KrisEmily McCrory, MD

’s blog features contributions from members of the medical community. The opinions are that of the writers and do not necessarily reflect the opinions of 

I have packed away the holiday decorations. I have also written off the missed opportunities and almost accomplished goals from the previous year.

I have started to focus my goal-oriented attention on the future. I have asked myself what I want to accomplish this year and how I will do it. Most of us take the New Year as a reflection point, a taking of an account, so to speak. I invite you to do the same. Ask yourself: What do I want to accomplish this year? How will I do it?

Here are five steps I am taking to accomplish my goals.

Our doubts can stop us even before we start, so start there. Identify your barriers: What do you think will stop you?

I want to elevate my public speaking to the national level. My inner critic quietly whispers my faults, my previous rejections, all the reasons I am not ready. We all have this inner critic. It’s how we choose to respond to it that matters.

This year, I shouted back at my inner critic: I am ready to try. I have practiced and improved my presentation skills. Observing experienced and talented presenters has helped me to fine tune my skill set. Feedback from regional and state presentations have helped me to smooth my idiosyncrasies and modify my style.

What about you? Are you ready to push back against your doubts and dream big?

Dreaming may be the first step, but you need take many more steps to get there. The second step is to plan out what you need to do to arrive at your destination.  

I like lists. Their orderliness keeps me on target. Breaking down a larger goal into small actionable items rewards me with the ability to cross off my progress and encourages me to maintain the forward momentum. The mere act of writing down steps provides a tangible road map to follow.

Getting onto a national stage to speak about medical education, women in medicine, or another medical topic I am passionate about requires forethought. My initial steps include identifying relevant conferences and turning to my network of physician educators for opportunities. I will draft ideas for a few presentations. That way, I will be ready whenever calls for proposals are announced and submissions are opened. Then I will commit to submit. Each of those steps also can be further divided as needed.  

What are your steps? What will your journey look like?

Don’t let the plan you have carefully detailed get in the way of actually reaching your goals. A change in timeline or new opportunities can bring you closer to success-if you maintain a goal-oriented perspective. For my own goal, tunnel vision could prevent me from seeing or seeking out previously unconsidered venues to speak.

When faced with potential opportunities and distractions, carefully consider how these affect your path. Ask yourself: Will this get you where you want even if the journey looks different? If it does, then consider taking an alternate route to your destination.

Sometimes, we get it wrong. Sometimes, we fail despite doing everything correctly. Learn and persevere.

I have submitted proposals that have been rejected. I have found that picking myself up, understanding provided feedback, and refocusing on the next submission keeps me from wallowing in discouragement.

Remember to celebrate even the small victories. I recently had a poster accepted for a national conference. It’s not quite a speaking engagement, but it’s still at the national level.

Each step forward matters. Look for wins that can keep you motivated on your journey.

I ask you again: What do you want to do this year? Once you have your answer, go do it!

KrisEmily McCrory, MD, FAAFP practices full scope, academic medicine in upstate New York. She works actively with family physicians both within the state and nationally in the area of medical education and curriculum, women’s health and maternity care, as well as issues related to the family medicine workforce.

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Think about what you want to accomplish this year, then list how you can achieve your goals.

5 ways to make this your best year yet 

’s blog features contributions from members of the medical community. These blogs are an opportunity for professionals to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions are that of the writers and do not necessarily reflect the opinions of 

The individuals I take care of on a daily basis are my patients. They are neither my clients nor customers. For several years, I have been mortified at the implication that I provide a service akin to selling a car. Referring to patients as customers shifts the focus solely onto customer service and the transactional nature of exchanging goods for money. When administrators with their business training subtly adjust the language, it profoundly changes the physician-patient relationship. As a physician, I feel it demeans the actual time and effort I take in caring for my patients. Recently, I realized what it does to my patients is even worse.

