The Cost to Patients of Physician Burnout: It Is Much Worse Than You Think!

The Cost to Patients of Physician Burnout: It Is Much Worse Than You Think!

By: Steve Moberg
Executive VP and COO at Team Care Medicine, LLC

This article is the third in a three-part series on the costs of physician burnout. The first installment provided the financial perspective while the second examined the physician’s personal perspective. This third round focuses on the cost to patients resulting from physician burnout.

Introduction

Most patients are unaware of the physician burnout epidemic and its causes. Nevertheless, it increasingly affects the care they receive. Patients may wonder why it has become more difficult to make an appointment with their primary care doctor or why their doctor seems distracted during the exam. Patients are surprised when they must ask their doctor, “Isn’t it about time for my next colonoscopy?” instead of the doctor identifying the care gap. They are frustrated when they cannot get in to see the doctor for an urgent issue, forcing them to visit the emergency room at far greater expense. Patients may not know to label these as consequences of physician burnout but they are aware of these changes and how it impacts their lives and care. 

Dr. Peter Anderson, founder of Team Care Medicine and a 30-year primary care doctor, identified accessibility, attentiveness, and accuracy as the three pillars necessary to achieve patient satisfaction and quality of care. Physician burnout is now quickly eroding each of these three critical foundations upon which so many doctors have built their practices.

Accessibility: Patients need more primary care doctors.

Access to care is the single most important determinant in patient quality of care — after all, there’s no care if the patient can’t see the doctor! An array of forces is driving a large and growing shortage of primary care doctors, and none is more insidious and preventable than physician burnout.

Demographic trends are driving increased demand for health care, with the US population growing and aging rapidly. While the total US population is projected to increase 10.3% by 2032, the population aged 65 and over is projected to grow by 48.0%, driving demand for care much more rapidly than the overall population growth would imply.

Meanwhile, physician burnout is eroding the supply of primary care on several fronts. First, burnout is causing practicing physicians to reduce their care hours. Physicians trade patient time for admin time to catch up on charts and other administrative tasks. Second, burnout is causing practicing physicians to retire earlier. With 42% of primary care physicians over age 55, this is an acute and growing risk. Third, as medical students perceive the high dissatisfaction of primary care physicians, fewer are choosing this career path.  

Increasing demand and eroding supply conspire to paint a bleak picture for patient access to care. A primary care physician shortage of 38,000 physicians is projected by 2032. The AAFP found that an increase of one primary care physician per 10,000 population was associated with 15.1 fewer deaths per 100,000 as well as 39.7 fewer ACSC hospitalizations per 100,000 and 712.3 fewer ED visits per 100,000. Real solutions are desperately needed to unlock patient access to care and thereby reduce ED visits, hospitalizations, and deaths. 

Attentiveness: Patients need more attention from their primary care doctors.

Patients reasonably expect their physician to be mentally present and focused during the exam. However, a common symptom of burnout is emotional disengagement. When patients feel their doctor is already under personal strain or overwhelmed, they tend to pull back and not share all their issues or ask all their questions. They do not want to add to the doctor’s level of stress, so they don’t. With less information available, the ability of the provider to offer quality patient care is obviously diminished.

One major contributor to burnout is the burden of administrative tasks and EHR Patient Chart documentation. To minimize the amount of chart documentation to be done later, many physicians feel compelled to enter data in the EHR even as they interact with the patient. Carrying on simultaneous “conversations” with the patient and the computer is exhausting for the physician and leaves all parties dissatisfied. So, not only is the burned-out physician emotionally unavailable to the patient during the visit, he/she exacerbates his/her emotional burnout by trying to maintain two conversations at once, continuing the vicious cycle. Meanwhile, the patient doesn’t feel heard and doesn’t share as much information, with dire consequences for health, not to mention patient satisfaction. 

Accuracy: Patients need emotionally well primary care doctors. 

As detailed in an earlier TCM missive on the financial cost of burnout, quality of care is jeopardized when a physician begins to experience burnout. Patients need a physician practicing at the top of his/her capabilities in order to keep up with the increasing complexity of primary care. Otherwise, missed pre-emptive screenings for cancer, errors in judgement when developing care plans, or charting errors can emerge. The 2019 Medscape Survey revealed 26% of depressed doctors say they are less careful when completing the visit documentation and 14% said they are making errors they wouldn’t ordinarily make. Survey results in a recent Mayo Clinic Proceedings article suggest a burned-out doctor is 120% more likely to make a medical error than a doctor that is not

TCM Model: A path to better patient health outcomes and satisfaction.

Burned-out physicians do not need to learn new breathing techniques or other mechanisms to cope with stress. They need real solutions.

In the InCrowd 2019 Survey, doctors were asked what they needed from their administration to help combat burnout. The number one answer by 66% of the doctors was to add staff. They understand that many of the tasks they perform each day can be performed by support staff. However, this is only part of the solution. Physicians need to reconceptualize their own role while surrounding themselves with a well-coached and properly equipped exam room team. 

The TCM Model eliminates burnout and restores the joy of medicine. In this system, the role of the physician is upgraded from overloaded work horse to team captain. The clinical support staff (usually MAs) are equipped to operate up to the limit of their license. They perform 7 new skills, including the bulk of the EHR documentation. This relieves the physician of all unnecessary administrative burdens before, during, and after the visit. With a larger team of higher functioning clinical support staff, the physician is able to concentrate on the patient (not the EHR), and focus on diagnosis and care decisions — the reasons they went to med school. 

