How Doctors Can Find Joy in Practice, Again

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Pursuing the practice of medicine is a pursuit of passion.  The desire to help at the most fundamental level, saving and protecting lives, and to apply knowledge and compassion to make lives better is in the DNA of most doctors.  You have to have a strong desire and passion for the work to endure the long and arduous education and training process.  Unfortunately, the pace of change in the field over the past 30-40 years is draining the joy from practice for many doctors and creating cynical young doctors focused on “lifestyle” sub-specialties where they can make more money and have a more normal lifestyle.  And it is hard to disagree with the aspiration to have a balanced life, especially with today’s demanding practice.  The Triple Aim is the national goal of achieving three improvements, simultaneously, for a defined population of patients: (1) improving the patient experience of care (including quality and satisfaction), (2) improving the overall health of the population and reducing the per capita cost of health care.  It is also suggested that we add the additional aim of improving physician satisfaction to the Triple Aim to create the Quadruple Aim (1).  How can we heal the patient when the doctor is sick?

Physicians, particularly primary care and emergency care physicians, are struggling in today’s healthcare system.  Physician burnout is increasing.  The signs of burnout include a loss of enthusiasm for work (emotionally drained), emotional distancing or treating people as objects (depersonalization) and a loss of meaning and sense of accomplishment in work.  Most studies show that 1 physician in every 3 is experiencing burnout at any given time.  Physicians are twice as likely to suffer from burnout as the general population.  Physicians are also twice as likely to commit suicide.  Unfortunately, things seem to be getting worse.   A 2015 Medscape survey showed a higher percentage, 46%, experiencing burnout and also showed a steep increase in the burnout rate compared to 2013.  This has profound implications for the care of patients because doctors experiencing burnout make more errors, provide more costly care, have less empathy and compassion, and establish less trusting relationships with patients.  Patients seeing physicians experiencing burnout are less satisfied and adhere to medical instructions less frequently.  If you are a patient with a complex medical problem, especially Medicare patients, and you need to see multiple doctors, your risk is compounded if 1 out of every 2 or 3 doctors you see is experiencing burnout.  Over 80 percent of physicians report that they are overextended or at full capacity and that non-clinical administrative paperwork takes up about 20 percent of their time. Only 10 percent of physicians interviewed in 2014 were very optimistic about the future of the medical profession (2).

Root Causes

We are wearing down a precious societal resource and driving doctors to sub-specialize rather than enter needed primary care fields.  Primary care physicians are working harder and getting paid less when you consider increased unreimbursed time related to increased demands.  A series of studies showed that given the increased demands on primary care, it would take the average physician caring for a 2500 patient panel 24.8 hours a day to provide all the services necessary.  

In addition, chronic diseases like diabetes and hypertension often require more time to manage outside of office visits due to the need for follow-up, coordination of care and repeated testing.  One study showed that a physician may need to spend an additional 6.7 minutes, for every 30 minutes visit, outside of the visit which adds up to an average of 7.8 additional hours of work per week (3).  This time is often unreimbursed.  We are not only asking physicians to do more for less but we are also asking them to do a job that is much harder.  In order to achieve the Triple Aim and improve related quality measures for a defined population, you have to influence the behavior and lifestyle choices of that population.  It is tough enough for us to influence our own behavior (e.g. lose that extra 10 pounds) and now we are telling doctors they must influence lifestyle choices for their panel of 2,500 patients and also ensure that patients have an excellent “experience” as well.   Furthermore, the EHR in its current state does not seem to be helping.  In addition to the often awkward and time-consuming interfaces, EHRs also add an hour a day to just deal with notifications (4).  

