly would yes that you're seeing the results of.

Elisha Yaghmai

All these things are happening. Yeah. You know and so that has a corrosive psychological effect. It has a very corrosive psychological. So one of the things that is that we see in medicine, I certainly see it is the psychological corrosion of of colleagues and right where they started in medicine as a certain type of person in a certain way.

Elisha Yaghmai

And by the time they've gone through five or ten years of this, they hate everybody. Yeah, just angry, you know, they're just unpleasant. Right. So here again, my patient was my doctor. Such a jerk. Right?

Jo O’Hanlon

Right.

Elisha Yaghmai

Well, some of us are just jerks, right? This could be, you know, other people. And they were jerks before they became a doctor. I'm still a jerk with an M.D., Right. But a lot of it is this process of slow, grinding that's going on just keeps getting worse and worse. And over time, you're getting ground down, you're getting older, your energy levels getting lower.

Elisha Yaghmai

Your level of idealism is now in the basement, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

And all this is happening and you're being asked to do all of this, right, and still present this, like cheerful smiley face. And for a lot of people, it's very difficult for them to do. And so for people that I've known for a long time, if I look at their progression over time, I've certainly seen it. I'm like, Wow, you know the difference between you when I first met you and you now is substantial.

Elisha Yaghmai

Not in a good way, right? Yeah. And you can turn that mirror back on yourself. I certainly can write and say the same thing. Right. Which is this is this is making me worse as a person. Yeah. Than I to be, right. It's just, just your, your patients, your tolerance, your kindness, all these things are just getting ground down and ground down and ground down.

Elisha Yaghmai

And you feel it right? But there's, you know, what else? Are you supposed to do? This your job, right? Yeah. So you just keep showing up for the thing.

Jo O’Hanlon

Which speaks back to that that phrase that you had heard, you know, the burnout is not about necessarily just being overworked. It's about working too hard to do the wrong, like doing the wrong thing. Yes. Or the things that you're not meant for. And I feel like that you're describing both being overworked but then also overworked with a high emphasis and time commitment to pieces that were not your motivation.

Jo O’Hanlon

Yes. Medicine. Yes. Yeah. Well, I'm with that. We're about out of time here, but I next time want to touch on where that burnout that is highly understandable how you arrived there. And thanks for describing all of that. That's really enlightening. But next, I want to talk about where that burnout led you, because I understand that that's a bit of a pivot point in your story and takes us up to date, which is how you and I have known each other some.

Jo O’Hanlon

We'll pick up there next time. Thanks, guys.