Access improves as daily visit volumes and work RVUs increase 20-40%. Patients can once again see their regular primary care doctor rather than a rotating cast of urgent care centers, emergency departments, etc.

Attentiveness improves as the provider is freed from EHR data entry. As one recent convert observed: “I never realized how stressful it was to have to carry on two conversations at once until I no longer had to do it.” 

Accuracy improves as the provider’s emotional wellbeing is restored, boosting patient health and satisfaction. 

Conclusion

Dr. Chaoui, president of the Massachusetts Medical Society, noted that “We need to take better care of our doctors and all caregivers so that they can continue to take the best care of us.” The TCM Model takes good care of the providers and, by extension, their patients. 

Emotionally healthy physicians make a life-saving impact on their patients every day. Here’s just one example: When Dr. Peter Anderson developed the TCM Model, he equipped his Team Care Assistants (TCAs) to collect background data from each patient before the exam formally began, affording the TCA an opportunity to ask a number of profile questions that Dr. Anderson often ran out of time to ask himself. One day, Howard, a 54-year-old male, had an appointment to evaluate a lesion on his scalp. While the TCA was going through her routine data gathering, she asked Howard the profile questions for which he qualified: “Do you ever have any pain in your chest or shortness of breath when mowing the grass, carrying in the groceries, or going up stairs? And if you rest a minute, does the pain/shortness of breath subside?” Howard pondered for a moment then responded: “You know, I have had some pain in my chest the last couple of times I mowed the grass but it went away when I was done so I kind of just forgot about it.…so yeah, I guess I did!” The TCA made a note of it in the chart and during her presentation of Howard to Dr. Anderson, she passed the information on to him. Dr. Anderson asked a few more questions of Howard and told him he needed a stress test. Howard received a triple bypass three days later. Without the TCM Model, Dr. Anderson often did not have time for these profile questions orthogonal to the purpose of the visit. With the TCM Model, Howard’s life was saved through high quality care by an emotionally healthy provider supported by a high functioning exam room team. 

For more information, go to www.teamcaremedicine.com.

The Human Cost of Physician Burnout: It’s Worse Than You Think

The Human Cost of Physician Burnout: It’s Worse Than You Think

This article is the second in a three-part series on physician burnout. The first installment focused on the financial costs of physician burnout. This second article focuses on the human or personal side of physician burnout.

Ready to quit

In early 2019, Dr. Miller was preparing to quit his hospital-owned practice near Cincinnati to launch his own concierge practice (we’ve changed his name to protect his privacy). Dr. Miller loved his patients, he didn’t want to do this, but he was trapped in a patient care model that was failing him. He found it impossible to provide the care he wanted to his patients while maintaining a life outside of medicine. The updating of patient’s charts in the EHR was totally dominating his evenings and weekends. He was single and hadn’t been on a date in months. 

As his frustration and dissatisfaction peaked, he decided to make the difficult change to a concierge model. The disruption for him, his patients, and his soon-to-be-former employer would be very costly, but he just couldn’t take it anymore. 

Nationwide problem

Sadly, stories like Dr. Miller’s are repeated all across the country. Long-term unresolved job stress has led doctors to feel exhausted, overwhelmed, cynical, and detached. A recent Mayo Clinic Proceedings article concluded that doctors are 50% more likely to battle emotional exhaustion than the average American worker. Primary care physicians are particularly susceptible – they’re 40% more likely to experience burnout than specialists.

As a result, many physicians are looking for an exit. They are seeking administrative jobs to reduce patient time or have accepted a half-day or even a full day of “admin catchup time” to avoid the negative impact on their families, to the detriment of their paycheck. Other doctors are simply retiring earlier than planned to escape the grind. Still others are transitioning to different practice models altogether. Many fantasize about quitting medicine and starting a new career. Collectively, these escapes reduce patient access without solving the underlying problems that precipitate burnout.

For physicians that are unable to escape, many feel the walls closing in month after month. They become disenchanted with their profession, even hating medicine. They detach from their families and friends. Medscape’s National Physician Burnout & Suicide Report of 2019 found nearly 4% of US doctors (35,000!) are clinically depressed. Tragically, some have even turned to suicide to end the misery. One doctor commits suicide in the U.S. every day – the highest suicide rate of any profession. And the number of doctor suicides – 28 to 40 per 100,000 – is more than twice that of the general population. It’s no surprise that solving physician burnout ranks in the top 5 on most hospital CEO’s list of priorities.

Unfulfilling work

Burnout starts with long hours: the average physician works 52.6 hours per week, or 30% more than the average US worker. It’s even worse for the 40% of doctors that work more than 60 hours each week. However, having persevered through medical school, long hours are not the sole cause of burnout. The nature of the work is just as much of an issue. With more and more time dedicated to data entry in EHR charts, many doctors have gradually lost their personal connection with their patients – they’ve lost the “Joy of Practicing Medicine”.

The tremendous pressure to close charts causes many physicians to feel they are simply a cog in the healthcare machine with no higher purpose than capturing revenue. They long for the day when they felt like a valuable knowledge resource, like a practitioner of medicine with an essential vocation. What they thought they were signing up for is NOT what they are experiencing.

Irritable and isolated

Physicians’ families have a front row seat to the destructive power of burnout. Spouses, kids, parents, and friends all see the internal battle between a desire to deliver quality care for their patients and their need for a personal life. 

