"I will never manage a panel of patients again. And that's because I love my patients and will not subject them or myself to the system."
32 y/o FP physician.
Its taken me a week to overcome the frustration and disappointment of the Health Affairs post on the critically important problem of Burnout in the physician workforce.
Frustration because this is not something new, yet the article leaves the impression that CEOs are just becoming aware. Disappointment because the eleven action items are essentially "form a committee to measure better." Physician burnout is not a new problem. The only thing new about it is that the severity and frequency is accelerating, and the average age is falling.
It would take me a day to - incompletely - write about all the causes of the situation, but instead I will focus on three action items (there are others). Each item below is grounded in (and titled with) solid management science concepts:
Efficient Workforce Strategy
Summarized best by “everyone working at the top of their license”, this concept has been lost in healthcare. More completely the concept is that no one should do any task that can be performed by another person with less training, and who costs the organization less. Why for example are physicians even touching keyboards or the computer mouse? Why can’t they “sign-off” on entries, made by someone else at their instruction, with a thumb print? And for that matter why are nurses entering data into computer systems when someone of less training, and lower cost to the institution, could be performing these tasks?
Suggestion - Scribes. Put care-givers back facing the patient instead of the computer screen.
Barrier – Short-sighted profit calculations that fail to include the cost of not doing it: burn-out, turn-over, errors, rework, and other efficiency losses associated with fatigue from menial tasks.
Caveat – Students seeking admission into graduate schools of nursing, medicine, pharmacy, physician assistant, physical therapy, etc schools are all likely candidates for eager and low cost scribes. There may be high turnover in this population but turnover at this pay-rate is always less costly than turnover of physicians (and nurses).
Management Science Metrics
“What you don’t measure you can’t manage” is a mantra that has overwhelmed the cautionary “Not everything that can be counted counts, and not everything that counts can be counted” (attributed to William Bruce Cameron and perhaps Albert Einstein).
Actually a modern management science and quality improvement guru – Dr. W. Edward Deming – is often pointed to as encouraging measurement and management. But he is also known for his Deadly Diseases of Western Management. The original five were:
- Lack of constancy of purpose
- Emphasis on short term profits
- Annual rating of performance “it is purely a lottery”
- Mobility of management
- Use of visible figures only
The two added later were:
- Excessive medical costs
- Excessive legal damage awards swelled by lawyers working on contingency fees
Now think about the all-too-typical hospital manager, especially in the large for-profit systems, that move every 3 years (#4), based on their performance (#2, #3) on this year's metrics (#1, #5).
Suggestion – “Balanced Metrics” collaboratively designed with the individual responsible for the performance. Every metric should have a “balance” of at least one measure that will alert us to having overdone the effort to meet the primary metric. Examples – LOS balanced by Re-Admission rate; C-Section rates balanced by Perineal Laceration and Unplanned NICU admission; Door to Admit Time (in the ED) balanced by Return to Imaging or Bed Transfer within 12 hrs of admit.
Any Human Resources professional worth their weight will tell you that performance measures that are imposed on a worker are essentially worthless (refer back to Deming’s Deadly Diseases #3, #5), or even more costly to the organization they are detrimental to total performance.
Barrier – It’s a lot harder and more time consuming to think about – and measure – the impact of a metric on something that might not be “under my purview.” If I am an ED Director, I want to meet national benchmarks on door to admit times and all the sub-parts (door to greet; door to disposition; etc) that I can measure. I don’t care about the impact that mis-diagnosis, partial diagnosis, or partial work-ups on the hospitalist. I don’t care about the disruption and added work, nor degradation in patient experience, that rapid admission has when there is a later return to imaging or movement to a permanent bed when the first one is the wrong bed for the complete diagnosis.
Caveat – Physicians have understandably, but perhaps overly so, rejected being measured because of past, often brainless, attempts at improvement. Like any other workforce that we would hope to manage, they should be involved with developing the measures. This will, in many organizations that haven’t yet, require some basic level education and leadership development. But the alternatives to this time-consuming effort have higher (although maybe not as measurable) costs. We can no longer work around physicians. We must work with them.
Spread and Sustain Best Practice
This aggravates physicians as much, if not more, than any other attempt to manage healthcare. And it is rampant in non-clinician efforts to improve clinical efficiency. If you take almost any “best” reported number in a system and transfer it to all parts of the system as an expectation, without any consideration of the differences between systems, patients, support structures, etc, you are engaging in blind assumptions. And physicians who try to point out the differences (my patients are different, this hospital doesn’t have XYZ support that aids in that care, the data are not reliable) are quickly labeled obstructionists, not team players, and/or autonomous individuals who can’t play on any team. Consider a simple example. “One hospital in our system has an average hospitalist patient census at 25. We should be able to match them.” And the new target is adopted, with no consideration for hospital size, complexity of system operations, type or severity of illness of patients, consulting support staff, nursing quality, etc.
Even more obnoxious is when the new “benchmark” is advanced from a clinical report that advises “consideration” and is converted by “corporate” into a mandate - “Guidelines Gone Wild”. Sepsis care is a recent example. Articles published with low level quality findings (expert opinion and single-site randomized trial), and recommendations to consider standardizing care resulted in several large organizations implementing mandatory testing, and when positive mandatory treatment protocols for “early sepsis.” The protocols were pushed on intensivists that argued for more bed-side judgement and selectivity. Some lost their jobs when they refused to comply with patients deemed not candidates, or inappropriate for this standard care. Later articles proved the “standard” to be overkill, costly, and of little or no benefit.
How many terminal event sepsis patients (metastatic colon or endobronchial cancer) were unnecessarily admitted to the ICU and had large bore central line catheters placed, in pursuit of corporate standardization?
Suggestion – Listen to your local physicians. They are your “front-line” workforce and understand your organization far better than the CEO and Board. And if they don’t understand clinical information better than your non-clinicians, then you have much bigger problem to deal with.
Barriers – It’s a lot easier to mandate behavior than to discuss, collaborate, build consensus, modify original plans with physicians. And admittedly, as discussed above, many physicians are wary of these proposals, and unwilling and/or unable to engage.
Caveat – There is undoubtedly waste in the healthcare system. There are almost boundless opportunities to improve efficiency in healthcare. Many ideas, because of their perspective and time and duty to find these opportunities, will come from non-clinical managers. As physicians, we should listen to their ideas, even when it is entirely a monetary gain proposed. After all, it is true - No margin, No mission. And there is a way to engage us that is more likely to succeed – see Management Science Metrics above.
I have personally witnessed, and strongly believe, that adherence to these three initiatives will serve any system well with addressing physician burn-out, and dare I say it, return the joy of practice to patient care.