2022 Physician Burnout Survey results

Is physician burnout actually on the decline?

Although most physicians have said they have experienced burnout during their career, the number who say they feel burned out now has decreased for the first time in the four years 

Ò has conducted its Physician Burnout and Wellness Survey. In 2021, 80% of respondents said they felt burned out at the time they took the survey. This year, that number was 73%. Check out the full results of our survey.

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Is the physician burnout crisis actually improving?

Physician burnout and suicide are serious issues that need addressing — but dealing with them can call for very different approaches.

Sept. 17 is National Physician Suicide Awareness Day, billed as a reminder and a call to action. Last year the awareness campaign reached 1.2 million people and received support from 54 medical and other organizations, resulting in 26,000 actions taken to prevent suicide, according to sponsors The Physicians Foundation, the Dr. Lorna Breen Heroes’ Foundation and FirstRespondersFirst.

Although there may be overlap between the two in symptoms and distress that people feel, focusing solely on burnout can create a risk of missing depression, a serious medical illness with potentially life-threatening consequences if left unaddressed, says Christine Yu Moutier, M.D., chief medical officer of the American Foundation for Suicide Prevention (AFSP).

Moutier was co-author of a study on feelings of depression and burnout in 2,281 medical trainees, staff and faculty at University of California San Diego Health, where the Healer Education and Assessment and Referral Program has been heralded as a model system for physician and medical staff suicide prevention efforts. The findings “suggest depression is a much more serious condition” with indicators of distress and suicide risk, including intense affective states, alcohol and drug use and suicidal thoughts and behaviors. Burnout without cooccurring depression was not associated with higher rates of suicidal thoughts or behaviors or with substance use, compared with respondents who screened negative for burnout and depression.

Yet burnout and depression are real problems that must be addressed with systemic change in medicine, say Moutier and Kristen Kim, M.D., corresponding author of a recent study on contributing factors to physician suicides across the country from 2003 to 2018.

Burnout is characterized by chronic workplace stress that can lead to a sense of emotional exhaustion, depersonalization or difficulty seeing others as human, and a low sense of personal accomplishment. Depression and suicide are clinical diagnoses requiring therapy and medications if appropriate, Kim says.

Solutions start with recognizing physician suicide is a serious problem and physicians must prioritize self-care in their everyday practices, Kim says. “I think medicine still, as a field, embraces this outdated sense that we need to sacrifice everything as a physician, including our own well-being,” she says. “And that is just simply wrong. At this point, it’s time to move beyond that and to really prioritize our own well-being in order to best care for our patients.”

In the study of physician suicides, one stressor was incapacity to work due to deteriorating physical health. Physicians tell their patients to stay healthy and they need to do the same, Kim says.

When scheduling appointments, physicians face the same barriers patients do. Primary care and specialist physicians often have office hours that overlap with work schedules, so physicians as patients sometimes must wait days, weeks or months for appointments. Flexibility in scheduling and telehealth could offer solutions, although telehealth limits physical examinations, Kim says.

AFSP notes primary care providers are “in a unique position to identify patients at risk of suicide and enact appropriate intervention methods,” including for fellow physicians. The foundation advocates increased training for physicians to better understand suicide assessment, treatment or risk management.

Even without added training, talking and listening can be a start. Physicians must be on the lookout for colleagues who are struggling and embrace the mindset that, as a community, “we can make a difference,” Moutier says.

“We don’t need to be their doctor or therapist; we’re being a colleague and a friend,” she says.

If physicians sought therapy or psychiatric treatment, Moutier suggests sharing that information with a colleague in distress.

“Give them permission to take those steps themselves by showing and modeling that that can be done safely and without any negative repercussions on your career,” Moutier says. “I’ve seen it happen innumerable times; there is so much more fear about that harm that will come from seeking treatment than there is. And the truth is that the true source of fear, and sort of danger, is actually from unaddressed mental health conditions when they’re left to go unaddressed because of the barriers that are in the way.”

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Physician burnout, depression, and suicide

The COVID-19 pandemic put working conditions into the national spotlight, so it should be little surprise that being overburdened often is an understatement for physicians, nurses and health care support staff. That new level of attention and awareness may be one of the good things to come out of the fight against COVID-19.

But physician burnout was a problem before the pandemic; if the virus were to disappear tomorrow, burnout would not. In a recent 

® survey, more than 93% of physicians report feeling burnout at some point and more than 73% say they feel it now.

® spoke with physicians and executives about the latest steps in the fight against burnout. There is movement to add leadership, rewrite licensing forms, approve legislation that could improve the workplace, and remove barriers to mental health care for physicians.

“Change is possible,” says Tait Shanafelt, M.D., chief wellness officer at Stanford Medicine in California and a nationally recognized researcher on physician burnout. “There’s reason for optimism and it’s going to take all of us as physicians really engaging with leaders of health care systems and organizations to drive the change that’s needed to reshape the health care system.”

Although definitions vary, researchers have noted burnout encompasses three key areas: physical and emotional exhaustion; feelings of cynicism, negativity and detachment from work; and inefficacy, feelings of incompetence and lack of achievement and productivity. It happens when job demands — heavy workloads, time pressures and inefficiencies — fall out of balance with resources such as meaning of work, job control and social support from peers and supervisors, as summarized by the National Academy of Medicine’s 2019 volume, “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.”

For many physicians, burnout creeps in when they must devote time to interactions that are not of value to patients or what is needed in their care, Shanafelt says.

Such situations exist in doctors’ offices, hospitals and health systems across the United States and many physicians are feeling pain, discouragement and disillusionment. But the nation has reached an inflection point for medical worker burnout, so now is the time for physicians to engage health care leaders for a cultural shift in medicine, Shanafelt says.

Physicians can start fighting burnout by maintaining their physical health. Workforce training on personal resilience and stress reduction may be helpful. Shanafelt says large-scale change must be rooted in organizational values, priorities, culture and leadership, along with adjustments to reduce or streamline administrative burdens, preauthorizations, billing documentation, reimbursement models that transactionalize care, and numerous in-basket messages.