After a full day of patient visits (often feeling pressured and running behind by the end of the day), many physicians come home, feed the kids, help with homework, rush the kids to bed, and then jump back on the computer for 2-3 hours of additional chart work. Spouses are forced to pick up the slack, often causing more stress and friction at home. 

Burnout manifests itself in increased isolation, greater irritability, more time away from home, less communication, less time together, a drop in physical intimacy, and emotional separation. Frayed relationships at home only add more pressure on the physician. A real-world solution is desperately needed.  

The solution: It’s simpler than you think 

Given the breadth and depth of the problem, a variety of solutions have been tested to combat physician burnout, often having little or no effect. Sadly, many so-called solutions fail to tackle the underlying issues and instead apply “Band-aids” like meditation, breathing exercises, and relaxation techniques. 

A recent InCrowd Survey asked physicians what they wanted their hospital administrators to do to help them combat physician burnout. Their #1 response (at nearly 66%) was to add more staff to help ease the administrative/documentation burden. Any serious attempt at solving the burnout problem needs to take this information seriously.

One common approach is hiring a scribe for each physician to interface with the EHR, a bit like a “human app” added to the computer. While this is a step in the right direction, the scribe model comes with a significant limitation: because the doctor is still in the exam room throughout the entirety of every patient visit, scribes don’t provide a boost in productivity sufficient to pay for their additional cost. As a result, hospital executives choosing this solution simply add more cost to primary care offices which are usually already operating deeply in the red. 

A better and more financially sustainable solution is to implement the Team Care Medicine (TCM) Model. The TCM Model is gaining traction nationwide and has been proven to significantly boost physician productivity and reduce/eliminate physician overtime (often referred to as “pajama time”). For example, a six-doctor primary care practice in the Midwest launched the TCM Model and within six months had reduced average “pajama time” by nearly 80% (see below).

Even as they reduced after-hours work, these providers were able to see more patients each day. As illustrated below, their average visit volume increased by 35%.

Best of all, these physicians are experiencing a restored “Joy of Practicing Medicine”. They’re reestablishing connections with their patients and with their families. Remarking on happy physicians, happy patients, and happy administrators, one doctor called it a “Win, win, win!”

After launching the TCM Model, Dr. Miller abandoned his plan to switch to concierge medicine. With his charts current before the end of each workday, he’s started exercising again and is enjoying a long-term romantic relationship. This was unthinkable just 6 months earlier!  

The TCM Model has been implemented in hundreds of doctor’s practices across the country. Here are just a few of their comments about its benefits.

 

“The executives and administrators see the upside of increased productivity, the quality of care is better and I’m having fun. I enjoy practicing medicine again.”   

Patrick Anderson, MD

Richmond, IN

 

“[Now] I go home with nothing to do but play with my children and I have no reason to come in on Saturday.” 

Travis Howell, MD

Winston-Salem, NC

 

“I realized this was the model we needed to adopt. Not only for our patients, but also for our own well-being.”

William Byars, MD

Greenville, SC

 

“As for my personal side, the TCM Model allows me to have a life outside of medicine, which I didn’t have before.”

Dick Albert, MD

Mebane, NC

 

“I love it…I am having ‘fun’ again!” 

Jerry Dempsey, MD

Cincinnati, OH

 

How does it work?

In the TCM Model, the role of the physician is upgraded from overloaded work horse to team captain. The clinical support staff (usually MAs) are equipped to operate up to the limit of their license, performing 7 new skills that relieve the physician of unnecessary administrative burden. With a larger team of higher functioning clinical support staff, the physician is able to focus on the patient (not the EHR), to focus on diagnosis and care decisions (the reasons they went to med school), while the MA experiences more meaningful work and the practice enjoys higher revenues. For more information, go to www.teamcaremedicine.com.

It’s much worse than you think! The financial cost of physician burnout.

By now, nearly all medical executives understand that their physicians are burning out at an alarming rate. However, very few grasp the full economic cost to their system. When a physician resigns, the replacement recruiting costs and the direct opportunity costs of missed patient visits are fairly obvious, but these account for just half of the overall financial impact to the system. Early retirement causes an expensive ripple effect which is often overlooked. And for the burned out physicians that have not yet quit, the malpractice risks to the system are substantial. In the context of primary care, these elements are explained and quantified below.  We conclude that a burned out primary care physician creates an actuarial cost of increased malpractice risk of $37K per year and that the early retirement of a primary care physician triggers a loss in excess of $1.0MM to the system. The assumptions, sources, and calculations behind these conclusions can be found in this Excel spreadsheet.

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Of course, this analysis still omits the human side of burnout, which will be discussed in a future article.

Burnout in a nutshell

Burnout manifests in physical and emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment. Sadly, this has become a nationwide phenomenon, affecting upwards of 44% of physicians.

The undisputed drivers of physician burnout are the EHR and related non-physician work. Physicians find themselves staring at the computer screen instead of engaging with their patients face to face. As documentation requirements for billing, for compliance, and for meaningful use standards continue to climb, their take-home work (e.g. “pajama time”) consumes their evenings. As a result, their personal lives suffer and work becomes all-consuming. 

Burnout creates medical errors and increased malpractice risk

Sadly, when a physician begins to experience burnout, patient health is jeopardized. The 2019 Medscape Survey revealed 26% of depressed doctors say they are less careful when completing the visit documentation and 14% said they are making errors they wouldn’t ordinarily make. 

