Are We Trading Happy Physicians for Efficient Ones?

Healthcare reform is meant to make hospitals and physician offices more efficient, but that is proving to have its costs.

To say a physician is stressed is like saying water is wet. Physician stress and engagement issues were not born from reform. Take this quote from a surgeon, featured in an article published 10 years ago: "The stress of our jobs is increasing due to the decrease in reimbursement for professional activities, increasing regulatory requirements and severe financial constraints placed upon the hospitals in which we must practice."

A decade later, those factors remain highly cited for physician engagement issues. But now other factors — such as increased workloads, electronic medical records and physicians' apprehension to work for hospitals — add another layer of complexity. Healthcare's pursuit of efficiency seems to be making the adoption of other values it endorses, such as patient-centeredness and continuity of care, more difficult. And nobody has a better understanding of this than physicians.

What's up, doc?
"A few years ago, doctors used to be in the lounge all the time," says Angela Jones, MD, an OB/GYN practicing at Community Medical Center in Toms River, N.J. She said the lounge was like a revolving door, with physicians coming and going for coffee, meetings, meals and rounding. Now when Dr. Jones does spend time in the lounge, it's mostly for indirect patient care, such as placing orders, researching patient history and filling out electronic paperwork.

"It speaks to the culture of hospitals now. It's so busy, the relationship between physicians and nurses has very much changed," says Dr. Jones. "It seems like the sense of collegiality — I don't want to say it's not there. But with all the computers and everything being paperless, it seems like there's less need to have real communication. Everything is so automated."

Dr. Jones' observations aren't specific to New Jersey. Many hospital physician lounges have become spaces for physicians to work rather than converse. Some hospitals are even eliminating their lounges all together.

"You don't see the camaraderie and discussion that you have seen in the past," says Rochell Pierce, vice president of physician relationship management with Aegis Health Group. Many American workers are grappling with increased workloads, and there are many occupations in which people do not have time to kick back in a furnished lounge and chat with colleagues. Even if they did, it would likely be seen as a luxury.

So why is it such a given in the medical profession?  

"What's hard for physicians is they are so isolated to begin with," says Liz Ferron, vice president of service delivery at Physician Wellness Services, an organization devoted to improving physician workplaces. "They have so much responsibility on their shoulders, and they are dealing with life and death matters. Many of them don't have a broad support network because they're so busy."

The loss of opportunity for physician collegiality isn't about physicians having less time to kick their feet up and relax. Rather, it is a testament to how the healthcare industry is inadvertently sabotaging the very values it spends so much time endorsing — physician collaboration, teamwork, alignment and trust — for the sake of efficiency.

This bait-and-switch is not wholly up to hospitals. For instance, tight budgets don't make physician socialization any easier, at least in the traditional sense. Ms. Pierce says she's seen fewer hospital-hosted physician dinners, galas and balls. Those that do occur are scaled back, and fewer physicians attend.

Physician collegiality may be changing, but there's a silver lining: Ms. Ferron and Pierce are seeing hospitals get more aggressive about physician engagement. In one month alone, leaders from three hospitals called Ms. Pierce, seeking to implement or revamp their physician relations programs. "It's definitely a top-of-mind issue with hospitals," she says.  

Hospitals haven't always taken a gentle-handed, holistic approach to physician affairs. Even five years ago, a hospital administrator was more likely to focus on correcting the behaviors of physicians who caused the most problems or disruption, such as refusing to cooperate with other providers. Those behaviors still aren't off the hook, but more leaders are working to address the underlying issues, says Ms. Ferron.

The physician, the patient and the EMR
Surely, part of a healthy physician culture comes down to how physicians interact with their peers. But physicians are also experiencing pressures on the relationship that means most to them of all: that with the patient.

Paul Rothman, MD, CEO of Baltimore-based Johns Hopkins Medicine and Dean of the Johns Hopkins University School of Medicine, is optimistic but recognizes the challenges facing physicians.

"From my perspective, a great physician culture is one that allows physicians to feel like they have the time and resources to do what's right by their patients," says Dr. Rothman. "As we get efficient, and as we try to get healthcare costs out as we reform the system, probably the biggest risk is when the physician-patient relationship — which is unique and, I would argue, essential for healing — is put under the test."

When physicians say they are short on time, it's not an excuse. A 2013 study at Hopkins found first-year residents in internal medicine spent just 12 percent of their time interacting with patients. That amounted to eight minutes to each patient, each day. More than 60 percent of their time was spent on indirect patient care, such as placing orders, researching patient history and filling out electronic paperwork. Forty percent of their time was spent behind a computer.

