Though many analysts, including one of us, have pointed the finger at the electronic health record as a major cause of physician burnout, the root cause may lie deeper. In the disappearance of collegiality, the fragmentation of physician communities, and a feeling of disempowerment by physicians in the future of the health systems they work with.
Connectedness and social capital in physician communities has withered as an increasing percentage of physicians no longer use the hospital to practice medicine and nothing has taken its place. Physicians everywhere feel that things are being done to them, rather than the other way around.
Medical care is hard work, made harder for procedural specialists by repetition and for primary care physicians by the frustrating challenges of patient-inflicted medical risk. However, in the past twenty years, physician communities have both fragmented and dispersed geographically.
Primary care physicians withdrew from following their patients in the hospital and ceded control over their patients to full time hospitalists.
Dermatologists, rheumatologists, medical oncologists, GI specialists, and many surgeons followed, as injectable or infusible drugs and flexible scopes enabled them to do more work in their offices or ASCs. Radiology decamped to freestanding imaging centers. Interpreting images drifted into remote locations as broadband and teleradiology enabled radiological coverage of nights and weekends from thousands of miles away.
As the baby boom generation of physicians aged, the compact whereby physicians traded hospital privileges for covering specialty consultations from the ER and ICU, and for after-hours anaesthesia and surgical call coverage broke down. Community physicians demanded call pay rather than serving on call panels for free.
In response, many hospitals contracted, first with local groups, and then with regional and national physician staffing companies, to cover their 24/7 EMTALA-driven coverage obligations, further weakening ties to local medical communities. This fragmentation has weakened collegial ties inside medical communities. It also weakened physician involvement in the governance and strategic direction of their hospitals and the systems that increasingly own them.
Somewhere along the way, hospitals ceased to be conveners of local physician communities. In the olden days, the hospital’s medical staff lounge was the equivalent of the watering hole in the African savannah, a place where erstwhile competitors and clinicians of all different stripes could meet in a safe space and exchange gossip, information, and referrals.
As physician communities fragmented into different clans based on employment status—hospital employed, corporate employed, and independent—there was no convening place where members of different clans could exchange information. Collegiality disappeared, along with an important channel for physician input into their organization’s operations.
With Obamacare in 2010 came an outburst of technocratic enthusiasm, and a wave of fresh requirements for physicians. Federal policy devoted itself to stamping out “fee for service” payment, as new payment models sought to replace the Medicare fee schedule. Hospitals created Clinically Integrated Networks (CIN’s) to work with physicians to contract with Medicare and private insurers in new value-based contracts. Physicians were also compelled by the 2009 HITECH Act to adopt electronic records, which morphed rapidly into a time-devouring instrument of social control.
At the same time, hospital systems and insurers were overtly encouraged by the Obama White House to absorb independent practitioners more directly to facilitate conversion to EHR-driven “value-based” models. From 2012 to 2018, hospital employment grew by more than 40% according to the American Hospital Association and UnitedHealth Group became the largest employer of physicians in the U.S.
Health systems cannot impose a new order on physician communities. Attempting to do so without meaningful physician input will increase their sense of disenfranchisement and aggravate burnout. But they should repurpose their CIN’s from seeking financial bonuses to markedly improving care continuity and removing needless or duplicative documentation requirements that distract clinicians from their core responsibility to listen to and respond to patient concerns. CIN’s also, importantly, span multiple facilities, and can serve as a conduit for physician input into the strategic direction of multi-facility health enterprises.
When the patient’s family physician has no idea of what happened to their patient in the hospital, and no communication from hospital-based clinicians about the key issues in follow up care, patients experience it as a dangerous and frustrating discontinuity in their recovery. If care protocols either do not exist or do not extend beyond the front door of the hospital, the care team’s job doesn’t get done.
There is also a financial reason why this collaboration is important. Health systems’ losses from treating Medicare and Medicaid patients pose a financial risk to those systems in any future recession or coverage expansion. These losses cannot be reduced other than through physician collaboration. Reducing variation in care that does not help patients and reducing medication errors, infections, and other care defects that increase costs and expose patients to risk cannot be achieved without broad-based collaboration across physician communities.
The overarching reason for physicians to resume working together is the shared commitment to patients. They and their families do not care where their physicians’ W-2s come from. They assume that all those physicians actually work for them, and in their interests. Continuity of care is about the clinical team working together regardless of who employs them to eliminate surprises and needless patient risk. We are not returning to the days when the “hospital medical staff” represented all clinicians in the community and could act to improve care.
Clinicians need to work together with their hospital systems in CINs across the “employment class” divide to eliminate wasted clinician time and improve communication, as well as to build protocols that structure and optimize patient flow through the system.
Collegiality and a new working relationship dedicated to an improved patient experience is the most effective cure for today’s epidemic of physician burnout. Health systems can help physicians regain a sense of efficacy and commitment to the system’s future by actively seeking their guidance and buy in to the health system’s future direction.
Jeff Goldsmith is president of Health Futures, Inc., and Chuck Peck, MD, is a managing director at Navigant, a Guidehouse Company.