Finances, practice size, autonomy, bureaucracy all factors in burnout, say Physicians Foundation leaders.
Physician burnout is “very disturbing,” “quite worrisome,” and “a crisis” in U.S. health care, said three leaders of the Physicians Foundation.
Before the COVID-19 pandemic, a physician burnout level stood at 40% in 2018, said Physicians Foundation President Gary Price, MD, PC, citing data from the Foundation’s survey.
The Foundation’s 2021 survey, conducted before and during the pandemic, found 56% of independent physicians reported often feeling symptoms of burnout, while 66% of primary care physicians reported frequent burnout symptoms. Overall, 61% of physicians reported frequent burnout symptoms in 2021, compared to 40% in 2018, Price said.
Price and Physician Foundation board members Joseph Valenti, MD, an OB/GYN physician, and Ripley Hollister, MD, a family medicine specialist, responded to Medical Economics questions about levels of physician burnout and ways to help, especially for independent practitioners and those in small communities and rural and underserved areas. Their written answers were compiled to create a roundtable-style discussion of this issue, in a question-and-answer format.
Medical Economics: What are leading causes of physician burnout in independent and smaller practices?
Price : Our surveys clearly reveal that the time spent with patients is the most rewarding aspect of most physician's careers. They list wasted time with obtaining preapproval for recommended treatment, growing mountains of bureaucratic checklists not pertinent to care, inefficient electronic records systems and an erosion of their ability to direct their patient's care as the leading causes of frustration and burnout.
Valenti: Physician burnout is a complex challenge but at its core it is caused by physicians losing clinical autonomy and navigating burdens impending on the physician-patient relationship, such as prior authorizations, electronic health records (EHRs) challenges and barriers to addressing patients’ social drivers of health (SDOH). On top of this, independent and smaller practices are dealing with rampant financial constraints including value for payment not keeping pace with overhead costs, pharmacy benefit managers driving up costs and stagnant government reimbursement rates. For example in Texas, Medicare just dropped 4% and Medicaid has been at the same rate for the past 23 years.
Hollister: Factors such as practice size and location, practice population makeup (local community affluence and socioeconomic status), staff support, professional training and support, peer connectedness and collegiality all contribute to burnout.
The Physicians Foundation’s studies shown a consistent reduction in percent of physicians who have ownership in their practices over the last decade, and the 2021 survey found that physicians expect even fewer independent physician practices after the pandemic. While independent practices have consistently decreased, physician burnout has consistently risen.There is certainly a relationship between autonomy and ownership.The link between loss of autonomy and burnout is also clear.
In my experience the key issue for practice satisfaction and personal resiliency has to do with an acknowledgement of the physician’s core values being realized daily; the opposite of moral injury.
ME: In independent and smaller practices, and rural and underserved areas, are physicians burned out because they are always working, because there aren’t enough of them to go around? Are they spread too thin, so to speak?
Price: Although overwork can certainly lead to burnout, I believe that hard stressful work has always been a part of the medical profession. Independent and smaller practices have been under unique stresses for decades, as federal reimbursement policy has favored hospital-based practices. Large insurers have denied these same independent practices any negotiating power and further shifted care into paradoxically more expensive larger systems. They faced proportionately larger financial challenges implementing EHRs which were not designed to make clinical work flows more efficient, and in fact had the opposite effect. During the COVID-19 pandemic, 68% of independent practices reported decreased incomes, while 44% of employed physicians reported that in our surveys.
Valenti: Independent physicians, especially those in rural and underserved areas, are absolutely spread too thin. The problem is that physicians in underserved areas are usually serving patients who are at or near the poverty level, so the reimbursement rate is often very low. If you had to have an all-Medicaid panel in Texas you wouldn’t be able to stay open, as Medicaid in Texas pays 63% of Medicare and Medicare is, on average, about 20% less than commercial insurance. They can’t make it work; they can’t attract people, they can’t keep overhead costs low enough and, certainly with the way people are changing jobs and increasing salaries, they can’t retain staff.
