“The men and women upon whom health care depends are running out of reserve because of the cumulative effect of well-intended regulation, performance measurement, and technology,” says Christine Sinsky, the American Medical Association’s Vice President of Professional Satisfaction. “We have to stop doing this. Collectively, we have to stop burning out those who have chosen medicine as a career, and we have to stop giving our patients burned out care.”
Fortunately, there are “bright spots” we can learn from. Sinsky describes Minneapolis-based HealthPartners, for example, which has embarked on an initiative to shorten the physician workday by 90 minutes. One aspect of this is a flow station where physician and nurse are seated side by side. In another example, at a family physician practice in Green Bay, Wisconsin, a medical assistant stays with each patient for the duration of their appointment. Having the MA record the patient’s information and relay it to the physician in this way enables him to give the patient his undivided attention.
“The most impactful solutions are at the systems level, of improving operational efficiency, culture, and teamwork,” Sinsky says. “What if joy in practice were a core metric of our health care system? What if every new policy and technology was assessed in part for its impact on the people who are doing the work?”
Sinsky shares some action steps to bring back joy in practice:
- For institutions: “Be bold.” Recognize the importance of higher staffing rations for optimal patient and provider care, and reengineer workflows to increase physician time spent with patients and with family at home.
- For measure developers: “Keep it simple and add it up.” Add the total time for compliance with all regulations and measures. “Less is more here,” says Sinsky.
- For regulators and technology vendors: “Support advanced models of team-based care.” Physicians often spend more time documenting care than delivering it. Health care regulations and electronic health records designed to support team-based care will help reverse that problem.
“Our work going forward, from wherever we stand in the health care ecosystem, is to consider: How can we contribute to transformation so that our patients no longer receive care from nurses and physicians who feel working in clinic is unbearable, but instead receive care from nurses and physicians who come to work every day feeling entrusted and empowered by technology and by policy and by teamwork?” asks Sinsky. “And can say, ‘practicing medicine is fun again.’”
From the NEJM Catalyst event Leadership: Translating Challenge to Success at Mayo Clinic, June 2, 2016.
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Abbey L Pachter PhD, RN
Although I sympathize with physicians' concerns about salary, I believe that at least part of physicians' joy should come from improving patient outcomes. Advanced practice RNs are not "physician extenders" but rather are alternative providers of health care who give cost-effective, evidence-based diagnostic, treatment, prescriptions and educational care to patients within their scope of practice in a wide variety of settings. Their preparation focuses heavily on being able to differentiate "normal" from "abnormal" and changing findings so they may properly consult or refer when needed, to physicians with whom they associate by contract. These are ways physicians can be less burdened. Of particular concern are some of the comments: "...MA record the patient’s information and relay it to the physician." Having a medical assistant record patient information and relay it to the physician is not an improvement in care, it is an abdication by delegation to less expensive employees who, to keep their jobs, practice beyond their training. Wording such as "physician and nurse are seated side by side" is often not accurate as "nurse" probably refers to a medical assistant. It can be great to have a medical assistant (MA) documenting the visit in the EHR so that the provider can engage "en face" with the patient. As long as physicians are required to review the notes for accuracy and sign-off under their own login. MAs may admirably aspire to become RNs, but they are not. Regarding this comment: "...within those specialty areas there is enough income generated through physician billing to hire the skilled physician extenders (PAs, NPs, trained individuals whom the physician can trust to properly reconcile medications, educate patients, write notes, etc.) to unburden the physician": Advanced practice NPs and professional RNs have an important place; physicians and healthcare enterprises should be encouraged/incented to hire them as evidence has shown improved outcomes from their care. However, other "trained individuals" refers to MAs whom physicians permit to practice outside of their scope of practice. MAs should not be the ones doing biopsies, entering medication orders, educating patients, writing (presumably, progress) notes that become a permanent part of the patient's electronic health record. All of these practices are occurring. To make matters worse, MAs may erroneously refer to themselves as "nurses" presenting a false image to the public, who may relay important medical information believing that this is a professionally prepared registered nurse, and expect that information they receive is evidence-based, when in fact it may come from such minimally trained individuals.