At TCM, we have encountered burned out physicians running up to 6 weeks behind in closing their charts! For medical malpractice trial attorneys this circumstance is a “dream come true”, making the line of questioning about chart accuracy an easy path to large jury awards.

Survey results in a recent Mayo Clinic Proceedings article suggest a burned out doctor is 120% more likely to make a medical error than a doctor that is not. Not only does this jeopardize patient wellbeing, it also substantially elevates the risk of malpractice lawsuits. We calculate the actuarial risk at an incremental $37K per year per burned out doctor. Though most systems provide malpractice insurance for their physicians, these incremental claims translate into higher premiums and higher deductibles that hit the bottom line. 

Burnout drives attrition, which is more expensive than you think

Direct Hiring Expense

Replacing a physician is a costly and time-consuming endeavor. Recruiter fees typically run one-third of base salary, whether an external cost or an internal overhead charge. A typical signing bonus is 15% of base salary. When training and legal costs are included, we see $161K in direct hiring expenses.

Direct Revenue Opportunity Cost

The loss of a tenured primary care physician leads to significant direct revenue loss as the panel disperses and patients must see another provider for their care. The direct revenue loss can be split into two phases.

First, while the position remains open, there is an obvious loss of revenue. In most cases, TCM has seen other providers in the practice shouldering one-third of the visits that would otherwise have been taken by the lost physician (adding to their own burnout risk). The remaining two-thirds is simply lost revenue. With primary care docs increasingly scarce, we see a typical recruiting period of roughly 6 months from day of resignation to first day of work for the replacement. The direct loss of revenue during the replacement hiring period averages $161K, during which time overhead charges continue to accrue. 

Second, even after the position is filled, the new physician typically cannot restore the full lost panel on Day One. Instead, they ramp up to full capacity over a 2-year period, operating with a 30% smaller panel in Year 1 and a 15% smaller panel in Year 2. The direct loss of revenue during the ramp up period for the new physician, compared to the lost physician practicing at full capacity, is $193K.

Thus, between the replacement hiring period and the replacement ramp up period, the direct revenues lost by the system add up to $354K.

Referral Revenue Opportunity Cost 

When contemplating the cost of a lost physician and the merits of investing in physician wellbeing, corporate finance teams often overlook the lost referral revenues when a physician resigns. Here, too, the costs are borne during both the replacement hiring period and during the replacement ramp up period.  ReferralMD reports that, after accounting for referral leakage, the average physician generates $672K per year in referral revenue to their system. During the replacement hiring period, this translates into $224K in missed revenues, even after accounting for some incremental visit volumes for the other physicians that retained one third of the panel. Likewise, during the replacement ramp up period, the system loses referral revenues of $302K. Combined, $526K of downstream referral revenues are lost by the specialists in the system when a primary care provider burns out and quits.

Where to from here?

When a burned out physician finally quits, it costs the system $1,042K after all the costs enumerated above are tallied up. And prior to quitting, the physician costs the system an extra $37K year-in and year-out in elevated malpractice risk. Investing against burnout is not only the right thing to do, it’s the rational thing to do.

Against a panoply of half-measures and flawed approaches, one solution stands out as an empirically-proven solution to burnout. The TCM Model is gaining traction nationwide and has been proven to significantly reduce or completely eliminate physician overtime (often referred to as “pajama time”). Survey results from TCM clients consistently show significant gains in provider satisfaction as the provider is freed from the myriad administrative tasks that weigh them down and enabled to focus on the patient face-to-face again. Numerous physicians that have deployed the TCM Model have put off planned retirements to practice longer and have cancelled plans to move to a concierge practice, saving their systems millions.

The TCM Model was developed by Dr. Peter Anderson in Yorktown, Virginia. Prior to developing the TCM Model in his practice, he was one of the 383,250 doctors totally burned out, frustrated and hating medicine. Once perfected, the TCM Model allowed him to triple his revenues, become the highest revenue producing doctor in his hospital system, and increase daily visit volume from 18 patients per day to 35 patients per day. The best part, though, was completing his charts before leaving the office so he could go home with nothing to do but enjoy his family time and relax.    

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Our COVID-19 crisis is greatly impacting all Americans, particularly our healthcare workers. We want quick answers to our COVID-19 questions.

COVID-19: Expanding Telehealth

COVID-19 – Expanding Telehealth

Written by Bruce Korus, Founder of Korus Health Innovation | Posted March 27, 2020

Introduction

Our COVID-19 crisis is greatly impacting all Americans, particularly our healthcare workers.  We want quick answers to our COVID-19 questions.  Primary care providers (PCP’s) are using telehealth to improve access, but are challenged to meet the surging demand.  This crisis will be a catalyst to future expansion of telehealth services. 

While sheltering in place, I decided to write this article about the COVID-19 crisis and expansion of telehealth services.  I expect this will be the first in a series of articles about how this crisis is impacting our health system and all Americans.

Growing Crisis

American COVID-19 cases are increasing more rapidly than other countries (Country by Country graph).  We will soon have more cases than China, Italy, or Spain.  Our COVID-19 cases are growing exponentially, with New York State reporting nearly 50% of total cases (Source – Worldometer).  During the past week, total US cases have increased from 6,400 to 54,800 (as of March 24th).  Cases are doubling every 3 days!

Due to delays in testing, I believe we have significantly underreported our COVID-19 cases.  New York has increased their testing from 1,000/day to 16,000/day.  As other states ramp up their testing, I expect we will see their numbers grow exponentially. 

