Berks County Medical Society Medical Record Spring_2018 - 10

m E d i C a l r E C o r d F E at u r E

Physician Burnout:
The Systems Perspective

by Michael Baxter, MD, Chair, Department of Family and Community Medicine, Reading Hospital
Lee Radosh, MD, Faculty Associate, Family Medicine Residency Program, Reading Hospital

s this issue of Medical Record clearly illustrates, there are
many causes of physician burnout. Certainly, several factors
are not specific to medicine but rather our hectic American
culture. There are a multitude of suggestions for what physicians
can do to recognize and address their own burnout symptoms.
However, focusing solely on the individual misses perhaps the
greatest opportunities for addressing the epidemic of physician
burnout: system changes.
Physicians work long hours, often under stressful conditions -
it is no surprise burnout is common. As family physicians, we can
relate to surveys showing that primary care physicians are among
those with the most burnout. However, a generation ago this same
group worked even longer hours, often rounding in the hospital
before and after completing busy office sessions; some of the
family physicians even found time to deliver babies - all in a day's
(and night's) work. And yet if you had asked them about career
satisfaction, most would have said "I love my work." Long hours
and stressful circumstances clearly are not the only causative agents.
Much of today's stress is derived from the environment created by
our current systems of practice.
Clif Knight, MD, Senior Vice President for Education at
the American Academy of Family Physicians, has described our
dilemma as: EMR + RVU = IM SAD. Much has been written
about the added stress placed on physicians by the demands of the
electronic medical record. While most physicians recognize the
value of electronic data at their fingertips, many feel that they are
working for the EMR rather than the EMR working for them. The
EMR is transforming healthcare delivery, and eventually, we will
not be able to imagine life before it. We are however in its relative
infancy; we are bearing the brunt of - not feeling the reward yet - of
such progress. We often feel like clerks placing orders, completing
forms and of course dictating, typing and clicking for hours. There
is no end to the data that constantly streams into the physician's
inbox. With few filters to separate the critical from the mundane,
physicians must address everything. Cleaning out an inbox before
heading home is nearly an impossibility, more accurately an illusion.
Add "compliance" requirements, insurance questions and annoying
preauthorization requests, and physicians are left with a steadily
declining percentage of their time actually "doctoring."

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Physicians are also faced with the constant pressure of RVUs
(Relative Value Units) that determine one's productivity. There
are efforts to replace the pure "fee for service" model (driven by
numbers - more patients, tests and procedures) with "value based"
models emphasizing quality, patient satisfaction and improved
health outcomes. There has been much talk of value over volume,
but at best, the transition will be very stressful, and at worst, will
not happen until the distant future. It is not a stretch to see oneself
as that proverbial cog in a constantly churning wheel of high
volume clinical care. More often physicians see themselves in a
"job" whether 8-5 or 12-12, rather than as a member of a profession
supported by trusted and supportive colleagues and valued for their
mastery of high level skills.
Of course all of these factors have their ultimate impact on one
of the most important aspects of physician satisfaction: the doctorpatient relationship. Many causes have been argued for the decline
of this relationship, including distractions created by the EMR,
high volume productivity demands, insurance plan "ownership"
of patients, and fragmented, confusing and often competing paths
of care patients can take. There are fewer and fewer long-term
physician-patient relationships. This alteration in trust and the devaluing of that relationship creates negative consequences for both
patient and physician satisfaction.
It may seem as if the situation is bleak. On the contrary;
defining the problems is the first step in remediation. There are
ways to steer the joy of the profession back on course. Systems
(including hospitals/health systems, insurers, and governmental
agencies) will need to respond. They must address these issues
if physicians are to find satisfaction in their work and practice
compassionate, cost-effective medicine to achieve outcomes that
our society expects. We need to implement true value-based care
recognizing the role of the doctor-patient relationship. Even now,
we can apply concrete fixes such as improved EMR workflows
and more productive use of ancillary personnel (e.g. scribes and
others to attend to the routine functions of practice). It is time to
let professionals be professionals, not typists or clerks. If systems
are designed to support physicians in the professional roles for
which they were trained, everyone will benefit and the incidence
of physician burnout will decline as physicians achieve an enriched
sense of professional satisfaction. We need to prioritize reclaiming
the joy of patient care that has been a hallmark of the medical
profession.

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Berks County Medical Society Medical Record Spring_2018

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