“How do we create more efficient systems? Eliminate that inefficiency, create more highly functioning teams and … a community of health care workers who are able to support each other due to the emotional demands that the work entails?” Shanafelt says. “If we really want to get at those more substantive things … we need dedicated leadership. We need a commitment at the highest level of the organization.”

There are leadership development programs to train and deploy health care leaders to start or expand physician wellness initiatives. Shanafelt leads the Stanford Medicine Chief Wellness Officer Course, a weeklong immersion program requiring written commitments of institutional support for future actions. Since starting in 2017, it has graduated 170 participants in four cohorts. A parallel, online Physician Well-Being Director Course has graduated thousands of leaders at the department and division levels for wellness efforts in units around the country.

Alumni include Nigel Girgrah, M.D., Ph.D., chief wellness officer for New Orleans-based Ochsner Health, the first health system in Louisiana to add a department dedicated to workforce wellness. Efforts started in 2017 with Girgrah chairing a well-being task force to survey staff and report to the executive team. Health system leaders announced the new Office of Professional Well-Being in fall 2018. Girgrah says the wellness team spent a year developing a strategy to focus on four areas: practice automation largely involving electronic health records (EHRs), promoting advanced team-based care, worker resilience, and enhancing provider communication.

Like the rest of the nation, Ochsner Health had to deal with COVID-19 starting in March 2020. Some of the wellness initiatives fit right in — executive communication reassured staff that their jobs were stable, and employees responded well to resilience training. Other initiatives were specific to the pandemic, such as setting up child care and ensuring adequate personal protective equipment for front-line staff. Some of the practice efficiency initiatives “sort of got paralyzed, for good reason” due to the pandemic, Girgrah says, but now Ochsner Health hopes to reboot those efforts.

Administrative burdens arguably are worse for physicians in independent practices or those in small towns and rural or underserved areas, says Sterling N. Ransone Jr., M.D., FAAFP, president of the American Academy of Family Physicians.

Independent physicians share some systemic inefficiencies with physicians in large health systems, such as user-unfriendly EHRs, prior authorizations and insurance paperwork, says Eileen Barrett, M.D., M.P.H., chair-elect to the Board of Regents of the American College of Physicians. Physicians in independent practices may have more control over workflow and workplace culture, but not all are trained or have tools to address those challenges, even though all deserve that, Barrett says. Physicians in larger health systems may have more of a financial cushion to address those issues if leadership is willing and able to prioritize them, she adds.

Ransone agrees. “When you’re in practice and you’re taking care of a small community, you’ve got so many people that you’re trying to take care of but you have to spend so much of your time doing paperwork that a lot of us feel is needless and doesn’t contribute to the health care of the individual,” he says. “And then (in) a smaller practice, you don’t have the resources that you can hire somebody to do a lot of this paperwork.”

In independent practices, finances can contribute to burnout or mental health distress. Young physicians begin their careers with debt totaling hundreds of thousands of dollars. For independent practices, especially solo practitioners trying to keep the lights on and the doors open, “you’ve got the issue of … how much can I work?” says Ernest R. Gelb, D.O., FACOFP, president of the American Osteopathic Association, who spent years as a private practitioner in rural Pennsylvania. Experts often suggest taking on more patients to make more money, but that can lead to overwork contributing to burnout and hurting marriages and family life, or to substance use issues, he says.

More patients mean more paperwork, which now means more time with EHRs. Ransone, a family practitioner in a town of 2,000, and Girgrah, overseeing wellness for 34,000 health system employees, both mentioned pajama time — work after work, when physicians are writing notes, reading in-basket messages, reviewing results and completing charts.

“Ideally for most, this should be zero,” Girgrah says. “But the goal is to reduce this, so folks are spending less time on a computer and are able to disconnect.”

The EHR was described as almost a panacea for improving patient care through faster, more efficient, informative records. “And what it turned out to be is just another bump in the road that we have to go over in our daily lives to see our patients and get paid for our services,” Ransone says.

Standardize and simplify administrative burdens so physicians do not have to fill out five different prior authorization forms for five insurance companies, or two pages of patient information for widely used prescription drugs.

Enable EHR systems to complete the forms and submit them electronically.

Cut the number of prior authorizations for tests or procedures when 95% of them are approved anyway.

Progress has been made in streamlining evaluation and management code documentation requirements for outpatient care, along with reduced administrative burden in treating people for opioid use disorder and improved performance measurement requirements from the federal Centers for Medicare & Medicaid Services, Barrett says.

“More needs to be done in all these areas to help physicians in independent and smaller practices,” Barrett says. “But these are a start, and when we get changes done it will also improve patient experience.”

Apart from systemic solutions, Gelb emphasizes work-life balance. “It’s a concept that none of us physicians with gray hair were raised on,” he says, but physicians must learn it and integrate it into their practices.

Gelb and Ransone agree it is a privilege to serve a local community, but there is a risk of work and life imbalance. Many physicians feel responsible for their patients and that gets amplified in a community where it feels like everyone knows everyone else and can drop in on the doctor anytime. Ransone says when he was a young father, he at first felt guilty taking Saturdays off for family time.

“There’s a really weird feeling like you’re abandoning your patients,” Ransone says. “But I realized that if I wasn’t happy and I couldn’t take care of myself, I certainly couldn’t take care of my community.”

Experts agreed mental health counseling could help treat distress associated with burnout, but physicians fear repercussion if they seek help. Confidentiality is key to changing that.

The University of California San Diego Healer Education and Assessment and Referral (HEAR) Program started in 2009 as a physician suicide prevention program. In 2016, HEAR expanded to nurses, then to all health professionals in the system, with the mission growing to include a support program to enhance the emotional and mental health of staff, prevent burnout, and help people access mental health care.