ME: In smaller, independent practices, do physicians have more control over practical steps in workflow, and in establishing workplace culture, when compared to large health systems? Can that help alleviate burnout? Or are they too busy to address these issues?
Price: One of the advantages of independent practice is more control over many practice-related issues. This kind of control can be used in scheduling, human resource issues, and technology adaptation, to name just a few. Empowering the insight of physicians at the practice level brings a tremendous advantage in these decisions, and restoring a sense of control over one's work is a key feature of reversing burnout. This adds another dimension to the work of independent physicians compared to their employed counterparts. Unfortunately, both groups are still faced with the major system wide sources of frustration and burnout I mentioned earlier.
Valenti: Physicians in smaller, independent practices do have more control and autonomy, which can help alleviate burnout, but the problem is that they don’t have the necessary resources. It’s like the joke: When a police officer pulls you over and says, “you have the right to remain silent,” you may have the right, but not the ability. These physicians have the right to have more control, and they have the latitude to do so, but they lack the resources and finances to implement the evidence-based programs, practices and policies that improve physician well-being.
ME: Apart from closing the doors, what are some steps that physician leaders in independent and smaller practices can do to alleviate burnout?
Price: Recognizing the reality and pervasiveness of burnout is the first step. I am surprised at the number of physician leaders who believe that it is not a problem in their own groups despite the disturbing statistics which have been reproduced in numerous studies. Next, a diligent and creative approach to identifying and resolving points of frustration in the daily workflow is required, including a hard look at the way EHR's actually impede or may facilitate care, how preapprovals and patient calls or emails are handled as well as after-hours records burdens, to name a few. Of equal importance is ensuring that a culture is in place encouraging physicians to seek help and providing access to that help for physicians who do feel symptoms of burnout. I would encourage all physician leaders to familiarize themselves with the ALL IN campaign, as well as the Vital Signs campaign. (Sadly, many surveys predict that an increasing number of physicians will be closing their doors.)
Valenti: Unfortunately, there is no one-size-fits-all approach to addressing physician burnout. This is a problem that requires a paradigm shift from a system where physicians think that burnout is something they must overcome by themselves to one where they see the support systems around them willing to help them. For those leading independent and small practices, resources are out there — state and local medical societies are actively offering access to well-being programs. For example, Travis County Medical Society Foundation, a Physicians Foundation grant-supported partner, developed and released a free toolkit to help health practice establish their own physician well-being program. There are also many national programs and resources independent physicians can access for themselves or their team, such as PeerRxMed,which is a free peer-to-peer program for physicians and other health care professionals that offers support, connection, encouragement, resources and skill building for optimal well-being, or the American Medical Association’s Practice Transformation Initiative, another Physicians Foundation grant-supported partner, provides a framework on how to create the conditions where joy, purpose and meaning are possible for physicians.
Hollister: Operating a small independent practice requires significant leadership skill. Physician leadership has been a core value of the Physicians Foundation, and central to the maintenance of the sanctity of the physician-patient relationship. In small practices, leadership means building an effective team, which works toward a common goal. That goal must encompass and validate the goals of all team members. In my experience, I hired a navigator whose purpose was to engage the patient outside of the practice. They would ensure that patients could adhere to the care plan, get ordered studies completed, have labs results and consults done and have results available at follow-up. Now, as navigation has become part of our team culture, this role has morphed into Chronic Care Management — which is reimbursable under Medicare.
The main point here to is understand that small practices are completely able to develop teams, similar to large practices, and that physicians should ensure that they unload the mundane issues, which impair their efficiency in practice, to team members who have the time to accomplish this process.
ME: Do issues such as too much time in EHR/EMR, and staff shortages, tend to hurt independent and smaller practices more than large health systems? Less? About the same, except to scale?
Price: Both of these issues are major problems in either setting and will require strong continuing efforts among physician leaders to effect systemic change. Our survey data would suggest that smaller and independent practices do suffer a greater economic burden and stress with these issues, as reflected in the practice income stress with COVID cited above, and the rapidly diminishing numbers of independently employed physicians.
