Most family physicians are familiar with the "triple aim" phraseology associated with improving overall health system performance. The triple aim calls for providing better health care, enhancing the patient experience and lowering health care costs.
Now, two primary care researchers, both general internists, urge consideration of adding a fourth leg to that triple-aim stool; namely, improving the work life of health care clinicians and staff members.
In an article(annfammed.org) published in the November/December issue of Annals of Family Medicine and titled "From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider," authors Thomas Bodenheimer, M.D., and Christine Sinsky, M.D., make their case.
Bodenheimer, a professor of family and community medicine at the University of California, San Francisco, told AAFP News that his and Sinsky's awareness of the physician burnout issue was heightened by the large number of comments they'd heard from physicians and medical clinic staff who detailed for them the stresses associated with delivering primary care to patients in today's health care environment.
Bodenheimer hinted that the burnout issue had been brewing for some time. "A number of excellent articles have appeared in the literature on physician burnout, most noteworthy (are those) by the physician researchers Tait Shanafelt, Lotte Dyrbye, and Mark Linzer, (all M.D.s)" said Bodenheimer.
- Primary care researchers recently examined the issue of escalating burnout in primary care practices around the country.
- Research authors suggest that the so-called triple aim framework that calls for better care, enhanced patient experiences and lower health care costs needs an additional aim that works on improving the work life of physicians and their staff members.
- Author Thomas Bodenheimer, M.D., notes that achieving the fourth aim will be difficult for primary care practices given the fact that patient panel sizes are increasing and excessive panel size is a sure formula for burnout.
Even so, this most recent article definitely touched a nerve with family physicians.
"We have had many family physicians respond, thanking us for the article," said Bodenheimer. "Dr. Sinsky and I have rarely had so many emails expressing that an article reflects what they (physicians) are feeling," he added.
Mounting Research Exposes Burnout
In the course of their research activities, Bodenheimer and Sinsky have visited primary care practices from coast to coast, and they've heard firsthand from physicians who have adopted the triple aim as a framework. Those same physicians said that stressful work conditions have impacted the ability of clinicians and staff members to achieve the three aims.
The authors noted that rising expectations demand that physicians provide patient-centered care that, for patients, equates to having access to health care services exactly when they want and need those services.
Unfortunately, society has not provided primary care physicians the resources to meet these "lofty benchmarks," said the researchers.
Authors pointed to previous research on physician burnout that highlights the gap between what society expects of physicians and the realities of practice. For instance, in a 2014 survey, 68 percent of family physicians and 73 percent of general internists surveyed said they would not choose the same specialty if they could restart their careers.
Another 2014 survey found that 43 percent of responding physicians said they spent 30 percent of their day on administrative tasks. In a national survey conducted in 2011, 87 percent of participating physicians named paperwork and administrative tasks as the main cause of work-related stress and burnout. And 63 percent of respondents in the same survey said their stress was increasing.
For many physicians, technology hampers rather than helps the situation.
More than 75 percent of physicians who responded to a 2011 survey said their electronic health record (EHR) "increases the time it takes to plan, review, order and document care."
Importantly, the research team said that burnout affected the entire health care workforce, not just physicians. "Physician and staff dissatisfaction feed on each other," they said.
Authors held up the Seattle-based Group Health Cooperative(www1.ghc.org), a member-owned, nonprofit health care system, as an example of how the triple-aim focus, implemented without consideration for clinician and staff work life, could backfire.
In the early 2000s, Group Health implemented systemwide reforms. "The unintended consequence was increased physician burnout and resultant quality reductions and cost increases," wrote Bodenheimer and Sinsky. Then, in 2006, the organization refocused its efforts and put the work life of clinicians at the top of the priority list.
"Burnout dropped substantially, with significant gains in clinical quality, patient experience and cost reduction," wrote the authors. "The Group Health story demonstrates that without addressing the work life of those providing care, triple-aim measures are likely to worsen," they added.
Reducing Stress, Reaching the Goal
The authors offered a few tips for primary care physicians looking to emulate Group Health's success. They suggested that physicians
- implement team documentation that allows for staff members to enter some or all documentation into the EHR,
- institute pre-visit planning and pre-appointment laboratory testing,
- allow nurses and medical assistants to assume responsibility for preventive care and chronic care health coaching as determined by physician-written standard orders,
- standardize workflows for prescription refills,
- station physicians and care team members in the same workspace, and
- ensure appropriate training for staff members who have been given new responsibilities.
Still, AAFP News wondered if accomplishing the fourth aim was an attainable goal for already over-burdened family physicians.
"Achieving the fourth aim will be extremely difficult in primary care," Bodenheimer acknowledged. He reaffirmed that instituting new processes such as team documentation would be good first steps toward reducing burnout.
Even so, there's no getting around the fact that the current shortage of primary care physicians runs smack up against an increasing demand for care, said Bodenheimer. That demand, prompted primarily by factors such as increased health care coverage under the Patient Protection and Affordable Care Act, an aging population, and a diabetes/obesity epidemic, will only increase the size of patient panels.
"And excessive panel size is a sure formula for burnout," said Bodenheimer.
"It will take a major increase in primary care capacity -- using nurse practitioners, physician assistants, nurses, behavioral health providers, pharmacists and better-trained medical assistants -- to allow family physicians to meet population demand without an increase in stress and burnout," he concluded.
Related AAFP News Coverage
Fresh Perspectives Blog: Changing the Trajectory of Burnout in Medicine