HEAR’s anonymous online questionnaire has led to 1,000 referrals for mental health care, and about 100 residents and fellows have ongoing, confidential, free therapy. UC San Diego Health has not had one physician or nurse suicide since the program started, says Director Sidney Zisook, M.D.

“We certainly cannot assume that we are the sole reason for that, but if we have helped save one life, the program is fully worth its fare,” Zisook says.

HEAR is guided by an interdisciplinary committee that meets as needed and is divided into task forces dedicated to research, education and other topics. Along with Zisook, HEAR has two licensed mental health counselors to work with staff, and the program was cited as a model for other health systems by U.S. Surgeon General Vivek Murthy, M.D., MBA, in his May advisory on health care burnout.

Confidentiality has become a goal for the Dr. Lorna Breen Heroes’ Foundation, which honors the life of Lorna Breen, M.D., a New York City emergency department physician who struggled to help patients with COVID-19 until her death by suicide in April 2020.

In March, President Joe Biden signed the Dr. Lorna Breen Healthcare Provider Protection Act, gaining attention, pledging resources and establishing national accountability for physician burnout.

Breen’s sister and brother-in-law, Jennifer Breen Feist, J.D., and J. Corey Feist, J.D., MBA, have a new target: state licensing boards, health system administrations and insurance companies that ask invasive questions about whether physicians and other licensed clinicians have sought mental health treatment. Apart from being potential health law violations, those questions may be lumped with queries about criminal convictions or moral fitness to practice medicine, says J. Corey Feist, a 20-year health care administrator.

“So, there’s a message that’s given to the health care worker, doctors and nurses: You can’t get help. And if you get help, it could cost you your license to practice, it can cost you your job at a hospital,” Feist says.

Before her death, Breen told her family about her fears of losing her professional license and reputation because she sought mental health treatment.

Because the questions effectively are a barrier to seeking care, the strategy is simple: Stop asking, Feist says. Other options include a single, inclusive question that complies with the Federation of State Medical Boards with no asterisks or fine print, or an attestation model with supportive language around mental health, according to the federation’s new Licensure & Credentialing Strategy Tool Kit.

Credentialing committees easily can audit documents, remove or revise questions regarding mental health treatment, approve the new paperwork and communicate it to physicians and staff. Feist said one health system amended its forms in less than a week.

“It’s very important because health care leaders are in this unique position to actually make the changes that are needed,” Feist says. “This is starting to take hold because organizations are looking for something tangible that they can do right now, and this is perfect. And literally this can take days. It’s not hard to do.”

Confidentiality is a key part of other programs and strategies with potential for relieving burnout by creating access to mental health care. In May, the Ohio State Medical Association (OSMA) launched the Well-Being Checkup And Referral Engagement Service, or Well-Being CARE, for physicians and health care professionals. The goal is twofold: connect physicians and staff with services if needed while creating another resource to normalize the conversation about mental health in the profession.

Physicians find it easy to talk about physical ailments and ways to fix them, says Todd Baker, OSMA CEO. “If you see a colleague struggling with mental health or burnout, that conversation is not so easy or not so normalized,” he says. Offering an independent source also helps because physicians or medical staff may be reluctant to seek treatment within the health care systems they work for, says OSMA President Brian J. Santin, M.D., FACS.

In the service’s first month, 105 individuals completed the anonymous, web-based assessment, and almost 30% requested information or referrals. “But just making sure the conversation never stops about this issue is really our marker, in terms of how we want to define success,” Baker says.

In Virginia, physicians have a new level of confidentiality set in law. The Medical Society of Virginia (MSV) advocated for creation of the SafeHaven program, which has a partnership with a physician-focused national behavior health consulting practice.

Melina Davis, MSV executive vice president and CEO, agrees physicians are reluctant to seek counseling because if they must reveal it, they fear they could lose licenses, have referral networks dry up, or get fired. But physicians enrolling in SafeHaven gain legal privilege that forbids release of any records, reports or communications originating in the program — even in malpractice lawsuits, barring a court order that meets a high standard of proof, according to MSV.

State lawmakers unanimously approved the program in March 2020. It was coincidental timing with the spread of COVID-19, but the pandemic spurred the program’s beginning and physician enrollment started in July 2020. State lawmakers were unanimous a year later in expanding SafeHaven for physician assistants, nurses, pharmacists and students of those protected professions.

Now SafeHaven has 4,400 members, with 48% using the program and 17% in coaching and counseling. Davis argues that rate is unprecedented for physician usage of employer-sponsored wellness programs in the United States. “It’s unprecedented because they feel safe,” she says.

SafeHaven will expand into Michigan and MSV wants to serve as a consultant to take the program across the country. Primary care physicians can do their part by advocating for the same legal protection in every state, Davis says.

“More people need to be asking for this,” Davis says. “More people need to be advocating that it be a normal part of your legal system and your service system for health care workers. They need it, they deserve and it’s here. It makes a big difference.”

At the state, system or individual level, change may not happen quickly, but physicians cannot afford to ignore symptoms of burnout. There are resources to help physicians, Gelb says.

“Burnout is something that should not be ignored. It’s going to affect you,” Gelb says. “It’s going to affect your family. It’s going to affect your performance as a physician and the liability issues that potentially may need to be addressed as well. So, this is something that is important to your health. And if you’re not healthy, how can you take care of somebody else? That’s my big take-home message right now: Get the help that you need, get the help that you deserve. It is out, it is available — all you have to do is reach out.”

Experts report on efforts to change the workplace and the culture of medicine

Solving physician burnout

Prior authorizations and Medicare reimbursements are some of the most consistently cited sources of issues at primary care practices. Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association, joined Medical World News® earlier this year to discuss his organization’s lobbying efforts in Washington, D.C.

The following interview has been edited for length and clarity.

Medical World News®: Your organization gave comments to the federal government on the state of prior authorization in (the United States) recently. Can you explain the issue?