Signs of hope

Given the passion with which physicians pursue their goal of becoming a physician, it stands to reason that a fundamental aspect of physician satisfaction is the ability to provide high quality care.  The evidence supports this point of view, however, physicians over recent years have seemed to encounter barrier after barrier on the road to achieving this fundamental beneficent goal.  Don Berwick in his typical eloquent way describes the possibility of a third era in the evolution of healthcare in the US, which he calls the “Moral Era” (5).  He states that “Constant conflict roils the health care landscape, including issues related to the Affordable Care Act, electronic health records, payment changes, and consolidation of hospitals and health plans. The morale of physicians and other clinicians is in jeopardy.”  This perspective is supported by the physician burnout stats.  He attributes some of this to the conflict of Era 1 and Era 2 of healthcare delivery.  In Era 1 dating back to Hippocrates, there was the ascendency of the physician and the practice of medicine as a noble and privileged profession.  A special warrant to self-regulate supported a strong culture of autonomy for the profession.  The idealism of Era 1 and that the doctor is always right was shaken when researchers found unexplained variation and inconsistent quality, and, in the US in particular, costs began to spiral out of control with little correlation with improved outcomes.  Era 2 emerged in response to these inconsistencies, driven by payers, regulators, and the government, to in some ways micro-manage and regulate the practice of medicine to try to ensure higher value and lower costs.  As Berwick states, stakeholders of Era 2 believe in accountability, scrutiny, measurement, incentives, and market forces while leveraging the tools of rewards, punishments, and pay for performance to attempt to improve the performance of the system.  Berwick suggests that this battle needs to be resolved by moving to Era 3 based on a “moral ethos.”  He states that it should be based on, at least, the following nine principles:

  1. Reduce mandatory measurement: He states “Intemperate measurement is as unwise and irresponsible as is intemperate health care.”
  2. Stop Complex Individual Incentives: He considers incentives at the individual physician level confusing, unstable, and invite gaming.
  3. Shift the Business Strategy From Revenue to Quality: A financial focus alone is short-term thinking and doesn’t fit the needs of the customer in healthcare for balanced outcomes.
  4. Give Up Professional Prerogative When It Hurts the Whole: The trump card of professional prerogative over the needs and interests of others is creating unintended harm and avoiding necessary transparency.  
  5. Use Improvement Science: For improvement methods to work, you have to use them, and most of us are not. Despite proven methods, they still are not as widely applied as they should be.
  6. Ensure Complete Transparency: Berwick states that “Anything professionals know about their work, the people and communities they serve can know, too, without delay, cost, or
    smokescreens.”  
  7. Protect civility: Authentic dialogue can only occur in an atmosphere of mutual consideration and respect.
  8. Hear the Voices of the People Served: True and systemic patient-centered care will be transformative.  Berwick suggests clinicians, in addition to asking “What is the matter with you?” that they should also ask “What matters to you?”
  9. Reject greed: Era 2 has been characterized by everyone trying to maximize their profits at the expense of or without consideration of other stakeholders.  Berwick advocates for “fair profit and fair pricing, with severe consequences for violators.”

The Era 3 Physician

Moving on to Era 3 can only happen with the engagement of physicians.  The Era 1 physician may never be happy on the Era 2 battleground while payers may never be at peak performance without physician alignment.  An evolution to Era 3 offers hope on both fronts.  The Era 3 physician must be open to the change and critical conversations necessary to move to true partnerships for the benefit of patients.  To operate with joy in the new world, physicians need an ecosystem of support to meet dramatically increased demands.  This may involve joining a medical group, partnerships with payers and/or alignment with health systems.  Team-based care, proactive planned care, increased administrative support, implementation and, most importantly optimization, of technology and automating workflows with standard protocols are ingredients to clearing away the new clutter from the physician’s day-to-day work so that they can once again connect with patients (6).  This ecosystem must support the physician in a new broader role as leader, coach, partner and manager.  If well-designed, with the patient in the center, physicians can rekindle their passion for patient care on a broader scale with greater impact.  At the end of the day, the cure for physician burnout is reconnecting with the energizing passion of making a difference in someone’s life.

References

  1. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014 Nov;12(6):573–6.
  2. The Landscape Of Physician Practice. Health Aff . 2016 Mar 1;35(3):388–9.
  3. Farber J, Siu A, Bloom P. How much time do physicians spend providing care outside of office visits? Ann Intern Med. 2007 Nov 20;147(10):693–8.
  4. Murphy DR, Meyer AND, Russo E, Sittig DF, Wei L, Singh H. The Burden of Inbox Notifications in Commercial Electronic Health Records. JAMA Intern Med [Internet]. 2016 Mar 14
  5. Berwick DM. Era 3 for Medicine and Health Care. JAMA. 2016 Apr 5;315(13):1329–30.
  6. Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. Annals Family Med; 2013 May;11(3):272–8.

 

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