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Burnout: A Pound of Prevention May Be the Remedy
The marketplace offers many options
by J. Duncan Moore, Jr., Contributing Writer, MedPage Today November 30, 2015
In the early 2000s, Group Health Cooperative in Seattle reformed its primary care practice to emphasize Triple Aim performance, which was intended to improve the patient experience, improve the health of populations, and reduce the cost of care.
It had the unintended effect of reducing quality, raising costs, and elevating physician burnout.
Starting in 2006, Group Health developed a medical home model that increased visit length and reduced patient panel size. The new program resulted in lower burnout along with enhanced clinical quality, lower costs, and better patient experience.
The revamped plan added a fourth goal: improving clinician and staff satisfaction. It is the quadruple aim.
"You can achieve the Triple Aim, but your clinicians might be unsatisfied," said Vineet Arora, MD, a faculty physician at the University of Chicago Pritzker School of Medicine.
And miserable doctors make miserable patients. "A healthier, happier nation is going to require a healthier, happier physician workforce," said Steven J. Stack, MD, president of the American Medical Association, which has invested $10 million in initiatives aimed at improving physician satisfaction.
Help Available
The good news is that there is plenty of help available. For example, here is a brief list of organizations, publications, and programs aimed at preventing burnout:
Dike Drummond, MD, a former family practice doctor in Seattle, operates a website and consulting business for physicians who want to address burnout in their practice. CEO of TheHappyMD.com, Drummond has created what he calls the Burnout Prevention Matrix, consisting of 117 ways doctors and healthcare organizations can lower stress and prevent burnout. He argues that an understanding of "the pathophysiology of burnout" can help doctors lower the stress and energy drain and raise their ability to recharge "physical, emotional, and spiritual energy accounts."
Daniel Friedland, MD, CEO of SuperSmartHealth, has developed a program for "cultivating resiliency in healthcare." Based on brain science, mindfulness, and cognitive training, it "leads you from a state of burnout to a state of creativity in your life," he said. The larger problem is how to design a healthcare system that is based on the creation of health, not avoidance of disease. "When we recruit into that system, then we have a self-sustaining cultural system of individuals who want to contribute and maintain that system," he told MedPage Today.
The Studer Group, part of Huron Consulting, has developed a website, learning modules, and seminars to train physician leaders to recognize and treat burnout in their groups. Quint Studer has authored a book, "Healing Physician Burnout: Diagnosing, Preventing, and Treating." "When physicians team up with the organizations they work for to pursue mutual goals, they are far less likely to burn out," Studer wrote. "And when organizations seek to prevent and treat physician burnout, they go a long way toward getting everyone -- physicians included -- working together to meet the same goals."
The AMA has developed a module of "16 ways you can make your practice thrive," which it calls AMA STEPSforward. The topics are all ones that the physician should be able to influence and control from within the practice. Some examples: pre-visit planning, creating strong team culture, purchasing electronic health records, encouraging medication adherence.
The American College of Emergency Physicians has published a "Wellness Book for Emergency Physicians," to explore the stressors in emergency medicine and provide guidance for coping mechanisms and wellness planning. It addresses such topics as scheduling, litigation stress, work relationships, infectious disease exposure, physician impairment, and discrimination and harassment. It also includes a chapter on the Adult APGAR, a pet project of "Wellness Book" co-author Shay Bintliff, MD. "How does the physician know when he or she is in trouble? Does one have to wait for burnout, be fired, to lose a license for drug or alcohol abuse, to be sued for malpractice, to be served divorce papers, or to develop an ulcer or angina?" Bintliff wrote. "The preceding events are what herald the impaired physician." She developed a five-question self-administered test, based on Virginia Apgar's scoring system for the health of newborns, that gives the physician a rough gauge of their professional mental health. A score of 5 or lower indicates "the physician is in significant trouble or pain and needs to make significant changes to bring his or her life back to wellness focus."
Focus on Primary Care
For primary care in particular, "joy in practice implies a fundamental redesign of the medical encounter to restore the healing relationship of patients with their physicians and healthcare systems," wrote Christine A. Sinsky, MD, of Dubuque, Iowa, in an article in Annals of Family Medicine co-authored with a team from the Center for Excellence in Primary Care at the University of California San Francisco.
The team visited 23 high-functioning primary care practices around the country and distilled a series of solutions to common problems. They found:
Pre-visit planning and pre-visit laboratory tests can reduce the total volume of work, save time, and improve care.
Practices can expand their capacity by transforming the roles of medical assistance, licensed practical nurses, registered nurses, and health coaches so they assume some responsibility for elements of care.
Medical assistants or nurses can speed the patient visit along by serving as scribes, entering orders, preparing the after-visit summary, and talking to the patient about next steps.
Separating prescription refills from patient appointments and putting them on annual renewals saves time dealing with phone calls and refill requests.
The inbox workload for doctors can be reduced and streamlined if a nurse or medical assistant handles all incoming mail and forwards to the doctor only those items requiring a physician's expertise.
Team meetings and co-location of doctors with nurses and medical assistants speed decision making and helps doctors leave the office on time.
Systems planning and workflow mapping can improve through-put in the practice.
The authors question "why young people would devote 11 years preparing for a career during which they will spend a substantial portion of their work days, as well as much of their personal time at nights, on form-filling, box-ticking, and other clerical tasks that do not utilize their training."
DIY Burnout Prevention
Many physicians have addressed their own feelings of burnout by reducing their practice hours or going part-time. Julie Lyons, MD, 40, a primary care physician in Idaho who has two small children, dropped to part-time status to "cultivate things in my personal life that bring me joy." She would prefer less hours and less bureaucracy in practice.
Her father was a physician, so she knew how demanding the job could be. Today, though, the revolution in electronics and communications means that "my charts are on my phone." She thinks about her patients all the time, whether she's on the job or not. A part-time schedule is a mixed bag, she says. "I work up their labs on my days off. I have meetings often, phone calls often, nursing home responsibilities often. It's really hard, unless you leave town, to leave medicine."
Kenneth Harkavy, MD, a 69-year-old neonatologist in Potomac, Md., went part-time because he wanted to spend more time with his family. "I don't feel pressured and I don't feel burned out," he said. All through his career, he told MedPage Today, he was careful not to overextend himself financially or put in so many hours that exhaustion set in. "That will not be on my tombstone: 'I wish I had spent more time at work.'"
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