The following is the speech given by PCMS President James L. Cristol, MD, during the 2019 PCMS Presidents Installation on Saturday, June 29:
And now a few words on health care costs and physician burnout… What are the problems that we as physicians must face in the coming year? According to PAMED, here are a few of the issues:
- Maintenance of Certification
- Informed Consent
- Health Care Costs
- Prescription Drug Costs
- Scope of Practice
- Opioid Addiction
- Prior Authorization
- Lawyer Venue Shopping
- Physician Burnout
- And of course the closing of a large, and venerable hospital institution
As president of PCMS I hope to prioritize the issues according to their importance to Philadelphia Medicine and our Society’s ability to affect change. Some of the issues are generational and may require the new younger generation’s ability to adapt to administrative and technical change. But most issues require immediate attention. Especially the Hahnemann closing which was announced too recently to formally discuss tonight.
One of the most serious related issues is and will be the issue of Health care costs. Somehow competition within the Health care system has become the name of the game. Costs are “reduced” by shifting those costs from one entity to another. Costs in the form of labor, are shifted to Physicians who are pressured to “improve productivity” by seeing more patients and limiting time spent with each patient.
Physicians must mitigate these restrictions by fighting for better payments from their employers, or by setting up their practices to be more efficient cash flow operations via ventures such as Clinically Integrated Networks. Hospitals can shift costs by merging into groups to gain more bargaining clout on rates or by signing up or buying up more physician groups to guarantee referrals. Health insurance plans can reduce cost by restricting services, imposing prior authorizations, bargaining for lower drug costs. pressing physicians to accept lower reimbursement, and by increasing deductibles and copays.
But cost shifting harms the most important party in the health care business—the patient. By far, the easiest way to cut costs is to increase production by the ”labor force” while not increasing their pay. This is happening. And the various actors in the health care industry are placing the burden of the effort on we the doctors. Indeed the most striking loser seems to be the individual doctor. and the burden of Big Data that is placed upon him, especially in the face an increased patient load.
Amassing data on outcomes will be useful in determining the best and most efficient treatments for each diagnosis. A patient would be healthier if his medical record was available to all qualified providers, but the doctor must be the guy responsible for generating the patient record on EMR/EHR. A patient would feel more a part of his team of care-givers if he had easy access to his own records through a patient portal, but it is the doctor who must interpret the chart entries that appear for each patient on EMR/EHR.
Meaningful Use requires that all health care providers ultimately use EMR/EHR, and it is often the doctor who must purchase and maintain that equipment, and it is the doctor who must comply with the associated, purchased non-intuitive EMR/HER software, be it from Epic or Cerner or other more specialized vendors. Also required is the conversion of all prescriptions to EMR/EHR generated products that must be sent electronically to pharmacy. The doctor must learn to do this, by learning the software and having access to the necessary equipment.
Efficiency and profit now require the physician to see, examine and converse with a different unique patient more times per hour then has been traditional, and such abbreviated patient encounters are not part of traditional medical school curriculum, and are antithetical to the reasons most of us chose a medical career. These increased patient visits and associated increased IT tasks have added to the work load of many physicians, often requiring 2 hours of additional bureaucratic production for each hour of patient care plus 2 full additional hours of desk work at home. According to NorCal more than 46% of doctors work more than 11 hours per week engaging with EMR/EHR.
For doctors who don’t have the resources to train and increase office staff, this insidious “administrative creep” work load greatly contributes to what we now call Physician Burnout. Doctors now burn out a higher rate than the general population, and, indeed have higher suicide rates than almost any other profession. In the USA, one doctor per day commits suicide. So Physician burnout must be highest on the list of priorities.
Indeed, global studies involving nearly every medical and surgical specialty indicate that approximately 1 in 3 doctors are experiencing physician burnout at any given time with some studies showing physician burnout prevalence as high as 60%. Burnout is a kind of shell shock. Its symptoms are:
- Emotional Exhaustion.
- Emotional Detachment or loss of empathy
- Feeling Useless or Meaningless.
- Work Is Taking Over Your Life.
- Tendency to Make Mistakes.
At some point in our careers we have all fleetingly had these symptoms, though probably not all at once. Burnout has them all at once.
The presence of physician burnout, has been shown to
- Decrease physician’s professionalism and the quality of medical care they provide
- Increase medical errors and malpractice rates
- Lower patient compliance and satisfaction with medical care
- Increase rates of physician substance abuse, suicide and intent to leave practice.
Any decrease in physician burnout should produce measurable increases in quality of care and patient satisfaction in addition to lower malpractice rates and lower physician and staff turnover. Organized medicine should realize that many of the negative consequences of physician burnout have direct bottom-line implications for provider organizations. So this is a problem we, at the county level, should and could do something about. What could we do? There should be an organizational intention to value, track, and support physician well-being. Some methods include:
- Institute regular monitoring for physician burnout amongst providers (MBI)
- Provide time and funding for physician support meetings
- Support flexibility in work hours
- Create other specific programs to support physicians suffering from symptomatic burnout, such as making EHR scribe services available and affordable.
So I intend to make the problem of Physician Burnout a high priority during my term of office—recognizing that the biggest obstacle will be physicians’ reluctance to admit that they even have this problem. Aside from that challenge, the first steps will be getting the EMR/EHR vendors to continue to bend their software into more intuitive interfaces, and to wait for the generation of younger doctors who grew up knowing no other method of record keeping to assume the mantle, or reveal discovered short-cuts in the systems. The major health systems should hire physician liaisons to work closely with the software developers, to tailor their systems to the doctors workflow and individual needs. The physician should not have to tailor his work flow to EMR/EHR needs. Vendors need to make physician liaisons available to all of us so work flow problems can be mitigated. My own son, a primary care physician in Delaware, is paid by his hospital to act part time as a liaison between EHR and the hospital’s various departments. Hopefully similar arrangements are or will be made by other Philadelphia institutions, in order to mitigate the negative impact of EMR/EHR on what has become drafted patient data collectors, the medical staff.
A 2017 NEJM Catalyst survey of Physician and healthcare executive respondents on burnout rated “increased clerical burden,” which is heavily influenced by electronic health records, as the biggest cause of burnout. . Does burnout really exist? 96% of executives, clinical leaders, and clinicians agree that physician burnout is indeed a serious or moderate problem in the health care industry.
I do believe physician burnout is real, and largely a consequence of the transition to EMR/EHR. Indeed, Burnout is economically harmful to medical practice, inherently dangerous to physician wellness, and if health care costs are ever able to be reined in, EMR/EHR must become less of a chore, less of a burden and more of a positive partner to all us physicians… and as soon as possible. And hopefully, we at PCMS can promote and encourage such change.
James L. Cristol, MD