Family physicians feeling the stress of practicing primary care medicine in 21st-century America need to know they are not alone. They also should be encouraged to learn that some of their colleagues have made practice changes that have effectively reduced the hassles and made medicine both meaningful and fun again.
Authors of research results published in the May/June issue of Annals of Family Medicine introduce their study this way: "By all reports, primary care physicians are at high risk of burnout. Fewer physicians are choosing primary care; many are leaving it. … Workdays are getting longer, and rewards are diminishing. Joy is in short supply."
Researchers involved in the study "In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices"(www.annfammed.org) note that more than half of general internists and family physicians have symptoms associated with professional burnout. They point to chaotic work environments, exploding regulatory demands and fragmentation of the delivery of care as some of the reasons for dissatisfaction with the status quo in medicine.
They also note that physicians spend "much of their days performing functions that do not require their professional training."
The percentage of physicians unhappy in their daily work is on an upward trend that shouldn't be taken lightly, the authors contend. "Physician burnout is associated with diminished patient satisfaction and reduced adherence to treatment plans; it also contributes to students' avoidance of primary care careers."
- Research published in the Annals of Family Medicine points to declining levels of work satisfaction among primary care physicians.
- Researchers highlighted 23 high-functioning primary care practices and visited 21 of those to learn how to revive the joy in practice and mitigate physician burnout.
- Teamwork, improved communications and previsit planning are some of the innovations explored.
In response to this increasing trend, the researchers looked at what kinds of innovations created high-performing primary care practices. In the process, they discovered practice innovations that made medical offices run smoother, kept patients and staff members happy, and enhanced physicians' joy in practice.
Practice Solutions to Common Problems
Physicians at 21 practices identified as high-performing welcomed at least one researcher for a full-day site visit; virtual visits were made to two additional clinics. The clinics, including 16 family physician practices, were set in urban, suburban and rural sites around the country.
Staff members from the AAFP and TransforMED served on the research team's advisory council, which helped shape the project, identified practices and formulated questions.
Researchers observed practice operations, interviewed administrative and clinical leaders, and summarized strengths and weaknesses in individual reports prepared for each clinic.
Their focus was on problems commonly faced in primary care practices, including
- unplanned patient visits and packed agendas,
- inadequate support to meet patient demand for care,
- time-consuming administrative and regulatory requirements, and
- poorly functioning teams within practices.
Study findings are solution-based and in a format that will prove most helpful to physicians.
For example, researchers report that at the Mayo Red Cedar Medical Center in Menomonie, Wis., lab work is completed several days before the patient visit. Family physician David Eitrheim, M.D., told the research team that patients like discussing the results of their lab work in person. "I can't imagine going back to the day when I used to send out letters to patients with results of HbA1c and lipid profiles and not use those results as an opportunity for motivational interviewing, goal-setting and developing an action plan."
The previsit planning and lab work saves the clinic at least one hour a day of post-appointment results reporting.
At the North Shore Physicians Group in Boston, the medical assistant's role was expanded to ensure adherence to clinical guidelines on preventive and chronic illness care. The patient "rooming" process increased in time from three minutes to eight minutes and was expanded to include medication review, agenda setting and form completion. The medical assistant reviews health-monitoring reminders, gives patient immunizations, and sets up appointments for mammograms and other necessary testing.
According to the researchers, the role transformation for medical assistants -- as well as other team-care protocols initiated at the practice -- resulted in a 14 percent increase in primary care physician satisfaction scores. An executive-level manager told researchers that prior to making changes in clinic protocols, it was no secret that physicians were unhappy with their patient interaction time. Physicians complained that much of what they were doing in the exam room was nonphysician work. "Now providers are begging us to get them started in the new model," the manager reports.
At the Cleveland Clinic in Strongsville, Ohio, the process was changed to allow a clinical team member to room patients and then return to the exam room to record notes while the physician performs the patient exam.
One year after implementing the change, the average number of daily visits increased from 21 to 28, and practice revenue increased as much as 30 percent. Kevin Hopkins, M.D., a family physician, told researchers that the medical assistants and nurses are more engaged in patient care and enjoy their work. Patients appreciate the change, as well, and quality metrics improved.
"I am far more satisfied. I leave work an hour earlier every day and have a very fulfilling relationship with my team… We're having fun," Hopkins told researchers.
Practices involved in the research study also found ways to save time and reduce physician hassles by
- re-engineering prescription renewal work,
- reducing unnecessary physician work through inbox management,
- strengthening team communication and
- improving team functioning.
Message to Family Physicians
According to the study's corresponding author, Christine Sinsky, M.D., of Dubuque, Iowa, for primary care to be the vibrant specialty physicians know it can be, "we need to redesign the way we do our work."
As an internal medicine physician in private practice since 1987, Sinsky knows all too well how primary care practice has changed in the past decade. "I think what's happened during the last 10 years is that all physicians -- and primary care physicians in particular -- have been given additional work to do," says Sinsky.
Much of the clerical, lower-level clinic work that nibbles away at physicians' time "could be entrusted to other members of the team," notes Sinsky. "We have to re-engineer our delivery model to allow physicians to be physicians."
She recalls correspondence from Benjamin Crocker, M.D., an internist in a practice affiliated with Massachusetts General Hospital in Boston. Sinsky first met Crocker in 2007 while conducting preliminary research for the study. After a site visit during which she observed him at work, he e-mailed her expressing frustration with the practice challenges he faced. "Working at Starbucks would be better," said Crocker in 2007.
Several years later, Crocker moved to a different practice owned by the same hospital, but the practice was built from scratch and touted as a "practice of the future." The practice also is one of the 23 included in the Annals study.
In 2011, with a fresh perspective from a new practice environment, Crocker again e-mailed Sinsky who tells AAFP News Now that the contrast in the two e-mail messages was so striking, she decided to highlight them in the study.
Crocker wrote about his new practice: "I look forward to going to work each day. I'm loving it."
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