When their industry is in midst of a systemic reform, things like eye contact can seem trivial to leaders and physicians. But nothing, even a blink, is inconsequential in healthcare. Nonverbal cues affect the system as a whole.

A recent study published in the International Journal of Medical Informatics found physicians who use EMRs, as opposed to paper charts, look at their patients less. While not necessarily a surprise, the finding is nonetheless troubling given the proven correlation between physicians' eye contact and patients' perception of empathy. Study authors have connected the dots: If patients feel like their doctors aren't being empathetic, they may be less likely to return for care, meaning they are less likely to adhere to medical advice or seek out care again, much less stick with the same providers.  

That doesn't sound efficient.

Dr. Rothman says healthcare is in an interim period, as physicians ease into new workflows and patterns with EMRs. Eventually, he says, technology will be leveraged to improve health. But what about now, while the broader workforce has yet to reach its prime for efficient EMR use? "I think it can have a detrimental effect to the time physicians spend with patients," he says.
 
Such cognizance in the C-suite has prompted some changes at Johns Hopkins. For instance, the system redesigned exam rooms to curb the phenomenon of wandering physician eyes. Now, when a physician is documenting the patient visit on the EMR, his or her back does not face the patient. "It's those little things you can facilitate to show the EMR does not have to come between the physician and patients," says Dr. Rothman.

The physician assistant will see you now
It's ironic that one way healthcare can gain efficiency tends to spark the most visceral of reactions. The relationship between physicians and mid-level providers has proven to be a contentious one, at best.

The debate over physicians, mid-level providers and their respective roles in care delivery is symptomatic of a systemic problem that has garnered little consensus among national physician and nursing groups. The argument is likely to ruffle feathers, as it comes down to how professionals define their work and view themselves. There is no easy solution, and early efforts to reach one are somewhat anemic. For example, the National Health Care Workforce Commission, formed in 2010 under the PPACA to address such issues, has yet to receive funding. 

Dr. Rothman prefers to focus his attention on "physician-provider" interactions more than physician-physician interactions. He finds himself in a unique position, as the CEO of a health system that employs roughly 2,800 physicians and as the dean of one of the top-ranked medical schools. He's also an MD-holder — a rheumatologist and molecular immunologist — but he approaches scope of practice issues with more logic than nostalgia or bias.

"As we think about how we'll take care of 15 million to 30 million more people under the Affordable Care Act, it will be more than a physician workforce taking care of people," says Dr. Rothman. "The healthy organization now only allows enough time to facilitate interactions between physicians, but also other providers in the workforce."

Dr. Rothman doesn't see much of a schism between physicians and mid-level providers at Johns Hopkins. That may be due, at least partly, to Hopkins' exceptional status as one of the most prestigious academic medical centers in the country.

But provider in-fighting is all too real for many other hospitals. For instance, about two-thirds of physicians said if a physician and NP provided the same service, physicians would do it better, according to a May 2013 survey from the New England Journal of Medicine. Seventy-five percent of nurse practitioners disagreed with that statement.

"In the old days, there was enough time that a physician could be the predominant care provider. Now you just can't do that," says Dr. Rothman. "It's a change, and academic medical centers and medical schools are really partnering with schools of nursing and pharmacy to ensure education about building a team, managing a team and interacting well with other providers is taught in medical school. It has to be patterned early on," he says.

But it's not just students who should be primed on these abilities — Dr. Rothman said residents and attending physicians should exhibit the spirit of collaboration for attendees at all levels.

Rather than spending their money, time and energy on physician alignment, hospital leaders may find themselves better off by devoting more time to alignment between clinicians of all degree types. What does physician alignment matter, after all, if the internist doesn't want to work with the PA?

Conclusion
There may be two ways to look at the healthcare landscape from here on out: This as the new normal, or this as an awkward adjustment phase in which physicians get up to speed. Dr. Rothman is rooting for the latter.

"Physicians didn't grow up with an iPhone at their hip," says Dr. Rothman. "They are having a little harder time, but healthcare providers are pretty smart and dedicated people. They want to help patients, so I think we'll come out of the transition with a better system."

Either way, health system leaders should think twice before viewing physician engagement through a superficial lens. Hospitals may become more efficient in certain ways through EMRs and heightened physician productivity, but little things — like an empty physician lounge or physician eyes glazed over by computer screens — add up. Dr. Rothman may be optimistic because he knows this; bullishness can stem from a place of preparation. He understands what healthcare has to gain and lose by becoming more efficient, and he's working to limit the latter as much as possible.

More Articles on Physician Engagement:
5 Ways for Hospitals to Get Physicians More Engaged
Top 5 Causes of Physician Burnout
12 Specialties With the Most Burned-Out Physicians

 

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