Prior authorization is a constant thorn in the side of our medical practice members. We did a survey a month ago, in which 80% of our members said that over the past year, prior authorization requirements had increased. We’re seeing that every year — just a continuing increase in the burden of prior authorization on medical practices. When we do our regulatory burden survey every year, it always rises to the top in terms of the largest burden our members face.

The request for information was a little more technical, but it was on what can we do to automate prior authorization, which is important. The way we responded to it is that (automation) is one piece of an overall strategy we think would be effective at reducing the burden on medical practices with prior authorization. We don’t want to just make it easier and have more prior authorization. Ultimately, our goal is to reduce the number of situations in which a health plan is questioning the clinical judgment of a physician and making that judgment on behalf of patients. Reducing the volume of prior authorization in this country is our first priority.

With that said, we think prior authorization can be very helpful. Something our members often run into is that there’s not one standardized way to submit prior authorizations or additional information — maybe clinical information or chart information — to the health plans. There’s not one standard in this country, so each health plan thinks they have the best proprietary way to make it really easy. However, I’ll use myself as an example, if I had 20 separate websites to log on to and have passwords for every one of those websites, it quickly becomes burdensome. Each website may be efficient, but each one is different. I would lose track of those passwords and it would be a problem.

Now, medical practices are more sophisticated than I am in that regard. However, they may have contracts with 20 to 30 major health plans in their market, and if each one of those has its own electronic portal with a password, each one’s different. The way it works is you have to hire staff to go in there and learn each one of those processes, which is time consuming and redundant. Ideally, we’re looking for one standard and one way of submitting them, such as pushing a button or maybe having it integrated with an electronic medical record and the clinical record. We could provide the information health plans need but do so in a streamlined way that isn’t just multiplied by 20 and having that staff burden.

Overall, electronic prior authorization is something we’re looking for and advocating for. As part of our letter, we gave some recommendations on how to implement the electronic version of it without creating more prior authorizations. Ultimately, there are multiple situations in which maybe a physician who has high quality and low cost is already being measured on value by the health plan, and we want to exempt those physicians from prior authorization. If they’re in a value-based arrangement, they’re already incentivized to increase quality and reduce costs. They’re held accountable already. Why layer any additional type of utilization review from the health plan to just add burden on the practice?

It was a great opportunity to complement some of what we’re doing with Congress. I’ll also mention that we are supporting legislation, the Improving Seniors’ Timely Access to Care Act — if you’re interested in that Senate Bill 3018, or House Bill 3173. We’re promoting that legislation to reduce the number of prior authorizations and help physicians in value-based arrangements get out from under prior authorization and focus on, in this case, Medicare Advantage plans, where we see a lot of it, and really get the ball rolling with Medicare prior authorization reform in this country. Ideally, each year, we want to reduce that number our members are telling us. It’s disturbing that 80% of them said it increased over the past year, and we’re responding accordingly.

MWN: What is your organization’s position on the Medicare Payment Advisory Commission (MedPAC) recent recommendation on Medicare reimbursements?

It was a bit surprising. It was disheartening and disturbing to hear MedPAC make that recommendation of a 0% update in 2023. The news almost came out the exact day we were getting CPI reports out of the government of (7% to 8.5%) increases in inflation.

Our members are reporting incredible problems. Recruiting staff is a big issue right now, and many of our practices in this current environment have had to limit their hours or close satellite locations because they do not have the clinical staff. It’s one thing if you have a doctor, but if you don’t have a team around that position to actually open up a medical practice to room patients (and) do all the things we all expect when we go to the doctor, then you can’t provide those services in the way you need to. It’s an incredible burden.

We want to make sure our members and medical practices across the country receive equitable payment from the Medicare program so they don’t have to limit the number of Medicare patients they treat. The last thing we want in this country is any kind of access problem for Medicare beneficiaries. It was concerning that MedPAC would say, “No, 0%. We don’t see any reason to update payments, even in this environment.” That’s definitely a concern.

Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association, joined Medical World News® earlier this year to discuss his organization’s lobbying efforts in Washington, D.C.

Prior authorizations and Medicare reimbursement: what you need to know

It’s time to admit that health care technology has largely failed to deliver on its promise to make the management of patient care simpler, easier, and less stressful for clinicians.

Two decades ago, technology was presented as the solution to so many of the U.S. health care system’s ills. 

 and other tools were going to streamline recordkeeping, allow seamless communication between providers and payers, and, most importantly, free up clinicians to spend more time on patient care and less on administration and paperwork.

Unfortunately, EHRs are sticky in that everyone uses one, but they lack in driving clinical outcomes as a standalone solution - which just makes things worse and detracts from payer/provider alignment. This is in direct contrast to what I encountered growing up in Israel, where patients, physicians, and the national insurer are all fully integrated, both in terms of interoperability and alignment of interests.

Technology hasn’t improved efficiency to the extent promised or inserted more caring into health care. It hasn’t driven down costs for patients and payers, and it hasn’t saved practices money. As a result, providers at all levels are still working below their licenses.

Nowhere is tech’s failure clearer than its role in clinician burnout, a long-smoldering problem that has burst into flames since the introduction of the “meaningful use” incentive program.

 Dr. Vivek Murthy sounded the alarm on clinician burnout in an advisory this May. The report detailed how an already serious problem has been exacerbated by the COVID-19 pandemic, causing providers to leave medicine in record numbers at a time when they’re needed more than ever before.

The advisory concluded that the country needs 1.1 million new registered nurses and faces a projected national shortage of more than 3 million low-wage health workers. The Association of American Medical Colleges predicts a shortage of as many as 139,000 physicians by 2033, with the greatest gaps in primary care.

The Surgeon General’s report is only the latest piece of research to cite administrative demands and 

 as leading causes of burnout. It found that, on average, for every one hour of direct patient care, a primary care provider will spend two hours a day on administrative tasks. That not only frustrates clinicians, but it also contributes to poorer health outcomes for patients.

So, what’s the solution to technology-caused burnout? 