Valenti: Many small practices haven’t transitioned to EHR; they’re still on paper, which can be sustainable if you only have one office. Personally, I find EHRs to be faster and enjoy the remote access to them. However, for those who don’t want to spend the time and money to transition to EHR, they might face greater challenges.
ME: What is the role of technology in addressing physician burnout? Are physicians ready to go back to paper charts? If time spent on electronic health record systems is part of the problem, how can health systems and physicians make them part of the solutions?
Price: Technology, which was designed primarily to facilitate billing and bureaucratic reporting tied to reimbursement, is one major part of the problem and will play an important role in the solution. I believe that this same technology can be used to make care more efficient, effective and gratifying to those who care for our patients. System wide recognition that most current EHRs are falling short of those goals, and a commitment to effect change will be required. Physician leadership in these efforts is and will be critical. I have yet to get a note done as quickly in any of the EHRs I use as I could on paper! Having said that, I am unaware of any instance in recorded history where things ever successfully returned to "the good old days”!
Valenti: I don’t think we should ever go back to paper charts; I think they are archaic. Once you get used to EHR, it is more efficient. Dictaphone is a helpful tool as it is quicker than typing. Another benefit is being able to prep charts before the patient visit and being able to edit them should something change during the visit. With paper charts, once you write something in there it can’t be undone. I feel as though I am more prepared to see my patients when I’m using EHRs and I don’t see myself ever going back.
However, I don’t think that’s the answer to burnout. I don’t think EHRs, or the use of EHRs, are the problem; it’s the lack of interoperability between the EHRs that is exceedingly frustrating. This is the issue that needs to be rectified. Interoperability is the number one frustration with EHRs, not the actual use of EHR. If I can’t get on another system to pull a patient’s charts, we’re going to waste time, money and effort by unnecessarily repeating processes and testing.
ME: In local, state and federal governments, what policy changes would help in alleviating burnout for physicians in independent and smaller practices?
Price: An unflinching examination of how governmental policies have led to consolidation of health systems, eliminated independent practices and added to rising health care costs without clear evidence of improved quality would be a good start. The recent passage of the Dr. Lorna Breen Health Care Heroes Act is a great example of a step in the right direction towards supporting the mental health of those caring for our citizens.
Valenti: Texas outlawed the corporate practice of medicine, which prevents corporate entities, including hospitals, from engaging in any activity that can be construed as the de facto practice of medicine. This has become especially important when faced with decisions about reproductive health.Physicians must remain the health care team leaders in every aspect of health care delivery. Medicare needs to life the moratorium on physician-owned hospitals; indeed the highest quality hospitals in the country were those owned by physicians, and allowing this will create competition for quality care. Finally, we need to support physicians financially by aiming for Medicaid and Medicare parity on a national level, as Medicaid payments are far too low for the work physicians in many states are engaged in.
ME: Our main audience is primary care physicians around the country. What would you like to say to them? Or, what would you like them to know?
Price: Primary care physicians are the backbone of our health system, and the Physicians Foundation recognizes their importance in making that system work properly. We want them to know that their work is valued as are they. Our foundation is committed to making sure that the physician's perspective is informing policy, and that physician leaders receive the information and training they need to effectively pursue those goals. Physician wellness remains a key pillar of our work and we are actively collaborating with organizations at the county, state and national level to address the unacceptable level of burnout present in our colleagues.
Valenti: Primary care physicians are the backbone of the entire health care mechanism, and we need to focus on reimbursements being adequate for what they do. The Physicians Foundation has worked diligently with CMS to ensure screening for drivers of health is billable work and has supported leadership development training throughout the country in hopes of creating groups of physicians that can better advocate for themselves and their patients.
Hollister: My recommendation is for physicians to strive to understand and define their own personal mission in life, then accept that the ability to follow that mission will have both wins and compromises. Physicians should ask themselves what is the most important to them? How does money fit into that equation? Is it possible to have both? While we can certainly have what is most important to us, we may have to dispense with the notion that every single box must be checked in order for us to consider our current situation a success.