Tuesday Jan 21, 2020
Burnout by Numbers
"Hello, Samantha dear, I hope you're feelin' fine"
-- Garth Brooks, Callin' Baton Rouge
Congratulations to the LSU Tigers on winning the college football national championship last week. I still consider "that time Bobby Boucher showed up at halftime and the Mud Dogs won the Bourbon Bowl"(www.youtube.com) to be the greatest moment in Louisiana college football history, but this was quite a run by Louisiana State University.
Of course, there also was a substantial amount of news in health policy the past couple of weeks. There is always a substantial amount of noise around health care innovation and investment this time of year, largely driven by the J.P. Morgan Healthcare Conference. This year's conference (which was last week) didn't disappoint, with numerous proclamations of the undeniable value of new technologies that will transform the health care system. The most interesting element of the conference, based on the news articles I read,(www.axios.com) was the growing concern with hospital costs. I will be curious to see if the finance and investment industries start putting pressure on hospitals to rein in their escalating costs.
Without question, one of the biggest stories during the past couple of weeks, if not months, was the publication of an evaluation study on the Camden Project. Led by family physician Jeffrey Brenner, M.D., the project was based on the concept of "hotspotting," or focusing resources on high-cost, high-need patients. It also was one of the first efforts to use social determinants of health data as a tool to risk-stratify a patient population and then develop care plans based on that stratification. It was an important project and was appropriately celebrated in the health policy world. Atul Gawande, M.D., M.P.H., wrote a piece in The New Yorker on the project called "The Hot Spotters."(www.newyorker.com)
The study, "Health Care Hotspotting -- A Randomized, Controlled Trial"(www.nejm.org) was published Jan. 9 in the New England Journal of Medicine. It found that with respect to hospital readmission, there was no difference between the control and intervention group -- a real disappointing outcome. Kaiser Health News had a good story(khn.org) summarizing the findings of the study.
A second study(annals.org) comparing the administrative costs of the United States and Canadian health care system also made some noise in recent weeks. It is a well-established fact that the United States spends significantly more on health care than any other industrialized country. Yay, we're No. 1.
According to the study, "the U.S. now spends nearly five times more per person on health care administration than Canada does. The U.S. administrative costs came out to $812 billion in 2017, or $2,497 per person in the U.S., compared with $551 per person in Canada." What this study and others like it are bringing into focus is the fact that a large portion of our health care spend is not going to patient care. Reuters published a nice story on this issue: "More than a third of U.S. healthcare costs go to bureaucracy."(www.reuters.com)
Although these studies were insightful, I am going to focus the rest of this post on a familiar topic -- the failures of the EHR. I will say upfront that I continue to believe that the electronic management and transfer of patient and medical information is foundational to a high-quality, efficient health care system. At the same time, I clearly understand that a system that fails to produce efficiencies in time and costs and one that may actually make the delivery of care less safe is not acceptable. It is also clear that the EHR (and activities associated with it) is one of the top, if not the top, driver of physician burnout.
The Wall Street Journal published an article(www.wsj.com) on Jan. 15 that examined findings from the Medscape National Physician Burnout & Suicide Report 2020: The Generational Divide.(www.medscape.com)
The report found that 38% of millennial physicians, 48% of Generation X physicians and 39% of baby boomer physicians are burned out. The report also found that 48% of female physicians report being burned out, compared with 37% of male physicians. Overall, 46% of family physicians report being burned out. An interesting trend in the data is that, generally speaking, the cognitive, ambulatory-based disciplines report much higher levels of burnout than the procedural and surgical disciplines.
My colleague Clif Knight, M.D., the AAFP's Senior Vice President of Education, is a recognized national leader on issues associated with physician well-being and burnout. I asked him for his response to the Medscape report and this is his top line summary: "Though the overall rate of physician burnout has improved slightly over the past five years, the disproportionately higher rate of burnout for women in medicine continues to escalate. The systemic factors in the physician work environment negatively impacting women need to be more overtly identified and addressed. Also, though rates of burnout are higher for Generation X physicians who are in mid-career, by far the great driver of burnout across all age groups is too many bureaucratic tasks. Addressing the forces that necessitate and perpetuate these tasks needs to be the priority of improvement efforts."
The AAFP has extensive resources and tools focused on family physician well-being via our Physician Health First initiative.
It all comes back to the fact that EHRs are causing extensive and potentially irreparable harm to physicians and the health care system. Here are four new findings to drive home this point.
- The AAFP Member Satisfaction Survey found that 61% of family physicians view the increase in administrative tasks and the associated burden of documentation, utilization review, quality reporting, etc., to be the most pressing issue for them and their practices. We hear consistently the frustration caused by these functions, most of which are performed using an EHR.
- The Medscape report asked physicians what contributes most to burnout. Fifty-five percent stated that "too many bureaucratic tasks, including documentation" is the leading contributor to burnout, followed by 30% who said that "increasing computerization of practice" is the leading contributor.
- On Jan 14, the Annals of Internal Medicine published a study -- "Physician Time Spent Using the Electronic Health Record During Outpatient Encounters: A Descriptive Study"(annals.org) -- that examined the amount of time physicians spend engaged with the EHR during a patient encounter. They found that physicians spend an average of 16 minutes and 14 seconds per encounter using their EHR. The top functions performed using the EHR were chart review (33%), documentation (24%) and ordering (17%). They also found variation between physician disciplines, with time spent among primary care specialties being higher than the average, up to 18 to 22 minutes per patient encounter.
- The proliferation of EHR-related activities isn't just impacting practicing physicians, it is impacting the training of physicians, as well. According to a 2019 study published in JAMA Internal Medicine,(jamanetwork.com) first-year residents spend nearly 90% of their work time away from patients, half of that interacting with the EHR and documentation. Wow. Congratulations on graduating from medical school. Now we would like to spend the next year familiarizing you with the mind-numbing, career-crushing, distracting activities that will dominate your professional career. Oh, by the way, none of these skills help you provide better care to your patients.
The AAFP continues to prioritize improvements in the EHR and associated modules and products. In 2019, we met directly with the two leading vendors to share our concerns. We also have launched a large-scale project aimed at identifying processes to assist physicians with common challenges originating from the EHR. I hope to share much more on this work in future posts. To close, here is a video demonstration of one way to "manage" your EHR functionality.
Posted at 08:41AM Jan 21, 2020 by Shawn Martin