It seems counterintuitive to prescribe technology to treat burnout caused by technology, but the answer is not simply more tech, but better tech — tech that will finally deliver on those 20-year-old promises.

Of course, there’s no turning back the clock. We’re not going back to paper records and manila folders. The American health care system will not be streamlined and simplified anytime soon; it will remain a thicket of incompatible systems and competing priorities.

Only tech whose design and processes are informed by the failures of previous systems can solve these problems. Unlike current systems, these tools will need to increase the efficiency of clinicians using them and drive down costs.

The good news is the problems aren’t insurmountable. In fact, they’re being addressed right now.

“And if you gaze long enough into an abyss, the abyss will gaze back into you.”

The philosopher Friedrich Nietzsche wasn’t referring to health tech when he wrote this, but any provider who has spent hours staring at a poorly designed EHR interface can relate.

It’s not surprising that a 2020 study in 

 found that EHRs scored in the bottom 9th percentile of technologies when evaluated for usability. They were supposed to package multiple streams of patient and payer information into simple, easy-to-manage bundles. That hasn’t happened.

But EHR experiences can be improved, primarily in two ways. The first is by investing in local provider organizations to improve workflows, implement user feedback loops, etc. The second is to deploy complementary tech solutions that improve the user experience, such as robotic process automation, integrated workflows, and EHR overlays.

These solutions can make health workers more efficient by reducing the need for them to manage disparate workflows, thereby lowering labor costs, and making it easier to manage the health worker shortage. EHRs are here to stay. Technology that understands this and mitigates their shortcomings for clinicians are indispensable in combating rising health care costs and reducing burnout.

Tech is simultaneously overwhelming and underperforming.

Clinicians and others must use too many tools and click too many times only to be delivered insufficient results.

Too many tech tools and non-integrated data sources result in information silos; obtaining a comprehensive picture of a patient’s care can require assembling data from emails, paper notes, EHRs, portals, and even faxes.

That sort of copy-and-paste recordkeeping wastes time and leads to lost data, compromised patient information, and poor patient experience. Health workers need a way to assemble all the information from multiple sources into a user-friendly interface.

Tech can consolidate touchpoints and tools and implement interoperability standards. Automation of routine tasks, such as checking authorizations, handling referrals, and entering ICD codes, reduces the number of tech touchpoints and frees providers to focus on the far more crucial lifesaving work we ask of them.

Everyone from patients to payers has an interest in keeping clinicians happy, engaged, and, most importantly, on the job and operating at peak efficiency.

Independent practitioners often suffer the most from tech burnout because they have fewer resources and less time to manage administration. As a result, many surrender and sell their practices to health care systems just to free themselves from drawing under administrative demands. However, that can result in higher costs for society and poorer care, while also carrying its own stresses for clinicians.

Tech that empowers smaller, independent practices to not only stay viable but to succeed in shared initiatives, such as value-based care models, can help preserve the dwindling ranks of independent practices and general practitioners.

Poor technology got us into this mess; good technology can get us out. In fact, it’s the only thing that can.

, a technology company building digital infrastructure for U.S. health care.

New technology that fixes the problems of the EHR is the best way to reduce physician burnout

Can Technology Solve the Burnout It Helped Cause?

One of the many duties of staff members at medical clinics is to ensure everyone is meeting the cleaning standards of the office. Even though staff and patient safety is the top priority, you also want the medical office to be clean and welcoming for patients. Having a clean, organized environment makes an immediate impression on patients letting them know you take all their health needs seriously.

Private practices are a highly competitive market, so keeping your patients happy is more important than ever. You may be doing the best you can to keep your medical office clean, but have you ever wondered if your current cleaning regimen could be more effective?

 have set industry standards for medical office cleaning. These research-based procedures ensure staff and patient safety, lower risks of health care associated infections and reduces cross-contamination. Here are the key areas for medical office 

Furniture, and other surfaces in high traffic areas, like the 

, are prone to collecting bacteria, dust mites, and other germs. Staff must keep up with industry standards when it comes to cleaning by wiping these areas down with 

In medical offices, the most common high-traffic areas include drawer handles, faucets, cabinets, chairs, and sinks. The same goes for specialty rooms like X-ray areas or suturing rooms. In the reception area focus the cleaning on phones, computer equipment, clipboards, door handles and counters.

When dust accumulates on surfaces it makes people wonder how clean the rest of the office might be. Dust buildup in medical offices can aggravate respiratory conditions and carry germs that can spread illness. Regular dusting of surfaces throughout the clinic is an easy way to keep the space feeling clean while eliminating dust mites and bacteria from getting into the air.

Stay away from using feather dusters. All these tools do is move the dust around without properly picking it up. Instead, use a dampened cloth, small handheld vacuum, or a microfiber duster.

Never wait until dust is visible on surfaces. The longer you wait to clean, the more likely it is to build up bacteria on these surfaces. Patients with allergies are susceptible to dust aggravating them so dust at least three times a week to keep your patients safe.

All areas of examining rooms need a thorough cleaning after each use. These areas are susceptible to cross contamination between doctors, nurses, and patients therefore it needs extra attention when cleaning. Clean the lights, countertops, and treatment chair with the proper disinfectants.

After each patient leaves, wipe down all doorknobs, cabinets, light switches, and other high-touch zones. These areas are extremely susceptible to germs as they often go unnoticed when cleaning. Keeping these areas disinfected will give patients peace of mind and allows staff to keep them safe from potential accidental infections.

It may seem like common sense to keep the bathrooms clean, but these areas often go unnoticed when the office becomes busy. The state of the bathroom reflects your clinic’s attitude towards cleanliness. Patients who use your bathroom and see that there are paper towels lying around, soap stuck to sinks and other dirty areas may not want to be treated in that office.

Restroom checks need to be done regularly at all medical clinics. Set a schedule for cleaning countertops, disinfecting toilets, sinks and other fixtures. Also always keep the bathroom stocked with soap, paper towels and toilet paper.