Physicians should look to their own professional organizations, who lobby to restrict advanced practice nurses from practicing to the full extent of their licenses. Relieving these restrictions and viewing advanced practice nurses as part of the health care delivery team, rather than solely as "physician extenders" would help relieve physicians of some of the burdens they accepted upon entering their chosen profession. Hopefully, it wasn't just "for the money." I encourage you to become part of the solution, by focusing on transforming healthcare so that it is safe, reliable, effective, efficient, patient-centered and equitable as envisioned by the Institute of Medicine.
September 20, 2016 at 10:41 am
Etah Kurland, MD
Dr. Canes,
I think you are imbuing meaning to my quote a bit out of context and I do apologize for any unintended slights.
I never stated that surgeons were less stressed specialists, only, in an earlier part of my comment, that they may be somewhat shielded from a reimbursement structure that medical specialists have to deal with. I am in total agreement that surgeons deserve to earn more than medical specialists for the many reasons you cite and have never felt otherwise. There is, nevertheless, a major skewing in the current reimbursement structure between specialties that should not be ignored- and an emphasis on procedures (not surgery here, but "testing" and "services") that may be directing precious health care dollars in the wrong direction.
September 02, 2016 at 11:53 am
Etah Kurland, MD
Dear Dr. Sinksy,
I am an endocrinologist in practice in New York City.
Your presentation hits upon important points, but a key issue is...
compensation.
What has evolved over the years is that those specialists with the money to lobby and represent their specialty's financial interests have seen to it that their physicians have managed to continue to enjoy respectable earnings, earnings that the public associates with "the rich doctor." Fields like anesthesia, radiology, even pathology and of course surgery routinely enjoy comfortable salaries. Their specialists may gripe about new regulations, even within their fields, but to some extent these specialists have been cushioned from what those of us in the cognitive specialties are increasingly forced to endure. And within those specialty areas there is enough income generated through physician billing to hire the skilled physician extenders (PAs , NPs, trained individuals whom the physician can trust to properly reconcile medications, educate patients, write notes, etc.) to unburden the physician.
What has accelerated the "burnout" of physicians within family medicine, internal medicine, and the "non procedural" sub-specialties within the field is the need to see increasing volumes of patients to earn a reasonable living. Coupled with mandatory forms and authorizations ("PAs") foisted upon us by insurers who are focused on their bottom lines, not on patient well-being. Even with a burdensome patient volume, compensation is still far lower for internists than that earned by less-stressed specialists. For those practicing within institutions, there is the expectation that a volume of patients must be seen, and compensation is dependent upon "RVA" relative value units (higher of course, if volume is higher). The per patient compensation for our cognitive work does not begin to properly compensate the physician, let alone the many assistants necessary to provide the unburdened type of care you describe and you envision.
Until such time as our essential contributions to health care are weighted correctly for the value they add to the health care enterprise overall, and until such time as there is a shifting in payment from the "big pie" of the trillions of dollars currently frittered on health care - to compensate cognitive physicians with better payments and with less money appropriated for often wasteful and unnecessary procedures - there cannot really be meaningful change. And burnout will continue. Because after all, the energy the doctor may expend on their day, when they have to weigh their poor quality of life, the personal sacrifices they are making to deliver the care, and what ends up in their bank account when all is said and done... it is truly discouraging. All the eagerness, commitment, and altruism that the doctor may actually wish to have ultimately gets subsumed in the draining process of the reality of medical practice in the early 21st century. With very little to show for all the efforts.
August 31, 2016 at 11:48 am
David Canes
"Even with a burdensome patient volume, compensation is still far lower for internists than that earned by less-stressed specialists. "
Take a deep breath, I fear my reply may not sit well with you, Dr. Kurland. I'm a surgical subspecialist - just wondering if you understands the extreme stress surgeons bear from the responsibility of doing major operations on other human beings. By referring to us as "less stressed" specialists I'm assuming you don't know the horror of sleepless nights worrying about patients who have entrusted us with the privilege of operating on them. You can't fathom the stress of dissecting the great vessels, where one false move separates the patients from some morbidity or even mortality. You can't empathize with the hours spent focused so intently on the patient in the operating room that we sacrifice our own bodies, our necks, our backs, our legs, not to mention our families. You can't know the horror of being woken up in the middle of the night at any given time, to help patients with one calamity or another.
Burnout affects all physicians - I'm not saying my stress is more important or severe then yours, but I certainly don't find it constructive for you to isolate and subcategorize docs against docs when it comes to this important issue.
September 01, 2016 at 10:01 am