The word client implies someone with a need that can be satisfied through an agreed upon payment to the provider of the service. To some extent, there is a balance of power. Clients have the ability to choose where to spend their money and can often use that as leverage to gain a desired level of service. Service providers want to attract customers who are likely to spend money. Significant time and money go into advertising and gimmicks that will bring in the right customer. Individuals who cannot or will not spend money are quickly pushed to the side to make way for paying customers. Service providers have a priority on profits. The goal of customer service lies in keeping customers happy so they will spend more money.

Medical care has been pushed more and more into a business model looking to reap profits. The rising costs of healthcare in this country attest to our nation’s inability to curb medical costs. In a business model, when costs go up, the price of services is passed on to the consumer. When the price of a car goes up, customers can buy a cheaper make or model, but healthcare is rarely as flexible. Customers have the ability to take their business elsewhere, but patients often do not. They are limited by insurance coverage or lack thereof. Barriers to care prevent mobility, as does access to reliable and convenient transportation. A client can usually live without a car, but lack of healthcare can-and does-kill patients.

A push for improved bedside manner and frustration at the system has lumped customer satisfaction into patient care. The original intent may have been better communication and patient well-being. But in many instances, low patient satisfaction is a result of not receiving the requested antibiotics, imaging, or other warranted diagnostic testing as opposed to poor medical care. The actual root causes of poor patient outcomes rarely show up on a patient satisfaction survey.

Within the very nature of a physician patient relationship there is an undeniable level of inequality. Referring to patients as clients does not remove that imbalance of power. Rather, it only serves to gloss over it. Patients are ill or injured, sometimes gravely. Patients are exposed. Patients are often alone. Patients are vulnerable. Service providers have a commitment to profits first and customers second. Physicians, however, have a responsibility to their patients.

I have a professional dedication to my patients: to care for them, to listen to them, and to give them the best of my medical experience. A physician-patient relationship implies shared decision making using my medical knowledge paired with my patients’ values and needs. When patients become clients, they seem less vulnerable than they are and less in need of compassion or care. Medicine must return to patient care and not merely customer service.

The push to provide customer service comes at a cost to the physician-patient relationship.

The danger in treating patients as customers

Everyone has a sweet spot: that moment when you are doing exactly what you are meant to do. Daily distractions try to pull you away from your sweet spot and those interferences can derail our progress. Amid the everyday hustle and bustle, how can you keep yourself focused?

First, know the vision or mission that defines your sweet spot. Are you passionate about teaching or writing? Looking to be an advocate or mentor? Take some time to sit down, reflect on, and identify your long- and short-term goals. Those will be your guideposts. Once you can articulate those, you will be prepared when distraction knocks at your door.

Each time a request demands your attention, ask yourself: Is this in line with my sweet spot? Will this get me closer to achieving my goals? If so, the request is probably worth your time. Conversely, anything that doesn’t bring you closer to your sweet spot merits closer evaluation before you accept. Your time and resources are valuable, and often you are the only one who can protect them.

When my current employer began the process of upgrading the electronic health record (EHR), they sought out a physician champion to liaise between the clinicians and administration. They approached me for this position, presenting it as an opportunity to act on behalf of my colleagues to create a more functional system. (Certainly, I would also be a mouthpiece for the administration with a duty to smooth the way in the face of skeptical physicians who felt they had been given little say in the new EHR.)

Initially, the offer intrigued me, and I felt flattered to be considered. However, I realized the time commitment would be significant. I was told it would be the equivalent of 10 hours per week. My current full-time position lists 40 hours per week on paper. In reality, my work consumes much more of my time. As a full scope family physician and residency faculty, I easily work an additional 20 plus hours each week on administrative, educational, and call responsibilities. Adding more responsibility meant something would have to be sacrificed either at work or at home.

In a meeting with administration to discuss potential logistics, I asked what compensation they anticipated for the position. They looked at me with blank stares. After some stammering, they explained there was no additional funding. Rather, they anticipated I would cut back on my current clinical, teaching, and administrative activities.