It’s important to have an organized reception area, but this doesn’t mean it has to feel sterile or cold. You can maintain cleanliness while keeping that warm welcoming feel patients want when visiting the doctor. The reception area is where patients get the first impression of the office, so keep it free from clutter.

Remove unnecessary paperwork, pens, and clipboards from the reception desk. If any files are not in use put them in their proper place. Most importantly wipe down the surface’s patients are using to fill out forms or other materials. Reception is also the last part of the clinic patients will remember. Maintaining a clean reception desk will leave a lasting impression on the patient’s visit.

The medical office reflects the service you are providing and shows your attention to detail. Keeping a clean medical clinic is not only beneficial for the patients but shows you care about the environment you are working in. Even when working with a professional cleaning service, don’t leave these areas for them only to clean. Implement these cleaning techniques for improved patient care and keep them coming back for years to come.

 in Phoenix, Arizona which provides professional cleaning services to over 500 clients in the Greater Phoenix Area.

A clean office is not only necessary for patient health, it's also good for business

5 best practices for cleaning a medical office

Many primary care physicians might say they are. After all, they have spent years building relationships with patients, sometimes treating multiple generations of the same family and learning as much about their private life as their medical history during office visits. Who better to give a diagnosis than someone who knows not only the patient’s ailments but where and how they live, and what nonmedical factors might be affecting their overall health?

But other primary care doctors know this nostalgic view of patient care is heading the way of house calls and the little black bag. Gone are leisurely discussions with patients aimed at pinpointing root causes of health issues. Now, there are corporate RVU goals, patient quotas and productivity spreadsheets. Time for patients is spent instead with electronic health record screens, administrative paperwork and computer systems that often cannot communicate across departments, let alone across the street.

To make matters worse, there simply are not enough primary care physicians. The American Association of Medical Colleges predicts a primary care shortage of between 17,800 and 48,000 doctors by 2034, and those estimates were made before COVID-19 drove some doctors into early retirement or other professions (40% of physicians reported feeling burned out before the pandemic). In addition, by 2034, the U.S. population is expected to increase by 10.6% with a projected 42.4% increase in those 65 or older — the people most likely to need care. More than 2 in 5 physicians will be 65 or older in the next decade, further thinning the doctor ranks.

America already trails most countries in doctors per capita. As of 2019, the U.S. average was 2.64 doctors per 1,000 citizens compared with the global average of 3.37 — an improvement from 1993 when the U.S. number was 2.4.

The result, predictably, is that the patient loses. Monthlong waits to see a primary care physician, rushed appointments, increasing costs taking money out of patient paychecks, and rising copays add up to frustration with the health care system.

Patients want a quick appointment to find out whether their case of the sniffles is anything to worry about; they do not want to be told they cannot see a doctor soon because they are caught up in the macroeconomics of the country’s inefficient health care system.

So, what happens? The patient takes charge. “Patient” is just a medical term for “consumer,” and today’s consumer does not want to wait.

“There’s a big focus on convenient care,” says Tom Florence, president, permanent physician placement, AMN Healthcare/Merritt Hawkins, a health care search firm. “A lot of patients, particularly younger patients, don’t want to wait around in the physician’s office, so fewer younger adult patients even have a regular family practice doctor. They want everything now.”

This demand is driving retailers like CVS and Walmart to get into the primary care game by opening clinics. The consumer wants medical care without a wait, and big corporations and private equity see an opportunity. Inevitably, someone will fill the gaps created by the shortage of primary care physicians.

So, who is in charge of primary care? The consumer, and that has led to a surge of nonphysicians willing to provide such care, often with little or no supervision from doctors thanks to increasing public pressure on legislatures to act.

In 2004 there were 106,000 nurse practitioners (NPs). Today there are 355,000, a growth rate of 235%. For physician assistants (PAs), in 2010 there were 89,019. Today there are 159,000, a growth rate of 79%.

With a shortage of primary care physicians leaving more than 90 million people without access to primary care, according to the Health Resources & Services Administration, it is not surprising that NPs and PAs are filling the gap and being sought to do so.

Retailer clinics are trying to provide more primary care access, but Florence says, “They’re doing a lot of that work through nurse practitioners or PAs.”

The same is often true for urgent care clinics. One startup, Mitesco, which owns The Good Clinic chain in Minnesota and looking to expand nationally, is staffed only by NPs — something it touts in news releases, saying they allow “equal care while cutting costs 25%.”

Mitesco is not alone. Florence says professional searches last year for NPs and PAs slightly exceeded those for primary care doctors for the first time, and searches for NPs were higher than for any other position. “Retail clinics, urgent care, a lot of telehealth are starting to trend toward specifically looking for advanced practice care candidates,” he says. “That’s more about the dollars and cents of it, meaning if we (the urgent care) hire a staff member who costs less, then our expenses are less costly, (and) then this becomes a more profitable venture for whoever is doing the hiring there.”

Despite increased demand for NPs and PAs, Florence says primary care physicians need not worry about a lack of job opportunities. “Family medicine was our No. 1 search for 14 years in a row up until last year; now it’s No. 2,” he says. “I do see a trend where the convenient care lens is a little more tilted toward an advanced practice candidate, whereas hospitals and health systems, generally speaking, prefer to have a physician in place and utilize advanced practice to help.”

The surge in NPs and PAs should not be surprising; both professions were founded as a means of providing more primary care. The first class of PAs graduated in 1967, with all four members having been Navy hospital corpsmen who had considerable medical training during their military service, according to the the American Academy of Physician Associates (AAPA). The PA concept gained federal acceptance and backing as early as 1970 as a creative solution to the physician shortage.

“PAs have been practicing primary care for over 50 years,” says Jennifer M. Orozco, PA-C, president of the AAPA. “I think where PAs fit in is they are often a patient’s primary care provider, just as physicians are, just as sometimes NPs are. Even with all that, we still have more than 95 million patients in the U.S. (who) lack access to primary care … and we have this growing need of chronic health conditions that need to be addressed, from diabetes to obesity. There’s no plethora of problems that are going to go away.”

