“I’m 45 years old, and I can’t do this anymore. I am just exhausted.”
It was the beginning of Steven Strongwater’s tenure as President and CEO of Atrius Health, and a group of physicians were taking turns introducing themselves. One of the physicians told the group that her father was a general practitioner well into his late 70s — but she did not see herself following in his footsteps.
“As I looked around the room, what was so frightening to me was that every other head, every other primary care doc in that room, was nodding their head in agreement,” says Strongwater. “That’s the story that we are facing, and the problem that’s facing our country, and it is increasingly getting worse.”
Strongwater was thrilled to learn of a burnout prevention model now being more broadly adopted that emphasizes a culture of wellness, efficiency of practice, and the need for personal resilience. But, while the components of the model are good, Strongwater argues that the pie shape is off. “What’s principally driving burnout in our country is the efficiency of practice — it’s the work, it’s the workflow, it’s the demands we’ve put on the plates of so many clinicians,” he says.
In a graph displaying different types of clinician work on the electronic medical record (EMR), the baseline, time, shows that the clinician’s workday starts at 4 a.m. — and ends at 9 p.m.
“Imagine doing that every single day for 10 years, 15 years, 20 years. I would argue that our primary care docs are incredibly resilient,” says Strongwater.
Employment status has changed, Strongwater adds. In Massachusetts, 85% of physicians are employed by large organizations, according to Strongwater. Across the U.S., more than half of physicians are employees, and some work for nontraditional medical employers such as insurers and payers. One might assume that more deeply financed organizations could improve the practice environment, but that’s not true. The Massachusetts Medical Society tracks a Physician Practice Environment Index. In the 1990s, that score was about 100; today, it’s about 70. “Things have not gotten better,” says Strongwater. “Indeed, they have gotten worse.”
In his book Drive, Daniel Pink says that professional satisfaction is driven by three things: purpose, autonomy, and mastery. Primary care doctors are certainly purposeful, notes Strongwater. “But we have forced them to make a trade: clicks before care. We have forced them to stare at computer screens and not into the eyes of their patients. We have disrupted that patient-physician bond.” With the majority of U.S. physicians as employees, they give up some autonomy in decision-making. As for mastery, physicians are facing a crisis, argues Strongwater. “We look on our cell phones and have such incredible ease of use, and then we look at our electronic medical record screen and we are searching and clicking, and the tools are not quite as sharp, yet, as they need to be.”
Few individual physicians can actually impact the current state, because they are employees. But they can go to their leadership. “This is a leadership demand,” says Strongwater. “There’s a leadership opportunity to step in and recognize that burnout is an issue, an important issue, and to help make investments that are appropriate in order to make change happen.” Having conversations on burnout is a step in the right direction, but to make any progress, leadership needs to walk away from those conversations committed to finding solutions and report regularly on burnout to their boards.
What can leaders do to reduce EMR time? Strongwater describes several approaches:
- IT bundle. To help physicians reduce their after-hours EMR time, the Atrius IT team created a five-component bundle that they anticipate will reduce between 1 million and 1.5 million clicks.
- PAYGO. In PAYGO, if you want something that costs money, you must offset it with something else. So if you want more EMR clicks, you have to take something else away.
- Streamlined forms. Leaders, at the negotiation table, can weed away unnecessary utilization requirements and pre-approval forms that are a waste of time.
- Scribes. “There are some things that are, quite honestly, below the top of the physician’s license, and we should fix that,” says Strongwater, by hiring scribes.
- Empathy training. “After 2 hours of interdisciplinary empathy training, our patient satisfaction scores went up dramatically,” Strongwater says.
On the harder side, Strongwater encourages all of us to demand that EMR user interfaces become as good and facile to use as smartphones and tablets.
“Our primary care physicians are not whining millennials; they really are working very, very hard. And we should thank them, because we’re going to need them, especially as all of us get older,” says Strongwater. “We need to ask our leaders and help the leaders see that this is an important opportunity for them. And I know they can make a difference. We have solved so many complex problems. This just has to become a priority.”
From the NEJM Catalyst event Physicians Leading | Leading Physicians at Intermountain Healthcare, July 12, 2017.