Addressing the main cause of physician burnout

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Keith Aldinger, MD, an internist who practices in Houston Texas. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

Recently, there appeared two perspective articles in the New England Journal of Medicineaddressing physician burnout (1,2). The points are well taken and the rising issues of physician burnout, early retirements, job dissatisfaction, etc. are undeniable. However, I think the main culprit and certainly the single most important factor is not being properly addressed.

The first article leads off with the description of a physician with a thriving medical practice who retires early largely due to the problems with the fourth EHR that her healthcare system had adopted. The main part of her clinical burnout was due to the Federal government’s required quality metrics associated with “Meaningful Use” of the EHR. As the article would suggest, the authors have concerns about restoring physician sanity within the present medical milieu. However, with the above physician’s healthcare system adopting its fourth EHR, perhaps the healthcare system’s sanity may be in question? After all, there is that definition of insanity of doing the same thing over and over and expecting a different result, not to mention the expense involved in each of those four EHR implementations.

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 The article also describes the experiences of the Department of Family Medicine at the University of Colorado in successfully reducing burnout symptoms among its physicians (1). The system it introduced to reduce burnout is entitled ambulatory process excellence (APEX). The process involves medical assistants doing much of the busywork involved in satisfying quality metrics. Corey Lyon, DO, the medical director of this family medicine center, has an insightful quote. “The chaos in exam rooms before APEX was akin to texting while driving.” Yes, while driving you need to keep your eyes on the road and your hands on the wheel and neither diverted to your smart phone. Likewise, when in the exam room, you need to keep your eyes on the patient and hands on the physical exam and neither diverted to your computer.

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Lyon also warned that launching APEX took a lot of work. However, what is most revealing is the manpower required to successfully achieve the desired result with APEX.  Before APEX, the ratio of medical assistants to clinicians was 1:1. After successfully launching APEX, that ratio rose to 2.5:1. This is hardly applicable to a small medical practice. With a small two-physician practice, three more employees would need to be added to successfully launch APEX. That two-physician practice would literally be entering into a new chapter in its existence, specifically Chapter 11. With APEX, the University of Colorado Family Medicine Center successfully decreased the burnout rate among clinicians down to 13 percent from a high of 58 percent. This is most admirable. However, the small medical practice would be more likely to experience a 58 percent increase in overhead and a marked decline in the physician’s income and viability.

Next: "Something practical and immediate needs to be done"

In the second article, the authors describe the collaborative efforts of multiple medical organizations to address physician wellness and burnout (2). In January 2017, the National Academy of Medicine, the Association of American Medical Colleges, and the Accreditation Council for Graduate Medical Education launched a National Action Collaborative on Clinician Well-Being and Resiliency. Later in the article, they comment that there is a strong commitment from more than 100 national organizations to make clinician well-being a priority.

I appreciate and applaud the efforts of all the authors and medical organizations above. However, something practical and immediate needs to be done. There is little argument that the EHR, and especially meaningful use of the EHR, are the main drivers of physician burnout and decreased productivity.

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Why not suggest and/or demand a pause in meaningful use of the EHR and its associated quality metrics? It certainly has not improved care, decreased costs, or improved patient satisfaction. In fact, it has done the exact opposite of all that was intended. When and if the IT industry introduces an EHR that is clinically useful, then we can resume meaningful use of that which is USEFUL. Until then, allow physicians to use their computers in a manner that best supports their clinical care of the patient.

There is strength in numbers. If the vast majority of the over 100 national organizations committed to clinician well-being, quoted in the second NEJM article, were to join this effort, we may have a chance of improving physician and patient well-being.

I am sure there are those who would suggest that I protest too much. They may suggest there exists EHRs that are clinically useful. They may even suggest that it is a poor carpenter who finds faults with his tools. However, those are HIS tools of HIS choosing. I would respond that it is a far worse bureaucrat who forces new unproven tools upon a competent carpenter.

References:

1.     Wright A, Katz I.  Beyond Burnout- Redesigning Care to Restore Meaning and Sanity for Physicians. NEJM 2018; 378:309-311

2.     Dzau V, Kirch D, Nasca T. To Care is Human- Collectively Confronting the Clinician Burnout Crisis. NEJM 2018; 378:312-314