NPs got their start in the late 1960s because more primary care services were needed for underserved populations. “NPs bring a comprehensive perspective to primary care,” says April N. Kapu, D.N.P., president of the American Association of Nurse Practitioners (AANP). “NPs assess patients, order and interpret diagnostic tests, make diagnoses and initiate and manage treatment plans, including prescribing medications. Today, 82% of adults report they’ve been treated or know someone who has been treated by an NP, and a vast majority of health consumers — nine out of 10 patients — support policies and legislation that remove barriers to NP practice and strengthen patient choice in the selection of a health care provider.”

Although there is some specialization among NPs, almost 89% choose primary care as their area of focus.

As their members’ roles have expanded, the AAPA and AANP have worked to shape their public image as more independent professionals and not just someone on a doctor’s staff. For example, in 2008, AANP petitioned pharmaceutical and health care product companies to use provider-neutral language in consumer print and broadcast advertisements. It has also invested in public relations efforts to change public perception of an NP’s role in the health care system. In late 2020, the AAPA voted to officially change the professional title to “physician associate” rather than “physician assistant” to better convey a PA’s ability to manage patients’ care autonomously.

NPs have full practice authority — meaning they do not require a supervising physician and can see patients on their own — in 26 states, whereas physician associates have full practice authority in just three states, even though their clinical requirements exceed those of NPs.

To become an NP, the person must have a bachelor’s degree in nursing, be a registered nurse, graduate from a master’s program with either a Master of Science in Nursing or a Doctor of Nursing Practice degree, and then pass the National NP Board Certification Exam. The graduate can then apply for state licensure. Most licenses must be renewed every two years, typically with continuing medical education credits of between 20 and 30 hours required annually, depending on the state. National certification by the AANP lasts five years.

PAs need a master’s degree from an accredited PA program, which requires supervised clinical experience in family medicine, emergency medicine, internal medicine, surgery, pediatrics, women’s health (prenatal and gynecologic care) and behavior and mental health care. Programs take three academic years and include classroom instruction and more than 2,000 hours of clinical rotations with an emphasis on primary care in ambulatory clinics, physician offices and acute or long-term care facilities. Once the degree is earned, they must take the Physician Assistant National Certifying Exam. To maintain certification, PAs must complete 100 hours of continuing medical education credits every two years and take a recertification exam every 10 years.

Requiring lower levels of training than physicians concerns some doctors. Physicians have tens of thousands of hours of training, with much more of it being hands-on experience.

“It’s not just the hours, but it’s the quality of their education, particularly nowadays, with many NPs simply graduating from an NP school that is completely online,” says Christopher Garofalo, M.D., a family medicine physician and member of Physicians for Patient Protection, which advocates for physician-led care and transparency around who provides it. “So, all their learning is online and there is no experiential learning. When they do get out into the clinics, if they even get out into a medical setting, the requirements for them are minimal, if at all. Yet when they come out, they essentially want to practice independently, just like a physician.”

The online schools have diminished the quality of nurse practitioners, says Niran Al-Agba, M.D., a pediatrician and co-author of “Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Health Care.”

“Nurse practitioners a decade ago or beyond were phenomenal colleagues with a phenomenal education,” says Al-Agba. “They were required to have, in general, five years of hands-on nursing experience, and it was, ‘OK, I’ve worked for five years in the (intensive care unit) or in a clinic, now I’m going to get my master’s education at a brick-and-mortar school.’ Now, you don’t even need to work as a nurse at all, and the first patient you see could literally be after your nurse practitioner degree practicing independently.”

She adds that being honest with patients about credentials and education level is paramount. “Because it’s too late to put the full-practice authority genie back in the bottle, I think we should be really clear about our roles and be clear about our identification,” says Al-Agba.

That’s something Orozco says PAs try to do. “We’ve been very clear who we are and what we do. We’re also very clear that we work closely with physicians, nurses and other members of the team so that (patients) know this is a team-based environment.”

Kapu says physicians must accept change. “The key is for all of us to recognize that health care is changing, and old-style hierarchical models are being replaced to put patients, not a single health care profession, at the center of the health care team. We have a shared obligation to modernize these outdated structures and we invite our physician colleagues to join us in achieving this goal for the benefit of our patients.”

Next month, part two of the series: Quality of care. Are NPs and PAs up to the challenge of handling patients on their own, and how do patients fare under their care?

Nurse practitioners and physician assistants keep taking on more primary care responsibilities, often without supervision of a doctor

Are primary care physicians being replaced?

Investors are frustrated these days as they seek to sustain portfolio values after the onset of the new bear stock market. Many are chagrined to learn that bonds, once a paragon of stability, are no longer an automatic solution for wealth preservation.

Although bond yields have been increasing on average lately, they are still quite low historically. Atop this, historically high inflation continues to pose a severe risk.

The current bond market also carries a high level of interest rate risk — the chance that the value of your bonds on the secondary market may be pummeled by rising interest rates. After all, why should anyone buy your bond at the yield you locked in at time of purchase when they can get higher yield from a newly issued one?

A market environment where stocks and bonds are both down is perplexing for investors who have long believed that bonds can be relied upon to provide income with low risk — a refuge when stock values are low. Yet, like stocks, bonds are now a source of angst for many investors.

However, there is an effective way of easing this angst. It is called a bond ladder, a strategy that involves buying bonds of varying, sequential maturities. This enables investors to rotate into higher-yielding bonds as rates rise, adding rungs to the ladder. To manage inflation risk, the average maturity of bonds in ladders should not be too long.

