Everyone is talking about burnout these days, with reports that almost half of all physicians are experiencing some symptom of burnout.1 But patient care and other responsibilities can keep physicians so busy that they do not have time to reflect on whether they are personally experiencing burnout symptoms. Aren't stress and exhaustion just part of the job?
Thoughts that may reflect symptoms of burnout include the following:2
Depersonalization: “The diabetic train wreck in Room 2 will put me way behind schedule,”
Loss of pride in work: “All I did today was click on the electronic health record (EHR) and document to meet billing rules.”
Emotional exhaustion: “I don't have it in me to figure out the cause of her headache. I'll just refer to neuro.”
Physicians who are experiencing burn-out may feel that they are drowning — that no matter how hard they try, they cannot accomplish everything required to give quality care to their patients. They might begin to believe that something is wrong with them and that working harder will fix it. It won't.
Physicians facing burnout need to know three things:
You are not alone. Knowing that others are experiencing the same emotions can be reassuring.
You are not to blame. The system is to blame.3
You are not powerless. You can take practical steps to bring some relief, as this article will discuss.
Although burnout is largely a system problem, physicians can take simple steps that will lighten their burden.
Electronic health record changes such as minimizing notifications and logins can save time and reduce distractions.
Workflow changes such as ordering pre-visit labs, extending prescriptions, or rerouting portal messages can also free up time and mental energy for more meaningful tasks.
WHAT'S CAUSING BURNOUT?
Many experts attribute about 80 percent of burnout to the chaotic environment in which physicians work and only 20 percent to personal factors.4 However, when organizations first address burnout, they often suggest interventions such as meditation classes, exercise, and eating right, all of which suggest that the problem is you. These suggestions may make you feel better for the moment, but they add to your busy day and don't address the real problem: the chaos in the delivery of care.
The causes of burnout are myriad. The knowledge explosion has led to the development of thousands of clinical guidelines. Many clerical tasks previously performed by nonphysician staff have been shifted to the physician within the EHR. Compliance, information technology (IT), and regulatory departments often overinterpret regulations out of fear (e.g., “If we just have the doctor do it, we won't get into trouble”). EHR demands leave less face-to-face time for direct patient care, which is necessary to build trusting relationships and is the source of much joy in our work. The EHR also has increased physicians' cognitive load due to the frequency of switching tasks and interruptions from alerts and notifications. Additionally, as more physicians are employed, many are experiencing malaligned personal and organizational missions: “Am I here to prevent illness or to put ‘heads in beds’?” This is why, in some organizations, it is easier to arrange a visit for a bariatric surgery evaluation than a diabetes educator. On top of all this, patients today often have more chronic diseases, poorer health habits, and higher service expectations.
As a result, many doctors feel unable to fulfill their calling — to deliver high-quality care, save lives, and ease suffering — in the time allotted. Rather than compromise care, they take work home and document during evenings, weekends, and vacations — away from family, community, and the parts of their lives that feed their souls.
Working long hours is not the issue; the average physician works 50 hours per week, and more than a third of physicians work more than 60 hours per week.2 The issue is that, at the end of a long day, we want to feel that what we did matters to our patients and brings us joy. We want to spend our time not in the EHR but in meaningful interactions that require our level of training and result in high-quality care.
WHAT PHYSICIANS CAN DO
Although burnout is a system problem that will require practice redesign, cultural change, and organizational resources to address it fully, physicians cannot be “bystanders hoping someone else will improve the health care work environment.”3 There are simple, no-cost steps all physicians can take to “get rid of stupid stuff” (GROSS) in their practice.5 Here are a few examples of ways to save time that you can control:
1. Change your prescribing habits for chronic medications. If you're in the habit of authorizing prescriptions for, say, 90 days, consider a one-year authorization instead (90 days x 4) but continue to see your patients at the same frequency so you can monitor their care and medication use. In six months, you will see at least one hour of time saved each day due to fewer phone calls and refill requests.6 It will free up time for your staff as well so they can help you with other tasks. A helpful resource is the American Medical Association's “Annual Prescription Renewal” StepsForward module.