So, there I was, being asked to contribute my time and resources for no additional compensation. I asked myself whether this new responsibility would put me in my sweet spot. Certainly, this could be a great opportunity to be more involved in higher administration, even leadership roles. But was that my goal?

My long-term goals include more leadership roles, but ultimately, I envision myself more in an academic leadership capacity. The physician champion role would have taken me away from my current teaching and supervisory duties. The position required more work but offered no pay. Although administration may have envisioned my time could be easily parsed out, I knew that my responsibilities to my patients, colleagues, and residents played out in a more fluid way. There was no way to cut out a discrete 25 percent of my duties. Medicine is not that kind of work.

In medicine, we are often fighting with our high-achieving selves. We want to say yes, and I did want to say yes. I feel compelled to answer the call in front of me. I think we all feel that way at times-a responsibility to honor one more request, to squeeze in one more task.

Sometimes that is OK. Sometimes, saying yes provides you the opportunity to work with someone or somewhere worthwhile or offers you a reward or compensation. Then, it may make sense to agree to do something outside your sweet spot. But at that moment, it was clear that while I could do the job, I was being asked to do more work for no additional compensation or benefit. I thanked them for the opportunity and politely declined. I knew the value of my time. This was not my sweet spot. It would not advance me in my goals nor did it align with my vision.

When opportunity knocks on the door, question its value and benefit before you add one more item on to your to-do list. Consider whether it moves you along in your journey. Consider whether it helps you achieve your grand vision for your career or life. Consider whether it puts you in your sweet spot.

Reflect on what requests you want to accept before obediently saying yes, especially those that detract from your career goals.

Protecting your sweet spot

Recently, a Goldman Sachs memo reportedly asked, “Is curing patients a sustainable business model?"

For this exact reason, health care cannot and should not be viewed in the same vein as other consumer goods. Lumping medical care into the same category as a buying a car or houses strips away its essential difference from other services. The increased focus on the business of medicine serves to remove the actual impact on individuals and society.

Health care is expensive, especially in the United States, where often bloated administration, unrestricted drug costs, and fractured care systems push up costs. Patients are easily blindsided by bills for services they do not understand. Physicians are forced to walk a thin line between the most appropriate test/treatment and what an outside entity will pay for.

Value-based payment systems cloaked in a false claim of improving health care penalize physicians for the inability to achieve quality measures but fail to address the actual barriers patients face. How can physicians deal with poor disease management in patients who cannot afford medication or have no leeway to miss work for an appointment? Patients in front of me live in a food desert, while the cost of insulin is hijacked by greedy pharmaceutical companies and the wisdom of the insurance company is to reimburse less or not at all for missing an imaginary quality marker the outcomes that actually matter suffer.

Curing patients is not a sustainable business model which is why we must move away from a private health care model. It’s built-in inefficiencies and unabashed focus on profit have left this country with a declining life expectancy and other health outcomes expected of a third-world country.

Improved health benefits society. Healthy adults can work and contribute the economy. Healthy children can focus at school. In a culture that places high values on the individual, it can be difficult to propose a single, national health care system. Yet, as Walter Cronkite once mused: “America’s health care system is neither healthy, caring, nor a system.”

-Kaiser Family Foundation poll found that 51 percent of Americans support a single payer, Medicare for all system. Evidence from other countries with socialized medicine demonstrates that by providing essential health care to citizens without burdensome costs increases access and improves health outcomes. Every other industrialized nation has figured this out, the United States needs to get on board.

Certainly such a system requires substantial changes from our current, splintered system. Yet imagine the improvement. A streamlined individual medical record that allowed seamless communication between a patient’s family physician and a specialist could save money in reducing redundant blood tests and imaging. Medication errors could be reduced if all members of the health care team could see that another member had stopped or started a prescription. Patients who have moved would not need to wait weeks or months for prior offices to fax (yes, we are still faxing) medical records.

