Friday, July 6, 2018
Physician frustration and "burnout": A wider breadth of practice helps!
Physician burnout is a topic that is much-discussed in the medical community. It’s not a very good term; most people have stressed, sad, or overworked days or weeks, but it is the one that we seem to be stuck with. It is true that many physicians are often not happy, feel overworked and stressed and unable to spend enough time with their families. Most important, perhaps, they feel that this leaves them unable to do as good a job caring for their patients as they would like to. The main factors are workload, both in terms of the number of people that they have to see in a day, and ever-increasing “administrative” work. A big part of this is charting on an Electronic Health Record (EHR). While this modern method of charting allows quick retrieval of much important information and makes it possible to maximize billing, it is very time consuming.
Primary care doctors, such as family physicians, have among the highest rates of “burnout”, exceeding 30% in some studies and rising to nearly half in younger physicians . A recent study by Young, Burge, and colleagues showed that family doctors spend more time entering data into EHRs than they do face-to-face with patients! Patients are justifiably upset when their doctor spends more time looking at the computer screen than they do looking at them, and it is bad for the physician-patient relationship. However, the charting still has to be done, so those doctors who are not spending time on the EHR during the encounter are staying late to do it after office hours or doing it from home on evenings and weekends, which also contributes to frustration. Studies also show that a higher percentage of female physicians report experiencing “burnout”, likely because in many or most families it is still the woman who bears the burden of household and family responsibilities, even when she has a full-time and demanding job such as a physician.
There are a variety of reasons why family and other primary care physicians are particularly vulnerable to burnout. Reimbursement per visit is lower than for most other specialties, which means there is less money to hire people or buy systems to make things more efficient. Since most physicians are employed, primarily by large hospital systems, rather than in private practice, the system drives the work, not the doctor. Of course, the logic for paying primary care physicians less is, well, non-existent, but there are many non-logical justifications, most of them based upon the tradition of “subspecialist have always made more money” and are self-serving.
One conceit is that the work of subspecialists is “harder” or “more complex” and thus justifies greater reimbursement. This is not always, or even usually, true. As I have previously discussed on this blog (e.g., Can you be "too strong" for family medicine?, March 19, 2013), the work of a family doctor is particularly complex. For each patient, the family physician takes care of, or co-manages, all of a patient’s medical – and psychological and social – issues, as opposed to just one, as subspecialists do. In terms of the day’s schedule, a family doctor sees a wide variety of patients: a person with a new acute illness can be followed by one with several chronic diseases, then a well-child, then a sports injury, then a pregnant woman, etc. I have documented this in an “AAFP One-Pager” published in the American Family Physician in December, 2014.
But, because subspecialists get higher reimbursement, their employers are happier and likely to spend more money supporting them. Some (ignorant but not rare) health system administrators wonder why a family doctor cannot see more patient in a given time, like, say, orthopedic surgeons do. The orthopedist sees someone referred for a specific problem, after x-rays or more extensive (and expensive) tests like MRIs have been done, often after the patient has been seen by another professional such as a physician’s assistant, does a quick exam of the particular area and decides if surgery is needed or not, and has someone else arrange it. It is, of course, the surgery, not the clinic visit, that earns the surgeon money. The family doctor is, as noted above, addressing all of a patient’s chronic and acute medical problems, as well as the social and psychological problems, and often has to fill out forms such as disability, FMLA, etc. even when another doctor (say, that orthopedist) is doing the procedure, because those subspecialists are “too busy” (ie., earning, directly for themselves or for the health system and then indirectly for themselves, too much money per unit of time).
It is, thus, unsurprising that those specialties that are the highest-paid (e.g., orthopedic surgery) and especially those with the highest income-to-work ratios (e.g, radiology, dermatology, anesthesiology) have little difficulty recruiting new doctors, while the lower-paid specialties, like family medicine, have much more. After all, the indebtedness from medical school –typically hundreds of thousands of dollars (which usually requires annual payments of far more than the average American’s total salary) is the same whatever specialty you enter. The higher revenue generated by subspecialists allows them – or the hospital systems that employ them -- to pay for non-physicians to do a variety of tasks, both clinical (nurse specialists and physician’s assistants) and documentation (scribes, coders, etc.) The American Academy of Family Physicians (AAFP) suggests that the root cause of family physician burnout is inadequate team-based care, but the fact is that the members of those teams have to be paid, and the greater the physician reimbursement the more team members there can be.
Given all this, one could reasonably worry that family doctors will no longer be happy doing all the breadth of care that defines the potential of the specialty, such as continuing to deliver babies, or take care of their patients in the hospital, or make home visits. After all, if they are stressed out “just” seeing patients in the clinic, wouldn’t this make it even worse? Take more time? Increase burnout and stress? To me, that would be a bad thing; one of the terrific things about primary care doctors, reasonably defined as “doctors for you” (rather than for a specific condition) is that they can see you, and care for you, in all settings.
Which is why it is gratifying to read the results of a paper just published in the Annals of Family Medicine by Weidner, Phillips, Fang, and Peterson called “Burnout and Scope of Practice in New Family Physicians”. Contrary to what one might fear, it turns out that, at least among younger physicians, having a wider scope of practice – specifically caring for patients in the hospital, delivering babies, and doing home visits – is associated with a lower rate of self-perceived burnout. This is heartening – maybe being able to function at their highest level, care for people in all the settings in which they seek care, provide real continuity, do good medicine is part of the answer. Some of this may be because the breadth of care, the different kinds of problems to care for, the possibility of being there for your patient in whichever venue their care is delivered, the caring for the whole patient, is why people chose family medicine in the first place, rather than a (higher-paid) specialty where you care for only a few diagnoses or do a few procedures over and over again.
Yes, doctors, even the lower paid specialties, make very good salaries compared to most Americans, and so it is hard for people who have lower-paying jobs, are afraid of losing their jobs, or have no jobs at all to feel too sorry. Yet it is in the interest of their health that their physicians are able to feel satisfaction with their work, most importantly to be able to do the best that they can to take care of a person’s medical needs. Medical care can be made more efficient than it is, especially in eliminating the ridiculous lack of communication between doctors, hospitals, and patients that characterizes our fragmented non-system. All workers feel more satisfaction and do a better job when they have the ability to exercise some discretion and not simply work on an endless assembly line. Medical care especially cannot be reduced to an assembly line, because you are a person, not a widget.
Our medical system needs to cover everyone, communicate within itself effectively, and be flexible enough to meet the needs of all people.
 Freeman J, Petterson S, Bazemore A., Accounting for complexity: aligning current payment models with the breadth of care by different specialties. Am Fam Phys 2014 Dec 1; 90(11):790. PMID 25611714