An example of a bond ladder would be bonds purchased in three maturity categories: short term (one to two years), medium term (two to five years) and longer term (five to seven years). When the shorter-term bonds reach maturity, the investor might want to buy more bonds at the top rung of the ladder (those with longer maturities). As a result, the top rung of the ladder may keep getting higher, or further into the future. For example, as they mature, bonds of shorter maturities can be rolled into holdings at the seven-year-maturity rung. The time horizon of the longest bond should be set according to the individual client’s risk tolerance and goals.

This strategy is only appropriate for investors with substantial portfolios. Many bonds require a minimum investment of at least $10,000, so it’s difficult for people with a bond portfolio of much less than $200,000 (and a much larger total investment portfolio) to achieve sufficient diversification — preferably achieved by maintaining a maximum per-issuer allocation of 5% of the total bond portfolio. Diversification of bond issuers is critical to managing risk.

For investors with smaller portfolios, a better alternative is to construct a ladder of bond exchange-traded funds or mutual funds, or to buy shares in one or more diversified funds owning bonds of different maturities. This affords more accessible exposure to laddering than owning individual bonds. Investors should be mindful of the risks stemming from having no underlying contractual maturity date. Holders of actual bonds have these dates.

For investors with total investment portfolios of $1 million or more, owning a ladder of individual bonds is a good way to invest in bonds in the current market. Such investors typically have advisers and investment managers, and when it comes to bond ladders, this is a good thing because this strategy requires extensive credit and market expertise.

Yet for investors with advisers, it is nonetheless important to understand how this strategy works so they can work with their advisers effectively. That way, they will have a realistic idea of what to expect and can adjust their long-term retirement or spending goals accordingly.

The main goal of a bond ladder is to hold bonds until maturity and reinvest the proceeds of retired bonds into those paying higher yields — the risk-adjusted yields available at the time. This way, inflation will not reduce as much of the buying power of your invested capital over time. Thus, over time, you will have opportunities to reinvest proceeds of lower-yielding bonds at higher rates.

Holding bonds until maturity reduces interest rate risk, as this enables investors to avoid selling on the secondary market, which may be pricing your bonds at a loss at the time you might decide to sell them.

Constructing and managing a productive, risk-managing bond ladder is more complex than it appears and requires extensive knowledge of the dynamics and nuances of the bond market.

The first rule of a bond ladder is to have discipline — to avoid selling a bond at a loss. Usually, the simplest way to avert this is to plan long in advance to hold bonds until maturity.

Many investors focus on yield alone, but this is a simplistic approach that can be extremely faulty. Known as chasing yield, this practice fails to assess various risks, credit risk being the most important. When even one bond becomes impaired or defaults, it is hard to recover. Chasing yield can also result in owning too many long bonds — those with maturities of 20 to 30 years. Investors who chase yield often overlook the importance of managing a bond ladder’s duration, or price sensitivity. The longer the duration, the greater the potential for volatility and the greater the risk. An adviser can help a client build a bond portfolio instead of just a collection of bonds.

Effective ladders can be built from various types of bonds, depending on an investor’s tax situation and risk tolerance. Most portfolios of individual bonds are composed of Treasurys, corporate or municipal bonds. Each type has its own tax implications, credit risk, yield ranges and other characteristics. Each type also trades differently. Credit risk is the lowest with Treasurys, but investment-grade corporates (those with credit ratings of BBB and above) are also a common option. Bonds below this rating threshold are junk bonds, euphemistically called “high-yield” bonds. These are usually a suboptimal choice for most individual investors, and now that many economic forecasts put recession right around the corner, they’re even less desirable because of an increased risk of default. Municipal bonds issued for general and essential services that are rated A or better are recommended for those in high tax brackets.

By working with an adviser and possibly a bond manager, you can structure a bond ladder that makes sense for your overall asset allocation, long-term goals and risk tolerance. Creating an individual bond portfolio can help you position for income and wealth preservation. During this difficult market period, these benefits can ease angst considerably.

David Robinson, CFP, is a director and senior wealth adviser with Mariner Wealth Advisors in the firm’s Phoenix office. He provides wealth planning services and creates custom financial plans to help clients grow and protect wealth, manage taxes and identify insurance solutions. He also prepares clients for retirement and manages estate plans. Prior to joining Mariner Wealth Advisors, he was CEO of Robinson, Tigue and Sponcil, an SEC-registered advisory firm in Phoenix.

A bond ladder is a strategy that involves buying bonds of varying, sequential maturities, enabling investors to rotate into higher-yielding bonds as rates rise, adding rungs to the ladder. 

Building bond ladders eases investor angst

Truth be told, we physicians traditionally and by design have avoided discussing end-of-life care with patients. For some of us, such discussions are too difficult or uncomfortable. For others, addressing the reality of death has wrongfully been considered a medical failure of sorts, despite a patient’s illness, age or condition.

If you think end-of-life care is a topic only for oncologists or gerontologists, think again. It’s for all of us who have patient contact, regardless of specialty. It is especially germane for primary care physicians who build trusting relationships with patients with a common understanding of patient prognosis and state of mind. A 2010 study from Johns Hopkins revealed that when people were given choices of where to get advance care planning advice, they overwhelmingly chose physicians. Despite that, we don’t initiate those conversations often enough, and patients are reluctant to do so when a standard primary care visit is only about 15 to 20 minutes.

Our culture values individual freedom and autonomy, yet we collectively abdicate those principles when it comes to advance care planning. It’s time to change that.

Following are five reasons why doing so is good for the patient, for the family, for the health care system and for the physician.

If you think end-of-life care is a topic only for oncologists or gerontologists, think again.

Medical Economics September 2022 edition

2022 Physician Burnout Survey results

Physician burnout, depression, and suicide

Solving physician burnout

Prior authorizations and Medicare reimbursement: what you need to know

Can Technology Solve the Burnout It Helped Cause?

5 best practices for cleaning a medical office

Are primary care physicians being replaced?

Building bond ladders eases investor angst

5 reasons why your patients need advance care plans

A health care price transparency revolution is at hand

Value-based care gains ground

Looking beyond high inflation

Dividend investing is a proven strategy for all seasons