Physician
burnout impacts 83 percent of hospitals, hampering patient-provider
communication and a positive patient experience.
The healthcare
industry is undergoing a period of rapid technical and clinical innovation as
it moves away from episodic, reactive care.
While data-driven
decisions and holistic approaches to patient management can bring significant
benefits, these new strategies are also creating a mounting problem: physician
burnout is increasing at an alarming rate.
Physician burnout is
a problem at 83 percent of healthcare organizations, according to a 2018 survey published in the New
England Journal of Medicine Catalyst.
The Agency for
Healthcare Research and Quality (AHRQ) defines physician burnout as “a
long-term stress reaction marked by emotional exhaustion, depersonalization,
and a lack of sense of personal accomplishment.”
As these feelings of burnout
fester, they seep into the patient-provider relationship and erode the patient
experience.
“The problem with
physician burnout is that it leads to worse quality care,” John Cullen, MD, the
president of the American Academy of Family Physicians (AAFP), said in an
interview with PatientEngagementHIT.com.
Part of minimizing
burnout is recognizing the value that physicians bring in to organizations,
financially and otherwise.
Physicians that do
not feel engaged by their places of employment are more likely to be
disaffected - and may, in turn, be more likely to retire earlier or seek non-clinical
roles. The resulting exodus from clinical practice is anticipated to have
a major negative impact on access to care.
And when doctors do
stay with their jobs in the medical field, the quality of care declines,
putting patients in jeopardy. Burned out physicians are at elevated risk of
errors that could result in patient safety concerns, research has shown.
At the root of the
physician burnout issue is the seemingly never-ending to-do list doctors face
each day. In addition to traditional clinical tasks, new payment models have introduced a
litany of administrative and documentation demands.
Rather than focusing
on the clinical duties and patient relationships that have long characterized
the medical profession, doctors are being forced to spend hours each day
working with EHRs to meet documentation requirements. Physicians
employed in larger health systems may also face additional burdens related to
system-level quality and performance.
“For family
physicians, working for a health system is one of the risk-factors for burnout,
more so than being in an independent practice,” Cullen explained. “A lot of
that comes from administrators not understanding what patient care is about,
and really demanding that family physicians do things that are really not where
our skills are best used.”
“What we should be
doing is working with patients. That's what we've been trained to do and why we
went into medicine.”
Although Cullen
speaks for his own specialty of family medicine, the importance of having
enough time to develop meaningful relationships with patients rings true for
nearly all doctors.
The 2018 Biennial
Survey of America’s Physicians from the Physicians Foundation revealedthat good patient relationships
are the greatest source of job satisfaction for 79 percent of physicians.
Doctors come to
medicine to treat patients. The grueling process of medical school,
internships, residency, and continuing medical education all become worth it
when a doctor can improve the quality of life for another human being.
It’s worth it for the
patient, too. Individuals seeking care do not want to interact with a
physician who is distracted, unhappy, or simply too exhausted to have a real
conversation about issues that impact the patient’s quality of life.
“As doctors being
having difficulties with burnout, they have poorer patient interactions because
doctors do not have the emotional bandwidth to communicate with patients in an
empathic way. And patients feel it,” Cullen said.
Eliminating physician
burnout is, therefore, not just an issue for the human resources department.
Burnout is a patient engagement killer, and preventing disaffection from
poisoning the patient experience is a key concern for health system leaders and
industry policymakers.
HELPING
PHYSICIANS MAINTAIN THEIR EMPATHY
Between analyzing
patient data, checking the boxes of the EHR, adhering to Medicare or other
payer standards, and fulfilling hospital or local physician group standards,
doctors are left with comparatively little time to see their patients.
In the primary care
environment, physicians may spend six hours a day on entering data into
the EHR, the American Medical Association says. That’s more than half of
the typical 11.4 hour workday for a physician, which already exceeds the amount
of time most other workers spend at their jobs.
Providers who reduce
their patient face-time further may be more able to keep up with their
paperwork, but are actually risking an increase in stress, says Cullen.
