Reports from the bedside: Observations on the ‘NMP’ Culture endemic in many U.S. health systems

by Gregg A. Masters, MPH

Introduction

In the fast-paced and complex world of acute healthcare in the United States, the ‘NMP’ (Not My Patient, Not My Problem), see New England Journal of Medicine) culture continues to compromise patient care quality, outcomes and experience for many. Historically and pre- EHR era, the code was occasionally noted as ‘NMP’ in physician notes, the practice remains embedded in the predominant and prevailing specialist culture found in most U.S. healthcare systems. The feature or perhaps better framed as a ‘bug’, is particularly evident in academic medial centers and their affiliated teaching hospitals. The NMP practice is characterized by a diffused lack of team based accountability, less than ideal teamwork, and most certainly compromised empathy, leading to detrimental effects on patient centric care and overall healthcare outcomes. In this article, I address the root causes of this problem and explore potential solutions to advance the triple aim, i.e., better experience of care, better outcomes at lower per capita costs.

Understanding the ‘NMP’ Culture

The NMP culture is a creature of a combination of factors within legacy U.S. healthcare. One key element is the fragmentation of care, where different clusters (team huddles) of specialist and sub-specialist physicians theoretically ‘supported’ by an army of related allied health clinicians, attempt multidisciplinary collaboration in host institutions with different workflows, cultures and degrees of independence. This compromises effective communication in team based care models deployed by ‘sacred cow’ department heads. This often uncoordinated and silo-ed approach fosters a sense of detachment (aka NMP) hindering effective team based collaboration among otherwise engaged and caring health professionals.

Moreover, the heavy workload, historical internecine power struggles between medical staff, nursing, administrators, and often “non-compliant” patients (especially those in head or brain injury units) and/or their family members, and demanding nature of healthcare contribute to a culture of burnout. Thus the need to ‘check out’ or distance themselves from the patient and even other members of the care team – sometimes in a passive aggressive style. Overworked and stressed healthcare providers may inadvertently adopt an NMP mentality as a coping mechanism to protect their emotional well-being. This, in turn, negatively impacts the quality of care they deliver.

Consequences on Patient Care

The consequences of NMP culture on patient care cannot be overstated. When healthcare professionals prioritize their own, perhaps narrowly cast, responsibilities (i.e., documentation for billing, QA, or other internal or external reporting requirements) over the overall patient experience, gaps in care are likely to surface. Patients may encounter fragmented treatment or worse treatment, missed or misdiagnoses, medication errors, and delays in receiving necessary care. These lapses can lead to compromised patient safety and suboptimal health outcomes.

Solutions to Overcome the ‘NMP’ Culture

Addressing the NMP culture requires a multi-faceted approach that involves various stakeholders within the healthcare system. Here are some potential strategies to foster a patient (v. historically provider) centric culture of collaboration and accountability. Absent same there is no holistic 360 vision of the patient’s experience or needs:

1. Enhancing Communication Channels: Implementing robust communication systems that facilitate seamless information sharing among healthcare providers can bridge the gaps created by fragmentation. This includes the integration and optimization of electronic EHRs and associated workflows and secure messaging platforms to ensure timely and accurate exchange of patient information.
2. Promoting Teamwork and Collaboration: Encouraging interdisciplinary teamwork through initiatives such as regular team meetings, case discussions, and collaborative decision-making can foster a sense of shared responsibility. This approach promotes a patient-centered care model and discourages the ‘NMP’ mindset.
3. Emphasizing Empathy and Patient Advocacy: Incorporating empathy training into healthcare education programs and continuous professional development can help healthcare providers recognize the importance of patient-centered care. Additionally, empowering patients, their proxies and/or family members through education and shared decision-making can contribute to a more proactive and engaged healthcare experience.
4. Prioritizing Work-Life Balance: Recognizing the impact of burnout on healthcare professionals is essential. Implementing policies that promote work-life balance, offering mental health support programs, and encouraging self-care can help reduce burnout and mitigate the NMP culture.

Take Away and Policy Implications

NMP culture in U.S. healthcare poses significant risks, challenges and upside to patient care and overall health outcomes. By acknowledging its root causes to implement targeted solutions, we can begin to foster a culture of accountability, timely and effective teamwork, and an empathetic patient centric care team. Embracing open communication, promoting collaboration, and prioritizing patient-centered care will pave the way for a healthcare system that truly puts patients first. We must re-examine the influence of our prevailing fee-for-services or ‘production’ driven medicine (do more to earn more) financing and delivery paradigm to transform a too often calcified and transformation resistant health system culture.

For additional context, see: In Memory of Anthony John Masters , Tony Masters Forever: Friends Share Their Experience and A Father’s Grief and Need for Answers.

Be social and follow hashtags #TeamTony, #EndNMP and #NMP on twitter for updates as well.

As colleague and author of Fragmented: A Doctors Quest to Piece Together Health Care Dr. Ilana Yurkiewicz notes during our conversation with her on Health UnaBASHEd for HealthcareNOW Radio:

‘there are no ‘bad actors’ in this space, only victim’s‘

Dr. Ilana Yurkiewicz

To which I add: patients, family, friends and colleagues who bear the burden of the memories and intense sense of loss.

We can and must do better! Lives are on the line, folks. Let’s end the NMP Problem in medicine!

Thank you for your support.

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Author’s note: written from the bedside of a head trauma patient admitted to a teaching hospital affiliated with a world class medical school in New York City.

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