Utilizing Telehealth

During this crisis, telehealth can help us provide more convenient and safe health services.  Providers face great risks in contracting coronavirus, due to exposure to undiagnosed patients.  Telehealth enables providers to minimize contact with COVID-19 patients.  On the other hand, patients want to avoid a clinic waiting room full of potential COVID-19 patients.  Telehealth provides patient visits at home on their smart phone.

I reviewed health systems offering telehealth services in the SF Bay Area, Seattle Puget Sound, Milwaukee, and Philadelphia (all places where I have lived).  Kaiser now provides more telehealth visits (through email, phone, and video visits) than in-person visits.  Although Kaiser has a well-established telehealth program, their video visits represent a small percentage of total telehealth visits.

Americans want to know, “How can I quickly get answers to my COVID-19 questions?”  These health systems offer on-line symptom checkers and/or provide a phone number for initial screening and recommended next steps.  Telehealth visits may be scheduled or provided on-demand.  Because of increased demand, consumers can expect delays in arranging virtual visits with longer than normal wait times.

Expanding Telehealth Services

Health systems are ramping up telehealth services as quickly as possible.  A major barrier to expanding telehealth has been the limited payments.  In response to this crisis, the federal government has passed emergency regulations to improve telehealth payment and licensure requirements for Medicare services. 

Our limited primary care provider (PCP) staffing will be a major challenge.  We have a shortage of PCP’s with many working part-time to improve their work-life balance.  Many PCP’s are over-whelmed by current practice demands and will have difficulty adopting new technology during this crisis.  Health systems are freeing up PCP time by deferring elective visits and closing some of their clinics. 

Well-established telehealth programs, such as Kaiser, Providence, and Penn Medicine, should have an easier time ramping up their services.  They can offer the options of email, phone, or video visits.  Their PCP’s are already very familiar with their telehealth systems.  National telehealth companies want to quickly hire more PCP’s.  But with our shortage of PCP’s, it may take months rather than weeks to hire additional PCP’s.

Summary

We must effectively utilize the time of our PCP’s, since they are at high risk for contracting COVID-19.  We can more easily increase email and phone visits, rather than video visits.  According to Dr. Ezekiel Emanual, we have fourteen days to defeat coronavirus and flatten the curve.  After working through this crisis, we will determine how best to utilize telehealth and expanded care teams in providing more convenient, affordable health services.

Bruce Korus is the Founder of Korus Health Innovation.  Expanded primary care teams will use telehealth to shift services from hospitals & clinics to homes & smart phones.  Please send your comments to bruce@korushealthinno.com

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Team Building vs. Building a Team

Team-Based Care Models Are Not the Solution to Physician Burnout

All across the US, well-meaning administrators seeking solutions to physician burnout are turning to Team-Based Care (TBC) Models. Few understand that TBCs were not created for the purpose of combating physician burnout or restoring joy in medicine. Rather, they were developed in response to new payment models that incentivize gains in the overall health of the patient. 

According to the Agency for Healthcare Research in Quality (AHRQ), “the primary goal of [Team-Based Care] is to optimize the timely and effective use of information, skills, and resources by teams of healthcare professionals for the purpose of enhancing the quality and safety of patient care”. While admirable and important, the primary intended beneficiary of TBC Models is the patient, not the physician.  

Team-Based Care Misses the Mark

Team Based Care and Burnout
Team-Based Care models place the patient at the hub of all functions and take the power away from the team.

The “team” in Team-Based Care refers to the primary care provider in addition to a host of adjacent healthcare professionals, such as care coordinators, triage nurses, pharmacists, and behavioral health professionals. For patients with complex health needs, coordination among these various providers is critical to good outcomes. However, when it comes to the mental well-being of the primary care provider, the TBC exacerbates the problem by adding more collaboration tasks and communication requirements to an already overwhelming workload.  

A host of evidence points to excessive administrative burden and EHR data entry tasks as the primary drivers of physician burnout. Providers report that they spend much of each visit typing on the keyboard rather than looking the patient in the eye. Most cannot keep up with their charts during clinic hours, but instead try to catch up in the evening, depriving them of rest and a personal life.

Any cure for physician burnout must involve relieving the provider of a meaningful portion of this administrative burden, allowing them to focus on the patient and on the actual practice of medicine for which they were trained. Such assistance must come inside the exam room, where the history is collected, the exam is documented, and the charts are updated. With its focus on an outside the exam room team, TBC is barking up the wrong tree.

Scribes Fall Short in Team-Based Care Models

Many systems have turned to scribes as a mechanism to take the keyboard out of the hands of the providers, freeing them up in the exam room. While this approach clearly yields some benefits, it doesn’t fundamentally change the equation for the providers that still perform virtually the entire visit themselves. Schedule delays and long hours remain a problem, as the scribe is little more than a “human app” attached to the EHR, which still must be directed at all times by the provider.

Team Care Medicine Cures the Illness

In order to truly change the game for providers, they must be freed to focus exclusively on the parts of the patient exam that require someone with their level of training. Everything else must be delegated to qualified team members. 

The Team Care Medicine (TCM) Model is built around this commonsense insight. In the TCM Model, the clinical assistants work ahead of and independent of the physicians. For instance, the clinical assistants gather all of the patient’s preliminary data, including chief complaint data, before the physician enters the exam room. They then present it to the physician verbally, in front of the patient, similar to how a resident presents a patient to their attending physician. The clinical assistants manage the EHR, including the capture of physical exam findings and recording of the diagnosis and treatment plan, thus freeing the physician to focus solely on the patient. The physician can then move on to the next patient, leaving the clinical assistant to provide patient education and close the visit. 