Beyond the potential safety benefits, a universal system that did not rely on individual, often insufficient, insurance could begin to breach the gap of care. Instead of seeking more expensive, emergent care once a condition has deteriorated, patients could receive appropriate preventive and early disease treatment. A single payer could have immense sway in negotiating with pharmaceutical companies as there would be few other avenues for sales.

Removing executives with an eye on profits in favor of physicians and clinicians focused on patient care will shift the emphasis from sustaining a business model to sustaining a healthy population. If I could spend my day truly providing patient instead of filling out absurd prior authorizations or being pressured to see more patients to make up for declining reimbursements, I could probably meet more of those quality measures. More importantly, with appropriate resources, I could have healthier patients.

This is, of course, just a starting step. Even if we are able to enact a true national health plan it only begins to address some of the larger problems. We need to continue to push for methods to fight poverty and the barriers to care that stem from being poor. Both insidious and overt racism within the medical care system must be fully acknowledged and overcome. Inclusion and diversity must be a guiding principle. In a country with the advanced capabilities and vast wealth of the United States, it is inexcusable that anyone here is denied the ability to live a healthy life. Business models are designed to include only those factors that fit the bottom line. What we need is a health care system that promotes health for everyone in a caring manner.

This doctor believes the American health care system can and must do better in terms of providing for patients.

A Health Care System that Cares

Over the past few weeks, illness has run rampant in my house. Three times, I have brought my husband to the emergency room, sat for hours in a busy waiting room, and then with him as he was on an uncomfortable stretcher.

Despite our diligence in getting our annual flu vaccine, he came down with influenza A and passed it on to two of our four children. We are rarely this ill and trips the hospital are uncommon. Our experience over the past two weeks has shown me how fortunate my family is and how quickly an unexpected illness can put people’s precariously balanced lives into turmoil.

The first endeavor to the emergency room came two days after my husband had returned to work following his paternity leave. A day of non-stop vomiting of anything he put into his body forced me to bring him in for IV fluids. We have multiple hospitals to choose from and I chose poorly.

For two hours we sat in the waiting room surrounded by other ill patients waiting for the overworked triage nurse to take the initial history and vitals. Then we waited for another hour despite his tachycardia and mild hypotension. Once we finally saw the doctor and received two liters of fluid and anti-emetics, my husband felt like a human being again. We headed home, not realizing that he was taking home a small viral friend with him.

Two days later the cough, fever, body aches, and more vomiting racked his body. We went to the emergency room and were eventually admitted, my husband missed the remainder of work that week.

When he got home two days later, with strict instructions to remain out of work, he lay exhausted on the couch, desperately wanting to help out around the house and with the care of our four children. Within 24 hours, our two teenagers had flu-like symptoms and I was left to tend the house, care for our two younger children, and get through work by myself. Soon, I had my husband back in the emergency room for pneumonia.

Despite the immense strain I felt, I knew I was actually lucky. I had family nearby that could help care for my children, while I sat with my husband at the hospital. My generous colleagues at work helped cover some of my duties. My health insurance covered the vast majority of the costs of the emergency room, admission, and medication. I had sufficient income to cover the co-pays. I did not need to choose between feeding my family or my husband’s medical care. I had the ability to transport him to the hospital.

Despite the challenge, I could in fact take care of my family in this time of illness and not be on the brink of losing my home or my job. That may sound ridiculous at first, but for so many individuals in this country, their reality is shift work with no paid sick leave. If they are not at work, they are not paid.

Since so many are barely living paycheck to paycheck, any loss of wages can create a nightmare where they cannot feed their children, lose their homes, and have the inability to provide basic support to their families. In a country that is as wealthy as we are, it is a disgrace that something like an acute, finite illness can devastate a family. This does not even begin to speak to the challenge of families trying to cope with chronic illnesses.

For so many, it is not merely about having enough money for necessary health care, but attaining true health care access. They lack time to get the care they need. The costs of treatments create barriers to appropriate or timely care. Inflexibility with employment means potential loss of work if they need to take time off for illness. The need to work multiple jobs to make ends meet forces inadequate sleep and rest.