“Spending less time
with patients to deal with administrative tasks further pushes doctors into
that cycle of increasing burnout,” Cullen said. “Conversely, having positive
patient interactions really helps open physicians up so that they have more
positive interactions in the future.”
Burnout results in a
loss of empathy with patients that can have dangerous consequences for both
participants in the relationship, he explained.
“In part, burnout is
a clinical depersonalization where one has difficulty reacting to patients with
as much empathy as he needs. From a primary care perspective, that sense
of empathy is so incredibly important,”
“If we see patients
and we're not empathetic, then they're actually not going to do as well,” he
continued. “There's something about the physician-patient interaction
where empathy plays a really key role. We have a tendency to think of illnesses
being a problem that needs fixing, and the physician is the repairman.
But it’s a lot more complicated than that.”
Cullen suggests that
physicians take time throughout the day for self-care and self-reflection -
even if it’s only a few moments here and there during breaks in the schedule.
“Just the act of
washing your hands in between patient encounters should be a mindfulness
exercise,” he stated.
“It is a way of
resetting emotionally. It’s almost like there's an emotional contagion that you
can bring from one room to the next, and washing your hands helps cleanse your
mind of that. I've certainly seen that when I go through very intense visits,
emotionally. If I'm not careful, I can carry that into the next room. And so
washing my hands in between patients is a mindfulness exercise.”
ADDRESSING
BURNOUT THROUGH ORGANIZATIONAL POLICIES
Organization leaders
also have a role to play in addressing physician burnout and its impacts on
patient care. Currently, doctors and hospital or practice administrators are
not always on the same page about physician workloads, Cullen suggested.
Administrative
leaders are focused on fulfilling certain clinical quality metrics, using
patient data to curb costs where possible, and transitioning to value-based
care models. These priorities are not necessarily a bad thing. They are all
central to a hospital administrator’s job and are critical for keeping a
practice or health system afloat.
But administrative
goals don’t always align with clinical realities, which can in turn create
physician burnout. When leadership loses sight of doctors’ responsibility to create
positive patient interactions, it can push physicians to disengage from their
work.
Hospital and practice
administrators have a responsibility to create policies and cultural
expectations that allow employees to work to their fullest capacity without driving
themselves into an emotional crisis.
Practices that give
physicians the resources to make their jobs easier and the benefits that allow
them to recharge will likely see lower rates of physician burnout than those
that do not, according to Cullen.
“Making sure that
everybody feels valued is really important, and even little things go a long
way in that regard,” he asserted.
“Just finding out,
for example, what people need, what would make their job easier, and then
making sure there's enough time for people to go on vacation, exercise, and get
enough sleep, is key,” he continued.
“A lot of family
physicians are spending two or three hours a night before going to bed just
completing the charts they have opened during the course of the day. That's
really detracting from family time, which is really important to prevent
burnout because you need to have those relationships.”
Additionally,
healthcare organizations can establish team-based care models to maximize
their existing resources, according to Jack Stockert, MD, the managing director
of Strategy and Business Development at Health2047.
Team-based care
models tap physician assistants, nurse practitioners, medical assistants, and
other relevant personnel to share responsibilities and allow all clinicians to
work to the top of their skill sets.
“How do we move some
of those things off the plates of physicians? What does it mean to be 100 times
more productive as a physician?” Stockert posited. “That's not seeing another
two, three, four, five patients in the day. It's really contemplating a
breakthrough in workflows, an ability to let clinicians practice in the highest
clinical acuity, and embracing the abilities of those around them.”
When a medical
assistant takes on the many administrative tasks she is qualified to address,
it frees up physicians to focus on complex clinical problems while building the
meaningful relationships they want with their patients.
When designing a
team-based care model, organizational leaders should consider which tasks
non-physician clinicians will assume and the extent to which physicians will
supervise personnel, Cullen recommended.
It is important to
note that burnout is an issue that impacts all members of a care team: nurses,
physician assistants, and medical assistants all also experience burnout, and
organizations need to be careful not to duplicate the problems physicians are
currently facing.
ENSURING
TECHNOLOGY DOES NOT CREATE BARRIERS TO RELATIONSHIP-BUILDING
At the root of many
of physicians’ problems is the onslaught of clinical quality measures, nearly
every expert agrees. Survey after survey reveals that physicians spend too much time documenting
and it is impacting their job satisfaction.
