May 17, 2018
Physician Burnout: It’s Nothing Personal
by Lisa Bielamowicz
1. Physician burnout is not (mostly) a work-life balance issue
As physician burnout has come to the attention of physician and health system leaders, many have attributed the symptoms of fatigue and frustration with practice to work-life balance issues. Doctors are working too hard and spending too many hours in the clinic, which is causing pressure on their lives outside of medicine—so the theory goes. (Sometimes this observation is coupled with a sideways remark about the changing demographics of medicine, noting that women surely feel more pressured about managing the challenges of home and practice.)
Tying burnout to work-life balance not only focuses the problem on individual failings (if a doctor is “burnt out”, she’s unable to personally manage the demands put on her), it also leads to solutions that paper over the real issue. In 2015, Stanford garnered a lot of publicity for its “time banking” program, which allowed doctors to earn credits for non-clinical activities like mentorship, committee service, and last-minute schedule changes. These credits could be “spent” on services to make the dull tasks of life inside and outside of medicine easier. Doctors could “buy” help to write a grant or get a gift card for their assistant, deliver meals, or clean their house.
While these services were much appreciated by doctors (as they would be by any busy professional), they did little to recognize that burnout doesn’t stem merely from having to spend longer hours at work. As a chair of surgery at an academic medical center I spoke with last year emphasized, doctors have always worked a lot of hours under pressure: “When I started practice in the 1970s, we worked 16-hour days, six days a week, and no one talked about burnout. It’s not the hours, it’s everything else that’s changed about practice”. He and others have identified that a change in how doctors are spending their time, not how much they’re working, is making the average doctor question whether practice is sustainable.
2. To solve the burnout problem, we need to rethink the workflow in clinical practice
In the past two decades, the distribution of a physician’s time spent on the job has moved away from clinical care delivery toward administrative and operational tasks. A study published in the Annals of Internal Medicine quantified just how profound this shift has been: the average doctor, across a range of specialties, spends just 27 percent of his time on direct patient care. The other three-quarters of the day in the clinic is taken up by administrative tasks: filling out paperwork, calling the insurance company, checking boxes on quality metrics, documenting or hunting for information in the EMR.
In hindsight it’s easy to see how these tasks have crept into day-to-day physician practice. Electronic medical records were never designed as workflow tools, but as systems to capture information for billing, coding and documentation. PCPs spend over half their day in the EMR. A common refrain from doctors: “Saturday night is Epic night,” when docs catch up on data entry. The average doctor spends over seven hours a week on documentation in the EMR after they’re done seeing patients. On top of that are the 785 hours per doctor and $15B spent on quality reporting every year. A host of programs aiming to improve quality, tie payment to value, capture critical patient information, and provide data-driven guidelines were well-intentioned but poorly-executed, leading to huge disruption for physicians with questionable returns.
Addressing burnout requires solving the “27 percent” problem: how can practice be restructured so that physicians can spend more time on the core tasks of care delivery, setting realistic goals that recognize fundamental changes in medical practice? This requires systems to rethink workflow, task distribution across a care team, and the use of technology in practice. Electronic medical records are here to stay—but systems must find ways for information to get into the EMR and back into the minds of clinicians without our highest-paid labor spending hours on a keyboard. Regulations and reporting requirements may be simplified over time, but we need to create consistency across dozens of performance metrics and initiatives. Physicians need to reduce care variation, but they require resources and leadership to take good ideas and scale implementation.
3. Beyond addressing workflow, we need to acknowledge that we’re in the midst of a structural change in medicine
Health system leaders recognize the need to invest in workflow solutions. Last year the CEOs of ten large health systems released a joint statement recognizing physician burnout as “a matter of utmost urgency.” They proposed solutions and pushed policymakers and other stakeholders to respond. It’s great that health system leaders are focused on the issue, but outside the provider community, complaints of burnout may fall on deaf ears. Policymakers recognize that myriad regulatory requirements create a burden on doctors. They’re looking to streamline, but mostly with an eye improving care and lowering costs—not making doctors’ lives easier. And the burnout argument doesn’t resonate with the average consumer. Imagine explaining to a patient who works two jobs to pay the bills that it’s a “crisis” that his orthopedic surgeon has to spend too much time on the computer and has lost the “joy of practice”.
The role of the doctor is changing, as it must. This is very hard for physicians—it feels like control is being taken away, and that’s a threatening feeling
Burnout is a systemic problem that requires real changes. But doctors also have to recognize that the field of medicine has fundamentally changed. Those who long for a return to the “good old days” of practice before EMRs, insurer bureaucracy and rising regulation will be continually frustrated. A spate of recent stories laments the loss of the “hometown doctor.” Witness this moving piece that ran recently in the New York Times. The article profiles a practice in which a group of doctors manages the full care needs of a small number of very complex patients. Providing comprehensive, continuous management of everything from heart failure to transportation, these physicians are able to keep patients out of the hospital, direct better end-of-life care, and increase well-being. It’s the kind of care we might all wish for.
But of course, we can’t afford that kind of care, not at scale. Those doctors have a panel size of only 200 patients. We simply don’t have enough doctors to return to a “Marcus Welby” model of care, fully delivered and managed by doctors, for the 80M Baby Boomers aging into their peak years of healthcare utilization. Having our highest-paid clinical talent spending a large amount of time focused on social care will increase labor costs unsustainably. Moreover, a younger generation of patients is signaling that they they’re just not interested in a return to the old model of practice. Millennials value access and convenience more than a consistent relationship with any single provider.
The aspects of practice that cause real frustration for physicians today are symptoms of poorly-executed efforts to rationalize a system that delivers expensive care at variable quality. It’s impossible to roll back changes in clinical practice, or the larger demographic and economic drivers that are forcing those changes. The role of the doctor is changing, as it must. This is very hard for physicians—it feels like control is being taken away, and that’s a threatening feeling.
Most doctors recognize that care delivery can be improved by reducing variability—finding a “right” way to practice and adhering to standards much of the time. And many of the things that doctors do today will have to be done by someone who gets paid less and has less specialized training. Solving the burnout problem will require physicians to participate in creating a sustainable, effective model of practice while acknowledging the reality that medicine—and the doctor’s role in it—will look different in the future than it has in the past.