The TCM Model enables the provider to spend less time on each patient, and thus see more patients per day. In order to keep the provider fully occupied at this higher level of efficiency, most practices hire one additional MA per provider. The cost of this additional team member is easily covered by the 20-40% increase in provider productivity, and by improved provider satisfaction and retention as they re-engage personally with their patients during the exam and no longer take charts home in the evening.  

A Purely Logical Solution

The principal drivers of physician burnout are found inside the exam room, so any solution must also transform the process and responsibilities inside the exam room. While there are admirable goals and benefits to a Team-Based Care Model, healthcare leaders seeking a solution to physician burnout would do well to consider the commonsense and empirically validated approach: the TCM Model.

Growing numbers of primary care physicians across America are struggling to make the business end of their practice work.

Preventing Physician Burnout

Physicians are burdened by an incredible amount of stress from not only their work but also from rising operating costs, new technology, increasing administrative burdens, and growing demands from patients. This takes an obvious toll on physicians and can lead to low-quality patient care, medical errors, and can cost the healthcare system billions of dollars every year. 

So, can anything be done to prevent physician burnout? 

Learn to spot the warning signs

Whether in yourself or in a coworker, it’s always a good idea to be able to identify the signs of burnout and determine where these signs cross the line between regular but manageable work stress and burnout. That’s where our previous article, What is Burnout, and the Maslach Burnout Inventory (MBI) come into play. According to the MBI, there are three symptoms common among most physician burnout cases:

Emotional and physical exhaustion

Emotional and physical exhausting is the most common sign of burnout, which is when someone is worn out and depleted from work but unable to recharge during non-work hours. 

Depersonalization

Depersonalization is a symptom that often comes out in the form of cynicism, frustration, and a negative or callous attitude. Often, this is displayed in a physician’s sudden inability to connect with patients and constantly finding themselves blaming others. 

Physicians are burdened by an incredible amount of stress. So, can anything be done to prevent physician burnout?
Source

Reduced sense of accomplishment

During this stage of physician burnout, the physician starts to doubt their qualifications see themselves as incompetent. They’ve lost confidence in their skills as a physician and start to believe that patients would be better off not under their care. 

As you are watching for these signs, be mindful that physician burnout looks different in different physicians. For example, male physicians and female physicians display these signs in different ways

Physicians are burdened by an incredible amount of stress. So, can anything be done to prevent physician burnout?
Source

Sometimes, the constant discussion of burnout in healthcare becomes burnout in and of itself, giving physicians a sense of hopelessness in thinking that there’s no stop to this epidemic, that it’s an inevitable part of this job. But, there is a way to counter burnout and it starts with Team Care Medicine and restructuring the healthcare organization’s framework. It starts with deconstructing the various points of stress and instead promotes strategies that improve the organization’s balance. 

If you’re ready to learn how to do this within your own organization, sign up for one of our 30-minute live webinars. Within this time, you’ll learn the basics of our trademarked and proven TCM Model and understand the path to launching our program to fit your own organization.

Measuring and Managing Physician Burnout

Measuring and Managing Physician Burnout

Physician burnout is widely recognized as a challenge not only for physicians, their families, and their colleagues, but also for the US population that depends on access to engaged and effective healthcare providers. The World Health Organization recently defined burnout as 

A syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: 

1) Feelings of energy depletion or exhaustion.

2) Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job.

3) Reduced professional efficacy. 

Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.”  

Despite near-universal awareness, the problem is poorly quantified.

Measuring Burnout

Quantifying the prevalence and severity of burnout is inherently difficult. First, burnout is an internal experience that can only be described by the person suffering from it. Second, burnout is a continuum rather than a binary state.  

The Maslach Burnout Inventory (MBI) is the most commonly used measure of physician burnout. The MBI delineates burnout according to three components: emotional exhaustion, depersonalization, and reduced personal accomplishment. However, the cutoff criteria of what constitutes burnout and where to delineate low, medium, or high severity is subjective and varies widely in academic literature.

Other measurement tools have emerged to improve upon the MBI, whether by framing some of the questions negatively or by addressing the high cost of the MBI materials. Alternative approaches include the Copenhagen Burnout Inventory, Oldenberg Burnout Inventory, Patient Health Questionnaire-9 (PHQ-9), Stanford Professional Fulfillment Index, and the Well-Being Index.  

The vast array of diagnostic tools and cutoff points can be dizzying, but they all point to the same high-level conclusions:

#1 Burnout affects healthcare providers at higher rates than the overall population

In a 2014 study, approximately 54% of physicians reported at least 1 symptom of burnout, almost twice the rate of the general U.S. working population. Physicians explain that an heavy load of bureaucratic tasks and excessive work hours (especially take-home work) are the primary contributors to emotional exhaustion, depersonalization, and reduced job satisfaction.  After all, they “didn’t go to medical school in order to enter data in the EHR.”  

#2 Burnout affects primary care providers at higher rates than specialists

In an Archives of Internal Medicine article, researchers noted “substantial differences in burnout were observed by specialty, with the highest rates among physicians at the front line of care access (family medicine, general internal medicine, and emergency medicine).” Confirming this result year in and year out, the annual Medscape survey across 29 specialties consistently places Family Medicine and Internal Medicine in the top 5 for burnout and bottom 5 for happiest at work. 