2. Stop unnecessary EHR notifications. When I turned off unnecessary notifications in my EHR, it decreased my inbox messages by 50 percent. You probably receive notifications when patients are transferred, discharged, or admitted. But if your practice has a staff member who monitors this activity for transitional care management purposes, you do not also need to be receiving these notifications. When you do need to know what's going on with a patient, you can easily view the patient's chart. Another common type of notification involves test results ordered by others, usually in the inpatient setting or the emergency department. If you are not the ordering physician, then you are not responsible for acting on these test results, other than reviewing them in the chart during the patient's next visit, so you should consider turning them off. Fewer notifications equals fewer distractions and more time saved.
3. Start ordering pre-visit labs. Having recent lab results on hand during a patient visit saves time and avoids call backs after the visit.7 I thought my patients would resist having to get their lab work completed in advance of the office visit, but most now prefer it and appreciate having a face-to-face conversation about the results and any adjustments to the care plan made during the visit. Pre-visit labs may not work for everyone, but even if they work for 50 percent of your patients, you can save about an hour a day.
4. Ask your team to order diabetes education for all your patients with diabetes. Medicare pays for 10 hours of education during the first year, but did you know it also pays for two hours of education every year after? How much better would your patients feel if they had 30 minutes of coaching and education every three months, and how much more productive would your visits be if patients were being educated separately?
5. Leverage your EHR. As much as we are reluctant to admit it, EHRs do have time-saving tools, many of which we may be unaware of or not using to our advantage. Asking a colleague for one time-saving EHR tip could save you hours each day. For example, in my system, typing “.risk” autopopulates the atherosclerotic cardiovascular disease (ASCVD) calculator for the current patient. Your EHR may also auto-substitute words or phrases so that when you type, say, “sob” it populates “shortness of breath.” Many EHRs can also track where you are spending more time than average (order entry, patient portal, refills, etc.) so you can focus on the areas that will help you the most.
6. Consider what else your team could do during patient visits. Ask your team members if they have any ideas to help save time. They can do more than simply room patients, especially if it helps them leave work on time too. Here are some simple suggestions:
Have your medical assistant ask patients with diabetes to remove their shoes before you enter.
Have your nurse recheck an elevated blood pressure after giving the patient five minutes of rest with feet flat on the floor.
Have front-desk staff print out and hand patients their current medication list to review in the waiting room, with directions to circle those that need refills, cross off any they no longer take, and put a question mark next to a medication they don't think they need anymore. This starts the medication reconciliation process and helps you assess medication adherence. It is also easier for patients to do this looking at a paper list instead of verbally or over a staff person's shoulder at a computer screen.
During flu season, when patients present their insurance card at check-in, have front-desk staff provide the flu vaccine information statement. This gets the conversation started and prompts the care team to act.
8. Reroute patient portal messages. Messages should be triaged by staff, and only those issues requiring a physician should be brought to your attention. I used to receive requests for scheduling because my settings were directing all patient messages to me (another physician liked it that way, so IT set it up that way for me too). After a brief discussion, we agreed that all of my patient messages would be triaged and only those that couldn't be addressed by other team members would be sent to me. This was a tremendous time saver.
Once you've had some success at “getting rid of stupid stuff” and can breathe again, consider your next steps:
Engage leadership about measuring burnout in your organization and developing plans to address its drivers.8
Talk with your colleagues about your successes. Get together to share a meal and quick solutions, or brainstorm together about changes you'd like to see in your practice and how to go about making them.
Organize a wellness committee to make burnout prevention a priority. If you sense resistance, call it the “Retention and Recruitment Committee.”
Experiment with more advanced ways of improving practice efficiency, such as pre-visit planning, team meetings, team documentation, streamlined medication management, and advanced team care.9
Reducing burnout and the conditions that produce it will take time, so focus on progress not perfection. Each step you take will make your burden a little lighter.