The root causes of physician burnout and practical options for addressing them

I walked into Dr. Smith’s office to demonstrate a new virtual scribe platform.

When I spoke with the receptionist she was agitated and unhelpful. Dr. Smith then came from the back of the office to greet me. He was rolling his eyes, believing that I could understand his frustration. The office was clearly tense. A new patient, who was twenty minutes late, rushed into the office and was told that he would have to reschedule. He was clearly upset and getting abrasive with the receptionist. Dr. Smith proceeded to yell at the patient, going on a diatribe about how patients are inconsiderate and demanding. Dr. Smith was expressing a great deal of anger and he was taking it out on the patient in front of other patients, office staff and myself. I was uncomfortable and concerned about how I should proceed.

Dr. Smith, and his entire office, were clearly in turmoil. This interaction occurred before Dr. Smith had even seen his first patient. He was already emotionally and physically exhausted and he hadn’t even started his day. This is what defines burnout: the inability to recover from the stress of the previous day. When burnout occurs, the physician loses his ability to be resilient. And the cycle begins as yesterday’s stressful day has already made today stressful.

Physician burnout is very common affecting up to 50% of all physicians. According to the Mayo Clinic, physician burnout increased between 2011 and 2014 in all medical specialties and the disparity between physicians and other professionals had also increased. The causes of physician burnout include:

• an inherently stressful job
• being not prepared for the additional non-clinical burdens i.e., documentation, billing, insurance, changing politics, malpractice, etc.
• inefficient work environment resulting from Electronic Health Records (EHRs) and lack of other support
• work-life balance is difficult to maintain
• loss of autonomy, flexibility and control which is very stressful. If the physicians have no control over how many patients they see, how many hours they work, how to comply with government and insurance regulations, they will no longer feel that they are providing good care.
• loss of meaning in our work exemplified by the deterioration of the physician-patient relationship

The effects of physician burnout are far-reaching. If burnout develops, physicians experience emotional and physical exhaustion which results in:

• clinical ineffectiveness and medical errors
• depersonalization where the physician treats patients like objects and may come across as callous or cold. This is further complicated by physicians spending a great deal of time looking at their computer to complete the EHR
• low personal accomplishment. According to the RAND Health Quarterly, “When physicians perceived themselves as providing high-quality care or their practices as facilitating their delivery of such care, they reported better professional satisfaction.”
• poor patient experience and outcomes

Physician burnout can be destructive to patient care, physician well-being and practice stability. It has become some such a big issue that for the first time, the Massachusetts Health and Hospital Association and the Massachusetts Medical Society have convened a statewide Physician Burnout Taskforce made up of 15 MDs and one medical student from across the Commonwealth. The goal of the task force is to identify and prioritize effective strategies to combat physician burnout and advocate for statewide adoption of identified strategies and practices.

Dr. Steven Defossez, VP of Clinical Integration at the Massachusetts Health and Hospital Association and one of the Co-Chairs of the task force, says that some of the key reasons for physician burnout include “loss of autonomy and being forced to use still-primitive EHRs which have effectively turned physicians into the most expensive data entry clerks on the planet. Having been forced to practice in an environment where every hour they must satisfy nonclinical authorities, fill out endless forms, key useless data into the EHR and argue daily with insurance companies to ensure patients get the care they deserve, physicians feel they are spending more time caring for the computer than the patient. Physicians have always worked long hours; what is currently driving them to distraction is the fact that today most of these long hours feel like mindlessly jumping through hoops to satisfy government regulators and bean counting insurance company gate-keepers.” Dr. Defossez points out that physician burnout is “not just a physician issue but a public health issue.” Solving this problem must be a shared responsibility.

Similar to the Physician Burnout Task Force, there are other entities that have been developed to help including:

• National Task Force for Humanity in Healthcare
• Appointing Chief Wellness Officers (CWOs) to help physicians reduce their administrative burden with peer-to-peer support
• American Medical Association’s Step Forward Initiative that provides help for physicians to navigate their EHR and improve workflow
• American Academy of Family Physicians’ Health First Portal whose slogan is “Caring for patients starts with caring for yourself.” Physicians can also take the Maslach Burnout Inventory to assess their level of burnout.
• The American College of Physicians “Patients Before Paperwork” initiative helps physicians to identify potential administrative improvements in order to improve their work/life balance

Medical scribes: a practical first step
Obviously, there is no single solution to address the complexities of physician burnout. Everyone in the medical field has to work together to combat this issue and many solutions will take time to implement. That said, one potential option that can alleviate the administrative burden is to consider medical scribe solutions. Scribes can almost immediately address the physicians’ administrative concerns and allow them to spend more time with the patient and give back some control to the provider. Currently, physicians spend almost 50% of their time documenting and only 27% with direct patient care. On average, for every one hour of direct patient care, the physician spends two hours performing clerical duties. A great deal of this time is spent navigating the EHR and detracting from the patient-physician relationship.

The Journal of the American Board of Family Medicine performed a longitudinal observational study to evaluate the impact of scribes in a family practice. Their study showed that integrating a scribe into a medical practice reduced physician documentation time, improved patient interaction and positively improved the physician’s satisfaction in practice. A study in JAMA Dermatology found that implementing a scribe program into a dermatology practice resulted in a 50% reduction in documentation time, the ability for 79% of the physicians to increase patient volume and a 7.7% increase in revenue.

Further support for medical scribes came from a study of the gaze patterns of physicians and patients during a visit. The study showed that the patient follows the doctors gaze. If the doctor looks at the computer, so does the patient. If the physician looks at the patient, the patient looks at the physician. Unfortunately, physicians spend about 30% of a visit looking at the computer. If a scribe can perform documentation, the physicians can devote their time to bonding once again with their patients providing greater satisfaction for both.
As every physician and practice is different, it is important to personalize your scribe initiative so that it addresses the specific needs and scribing preferences of each physician to drive engagement. There are several different types of medical scribe options to consider:

• Physical Scribe – accompanies the physician during the visit, helps with EHR entry, orders, prescriptions and coding
• Virtual Scribe – listens remotely and records the patient visit. Scribes into the EHR through screen sharing capabilities and can also help with orders, prescriptions and coding
• Voice recognition – similar to transcription; unable to help with orders, coding or prescriptions

Due to improved efficiency in note completion and improved billing and coding, medical scribe solutions can also generate a positive return-on-investment in less than a year alleviating financial pressures for the practice.

Physician burnout is a pervasive problem which can have a huge impact on patient care. Fortunately, this problem is being acknowledged and addressed on many fronts by the leaders of the medical community. Physicians have to help each other as well as accept that they need some assistance. Physicians like Dr. Smith are in a vicious cycle and it may be difficult to get them to try anything to help themselves. Moving forward, it is imperative to prevent physician burnout by addressing their concerns before burnout occurs. Medical scribes can address many of the physicians’ concerns and prevent significant burnout by allowing physicians to bond once again with their patients and provide optimal care.

Bio for Andrea Caliri, MD: Dr. Caliri is a OB/GYN who serves as Mindleaf’s medical consultant for the company’s medical scribing services. Dr. Caliri is an industry thought leader on the topic of engaging physicians and medical practices in medical scribing solutions that help them improve their workflow so they can experience the joy of practicing medicine again.

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