#3 Burnout is reported at higher rates for women than men 

Among US physicians, women report burnout at 25% higher rates than men. Researchers note that women may be more likely to admit to psychological problems and seek help than men. Women also disproportionately assume childcare and family responsibilities, increasing the cost of challenges to work-life balance.

Healthcare executives must seek solutions to the root causes of burnout – excessive clerical tasks borne by the provider and the take-home work that results. Without a change, provider turnover will continue to climb and patient access will continue to erode.

What is Physician Burnout?

What is Physician Burnout?

Physician burnout has become a national epidemic with multiple studies proving that about half of all doctors suffer from at least one of the three common symptoms associated with this condition. Physician burnout negatively impacts quality of care, patient safety, physician and patient turnover rates, and patient satisfaction in addition to increasing the number of medical errors that have become common in the United States. According to a Mayo Clinic Proceedings study by Daniel Tawfik, MD, medical errors are responsible for 100,000 to 200,000 deaths each year. However, research connecting physician burnout to these errors is limited. 

Up until pretty recently, the most prevalent approach to reducing medical errors was to fix the workplace safety by adding in more checklists for physicians to complete and adding in “solutions” like yoga and breathing exercises for the physicians. Tawfik’s study shows that this is insufficient, comparable to placing a Bandaid over a large gash. Fixing these medical errors starts by addressing physician burnout, understanding what it is, how to identify it in yourself and your colleagues, and finding ways to prevent it. 

Defining Physician Burnout

An accurate comparison for physician burnout is that energy is like a bank account that can have a positive or negative balance. Every time a physician engages in the activities of their life and medical practice, he or she withdraws energy and the balance decreases. During times of rest and rebalance, energy is deposited, causing that balance to increase. The problem comes when it dips into a negative balance. The account doesn’t close; instead, energy is still spent (in this case working) despite the fact that the currency (energy) is, in fact, depleted. 

Burnout is a long-term stress reaction characterized by a series of symptoms we will later discuss that is a result of a constantly depleted energy account and with a negative balance over time. Yes, a physician can continue to function and work in this state but as only a shadow of the doctor that he or she is when the account has a positive balance. 

Signs & Symptoms of Physician Burnout

The industry-wide accepted standard for burnout diagnosis is the Maslach Burnout Inventory that was developed in the 1970s by Christina Maslach and her colleagues at the University of San Francisco. She described burnout as “an erosion of the soul caused by a deterioration of one’s values, dignity, spirit, and will.” The three distinct symptoms most commonly associated with physician burnout:

Symptom #1: Physical and Emotional Exhaustion

The physician is feeling both physically and emotionally drained, depleted, worn out, and unable to recover during non-working hours. This is by far the most common symptom of burnout and is the one most physicians identify with when taking burnout prevalence surveys. A thought process that the physician suffering from physical and emotional exhaustion may identify with is, “I’m not sure how much longer I can go on like this.”

Symptom #2: Depersonalization

When physicians display this symptom, it often comes in the form of cynicism, a need to vent about their patients or their job, and a negative or callous attitude. Doctors in this stage are feeling so emotionally drained that they are not emotionally available for their patients or anyone for that matter. 

Symptom #3: Reduced Sense of Personal Accomplishment

In this stage of physician burnout, you may begin to doubt the meaning and quality of your work and see yourself as incompetent. A piece of internal dialogue commonly associated with this symptom is thinking, “What does it matter? My work doesn’t really serve a purpose anyway,” or even, “I’m afraid that if I don’t change something, someone is going to get hurt and it’ll be all my fault.”  

Effects on patients, practice, and physicians

Physician burnout affects all parties involved: the physician’s patients, the practice, the physician’s family, and, of course, the physician him/herself. Physician burnout is directly linked to a series of unsavory consequences that you definitely want to keep out of your practice:

  • Lower patient satisfaction due to poorer quality of care
  • Higher physician and staff turnover
  • Higher and more severe medical error rates and malpractice risks
  • Physician alcohol and drug abuse and addiction
  • Higher physician suicide rates

There is a higher risk of death by suicide for both female and male physicians relative to other professionals but goes widely underreported. 

Physician burnout fits with the old adage “death by 1,000 paper cuts.” It can happen slowly over time, each day and each task exacerbating the physician’s condition until it comes crashing down with a trigger like a lawsuit, a tragic circumstance in one’s personal life, a significantly damaging medical error, etc. If left untreated, physician burnout will only erode the mental health of doctors and threaten patient care. 

Our Love/Hate Relationship with Provider Productivity

Our Love/Hate Relationship with Provider Productivity

This is the first in a series of communications on productivity and its far-reaching effects on our individual futures and the future of healthcare. In upcoming blogs, we’ll examine the link between productivity and an effective medical home, discuss some of the impediments to greater productivity and then see what it looks like in the exam room.

The driving factor in lack of access

There’s always talk about improving access, but low productivity, the driving factor behind reduced access, doesn’t get much respect. It should. It’s estimated that 38 percent of primary care visits in 2015 were unnecessarily diverted from the PCP office to the ED, urgent care centers and retail clinics. That’s a lot of lost visits, to the detriment of the practice – and especially to the patient because fragmented, limited care is no substitute for the kind of cost-effective quality that comes with continuous, comprehensive care.