The stress of even a minor illness plagues families. We desperately need to look to developing a system that truly helps and cares for people. This country needs to be a compassionate place where patients get the appropriate, necessary care without the burden of skyrocketing costs or loss of livelihood. A place where they can get well.

A recent wave of sickness in this doctor's family made her realize how inconvenient it is for many people in this country to be ill.

The Cost of Being Sick in America

 found by a passerby sitting in a wheelchair clothed in only a hospital gown appalls physicians and non-physicians alike. Yet these types of occurrences are not uncommon in our broken health care system.

Given the recent attacks on the Affordable Care Act and likely further rolling back of Medicaid and Medicare, this kind of patient dumping will only get worse. Incidents such as this highlight the need for a system overhaul. Patients requiring acute care need access and I am reminded that our expensive acute care system is not even the best venue for care for many of our patients.

One evening, I received an admission request from the emergency room. Listening to the history provided, I knew that an acute inpatient facility was inappropriate. The elderly woman in the emergency room had no acute medical condition,-no injury, no acute mental status changes, no illness. She had dementia and her family, who had been caring for her at home with no outside help, dropped her off in the emergency room and left.

I tried to explain to the ER physician that I had no resaon to admit this patient. Utilization management would be quick to call me and explain that the patient did not meet admission criteria and we would likely not be paid. He argued back that he could not simply discharge a demented elderly woman onto the street. Of course, he was right. She met no admission criteria, but I had no choice but to admit her, there was nowhere else for her to go.

Her family, likely burnt out from caring for her with minimal or no services, reached their limit. She couldn’t stay in the emergency room, but bringing her up to an acute floor would tax an already overburdened nursing staff, take a bed from a patient who needs an acute bed, and ultimately not offer the type of care this patient actually needs.

From previous experience, I know that procuring the maintenance and respite care needed to keep her home with her family costs more than most families can afford. This is especially true of families in my poor, urban communities. Even with all available resources, caring for a demented family member strains even the most altruistic individuals.

Obtaining nursing home placement for patients with dementia can be equally challenging and time consuming.  Most private payers do not cover nursing home care. So while we wait for weeks or months for families to figure out the financials, for the patient to qualify for Medicaid, and an appropriate nursing home to accept the patient, they sit in a hospital bed. Administration will call every day asking about length of stay and what the team is doing to get the patient out of the hospital.
During this time the patient will be potentially exposed to any number of infections and other nosocomial conditions. She will be in an unfamiliar, scary environment increasing likelihood of behavioral issues that decrease her chances of a nursing home offering a bed.
Our current system fails many patients and families in these situations. Rarely do families have access to resources to care for elderly relatives, especially demented patients, at home. Even when money can be found, the number of competent caregivers available is limited. Nursing home care is expensive and can be cumbersome to access.

Again, competent care can even be challenging to find as these facilities and overtaxed staff may find themselves lacking resources as well. So these patients ping pong in a system ill-equipped to help them or their families. These scenarios are not limited to merely our demented elderly, but can be seen in patients seeking timely mental health treatment and other chronic conditions that should have been able to be managed in a non-acute setting.

This country needs a health care system that affords families the resources to access help, allows physicians to provide appropriate care, and identifies appropriate facilities for patients. Our current system focuses almost solely on episode-based acute illnesses and injuries and, as such, our emergency rooms and hospitals are generally designed to care for these conditions, not the chronic, often debilitating illnesses.

A strong primary-care presence can help patients and their families before situations become dire and desperate. A system with robust social services and ample case managers and social workers to help navigate could bring patients both the non-medical and medical care they need. A payment system not weighed down with excessive administrative costs and inefficiencies would allow physicians and other members of the health care team to provide appropriate, necessary care in a timely fashion and appropriate venue. No patient should be left in the cold.

A recent case of a patient left in the cold in Baltimore is not an aberration, it's a symptom of a larger problem with this country's health care system.