“We're spending
almost two for one right now doing administrative work behind the scenes, so
two hours for every one hour of patient care,” Cullen said. “And that's
something that has significantly increased over the last few years, mainly with
the introduction of electronic health records, unfortunately.”
Consequently, that
computer has literally and figuratively gotten in between the physician and the
patient, hurting patient satisfaction.
The healthcare
industry as a whole can address this by rethinking clinical quality measures,
Cullen said.
“One of the issues
that we're dealing with is the extreme amount of work that we need to do in
order to get things done for our patients,” Cullen stated.
Documentation for
clinical quality measures is a significant part of value-based care, but it’s
getting in the way of physicians delivering patient-centered care, Cullen
pointed out. Doctors who are too focused on documentation are missing out on
patient interactions, and could even miss an important part of that patient’s
diagnosis or clinical care.
Unfortunately, this
is not an area doctors themselves can control. They are beholden to whatever
measures different payers, including Medicare and Medicaid, may want from them.
But payers and
policymakers are starting to take these provider demands into account. CMS, for
example, has been hard at work to simplify provider documentation.
The Meaningful
Measures initiative, announced in the fall of 2017, aims
to look at clinical quality measures most relevant to improving patient care.
The 2019 Physician Fee Schedule (PFS) will streamline evaluation and management
(E&M) measures that many provider groups said were burdensome.
But reducing the
number and complexity of quality measures is only a first step. The
industry must address the fundamental problems of the electronic health record,
Cullen said.
“Electronic health
records still just don't work very well,” Cullen stated. “They’re improving,
but the problem is that electronic records, by and large, are kind of check
boxes. And that's really not how we interact with patients. It's much more of a
holistic, empathetic interaction, and it needs to be in order for us to do our
job. It's hard to translate that into an electronic record.”
The EHR also does not
do a good enough job with presenting the information physicians need, when they
need it, Health2047’s Stockert added.
Between the
clunkiness of the interface and the data that is buried within it, doctors need
to spend time clicking through the EHR before they can begin getting to the
crux of the patient encounter.
“Part of the issues
inside those systems are that they need to enable new types of interfaces for
clinicians to see exactly what they need for this patient in the moment they’re
walking in to see that patient,” he said.
“Right now, doctors
have to spend 10 minutes going around the EHR to find that information. What a
doctors needs is different for one patient than if they’re going to see a
patient with different issues or different conditions.”
Clinical quality
reporting may be outside of any one organization’s control, but the EHR isn’t.
The vast majority of EHR systems allow for significant customization and
optimization.
Organizations that
bring clinical users to the table when designing new workflows are likely to
see the greatest downstream success, Stockert said.
“The best innovations
are dreamed up by the people who will end up using them,” Stockert asserted.
“They're the ones with the pain points, they're the ones with the use cases.”
“As we move beyond
this first and second inning of EHRs as administrative tools, as we've now started
to shine a light on the power of the right clinical decisions actually
impacting business in a positive way, we need to more effectively empower the
right clinical decisions. And to do that, clinicians should be encouraged to
help dream the visions of what is possible.”
Cullen agreed,
sharing the EHR features he believes would improve his own practice and reduce
physician burden.
First, the EHR needs
to be more hands off, with the voice-enabled technology that could
document for the provider. Right now, medical scribes are fulfilling this need for
many providers.
Next, clinical
decision support systems need reworking. While these tools are an integral part
of the EHR, clinical decision supports should be more discrete and integrate
into the technology to prevent alarm fatigue.
Finally, a tool that
creates a care team to-do list—without requiring literal check-boxes or
creating alarm fatigue—would help enable team-based care, Cullen said.
Efforts to address
the physician burnout problem are fledgling, and as industry leaders consult
different solutions to burnout, they must consider which are most beneficial
and feasible for specific physician needs.
Ultimately, these
solutions need to focus on putting patient care at the forefront. Reducing
physician burnout will require allowing doctors to do what they do best:
treating patients.
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