What’s to love about productivity?

Getting back to our love-hate relationship with productivity, the “love” part is a matter of economics. While there are some exceptions, compensation has historically been based on the number and intensity of services provided. Metrics and methodologies can vary, but for the most part, the more patients seen, the more the likelihood of financial success. Although we continue moving toward fee for outcome-based payment models and next-era indicators for productivity, the wRVU standard remains in place for the majority of employed physician and physician owner practices.

And what is it that we hate?

As it turns out, there’s a darker side to this straightforward work-pay relationship. For primary care providers who already feel maxed out, it’s the vision of the hamster wheel. You hear the word “productivity” and you think of an industrial age assembly line, complete a conveyor belt, bringing endless numbers of patients in and out of the exam room. This scenario may be a bit extreme, but a system that incentivizes volume without supplying support staff with the specific skills need in primary care exam rooms can end up creating a negative impact on the missions of preventive medicine, wellness, education and basic patient care itself.  As a result, productivity is not only distinct from, but may also be anathema to quality and service.

If that isn’t bad enough, increased productivity carries the threat of overwhelming the already fragile work-life balance that providers often struggle to maintain. That’s why discussions of productivity can create concerns in the areas of both professional and personal satisfaction.

Why greater productivity is a necessity

In recent blogs, we’ve talked about how pursuing the Institute for Healthcare Improvement’s Triple Aim remains critical for maximizing overall health system performance and a reliable constant in the ever-changing map of healthcare. We’ve also discussed the value to primary care providers of capturing more acute care patients who might otherwise seek to have their medical needs met at retail clinics or urgent care centers due to limited access at their provider’s practice. The common element in both of these objectives and the most effective way to achieve this improved productivity.

However, without a corresponding increase in the kind of efficiency that supports productivity – and in turn leads to greater access – our ability to attain the Triple Aim, along with our hopes for meeting the needs of acute care patients will never reach fruition. And as we will discuss in the next blog, neither will our ability to bring the medical home to an effective reality.

Uncommon Bedfellows: Access, Expanded Hours, and Provider Wellness

Uncommon Bedfellows: Access, Expanded Hours, and Provider Wellness

In the first installment in this two-part look at the role of acute visits in primary care, we focused on the benefits of building this capability. In this continuation, we’ll discuss what needs to be in place in order to get there.

Improving access for acute, same day patients offers important benefits to practices and patients alike, but it takes a little thought and effort. The good news is, the mechanics are well within reach. I promise not to delve into queuing theory, wait-time metrics or any elements of what can be the surprisingly complex subject of medical scheduling. But I will share with you a bit of my own practice experience.

Opening up an adequate block of time at the end of the morning and another at the close of the afternoon…

…allowed us to better balance acute patient needs with organizational resources. What’s amazing is that these blocks were the easiest and most pleasurable part of patient visits for my clinical staff even though there could be 6-8 patients scheduled for each hour-long block.

This approach, which did not include a move to a true open access model, enabled us to stay on track with our scheduled patients and then see acutes collectively. Generally, it offered enough choice to accommodate individual patient schedules. If not, we could usually bring them in whenever they could make it and adapt accordingly because of the efficiency of our exam room process.

Utilizing high-functioning assistants who are empowered with the specific skills needed inside the exam room…

…is the single most important factor contributing to timely and consistent access for acute care patients. By building a more effective team in the exam room, providers can focus on direct patient care, those things that are commensurate with training and skills – and not the non-provider activities that can represent up to 60% of the patient encounter.

For example, in the typical routine (non-acute) primary care visit, the provider spends 10-15 minutes with what would be considered exclusively provider responsibilities and 10-20 minutes with non-provider responsibilities. Now, with the staff handling all the non-provider responsibilities inside the exam room, the provider is free to move on and see the next patient much more quickly.

I’ve seen improved exam room protocols work effectively in my own practice and in scores of other primary care and specialty practices with which I’ve been involved on an educational and training level. However, it’s important to note that the kind of transformation needed for more acute care capacity as well as all other patient visits isn’t simply a function of adding personnel. It involves true process redesign and a commitment to culture change, with a bit of professional flexibility and patience thrown in.

Expanded hours…

…have to be part of the solution if a patient’s need for access is going to be truly met by a familiar primary care provider. By building a more efficient team inside the exam room, increased productivity will allow for shortened shifts as well as fewer shifts per week. The result is that a small group of providers will have evening and weekend access collectively for their patient panels while promoting a very healthy work/life balance for providers individually.

Extended weekday and weekend hours and greater flexibility in overall scheduling are providing additional options and removing more of those times when, as the urgent care promotions put it, “your primary care provider is unavailable or you’re unable to make a timely appointment.” It’s not always easy, but an improved exam room process and the productivity that goes with this make expanded hours eminently doable.

Realizing that the time and energy spent on seeing more acute visits is not a distraction…

…but rather an opportunity with a range of inherent benefits is the most important step in preparing a practice for increasing acute visits.

Despite ongoing uncertainty in the direction of health reform, the four legs of the primary care table continue to be competence, continuity, accessibility, and affordability. A practice without timely access to a familiar provider when a patient perceives an urgent need is like a table with only three legs. Missing that access leg doesn’t make for productive quality-based primary care any more than it forms a solid, reliable and well-functioning table.

And speaking of tables, we’re leaving too much on them if we’re not ready to increase access for same-day, acute care patients.

© 2020 Team Care Medicine