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.[1]

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.

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[1] 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

Specialty Hospitalists: what is best for the patient?

In a “Viewpoint” article in JAMA, April 25, 2012, John Nelson, Laurence Wellikson, and Robert Wachter discuss “Specialty hospitalists: analyzing an emerging phenomenon”.[1] They describe the progression of the hospitalist model – doctors who just care for patients in the hospital, rather than seeing them also in the office from general medical care to specialty care. They note that in recent years hospitals have hired physicians in a variety of specialties, including neurology, orthopedics, obstetrics/gynecology and others, to take care of patients, particularly at night or in emergency situations, so that other doctors to not have to come in to do so.

An argument in favor of this arrangement is that these physicians are present for urgent events (e.g., the neurology stroke specialist who is there right away to care for a person who comes to the emergency room with an acute stroke) and that they may have specialized knowledge that a more “general specialist” doesn’t. In a useful “box”, the authors summarize the criteria that might be applied to deciding if a specialty hospitalist is a good idea. These include the number of inpatients who might require their services, the urgency of the need for those services (is it a matter of minutes that may save a life?), whether the other specialists are so tied up in the operating room or office that they could not respond promptly, and if there so much “sub-specialization” that many doctors in that specialty would not be capable of addressing the needs that arise in the hospital.

I have previously written about “generalist” hospitalists, (Hospitalists, Dec 4, 2008) and expressed my concerns about this movement from the point of view of the patient. The advantage for hospitals and health systems that employ physicians is obvious – they can have some doctors that work in the ambulatory setting, and some that work in the hospital, and each can be most “productive” in that setting and not have to leave to go to the other, decreasing efficiency.  In theory, at least, the hospitalists are very good at managing the problems of people in the hospital, so quality may improve. And, to be sure, doctors often like it also – it makes their lives easier, or more controllable – they are only responsible for outpatient medicine, and don’t have to travel to the hospital to see their patients, or if they are hospitalists, don’t have to go to the office. While not one of those listed by Nelson et al. as a benefit of having hospitalists, this advantage for doctors is real.They can work set shifts, like many of the most popular specialties such as emergency medicine and anesthesiology and intensive care – and then be off.  

This, of course, leaves the patients. While hospitalized patients certainly want to be cared for by a physician or physicians who are skilled in addressing the problems that they have, it is also often a very scary time, and a good time to have the involvement of someone who knows you, who knew what you were like before you got so ill that you had to be hospitalized. Your primary care doctor, if you are lucky enough to have one. The technical skills of the hospitalist may be fine, but they do not know what you were like before, and will not be involved in your care after, your hospitalization. Plus the same attractions that lead to hospitalists in the first place now have led to a sub-species of hospitalist called “nocturnists”, and mean that you will not necessarily even have the same hospitalist making decisions about your care, even during the day, for the duration of your stay.

In addition, the skill sets of hospitalists vary. Dr. Wachter is one of the founders of the hospitalist movement and heads a long-standing hospitalist service at the University of California San Francisco (UCSF). His 1996 article, The emerging role of "hospitalists" in the American health care system,[2] written with Lee Goldman, is one of the seminal articles in the field. But the results that are achieved by teams of experienced career hospitalist groups such as his, in terms of both quality and cost, may well not be replicated by hospitalists who are just out of their residency training and spending a year working in this role prior to subspecialty fellowships in cardiology or gastroenterology. Nelson, et al., cite a study by Seiler et al. showing that patient satisfaction with hospitalist care is equal to that provided by primary care doctors,[3] but this doesn’t separate out the satisfaction of patients who have primary care doctors who are now not seeing them from those who do not.

That said, I do not have a problem with most specialty hospitalists. Specialists are not generalists, unlike primary care providers, we don’t think that every person should have one of each. The person who comes in to the Emergency Department with an acute stroke and benefits from having a stroke neurologist right there is not likely to have a general neurologist. The same can be said for orthopedics and otorhinolaryngology (ENT) and neurosurgery, among others, or for people who need emergency intervention for an acute heart attack. The case of “laborists” is somewhat different; the women having a baby (arguably the most common reason for people being glad to be in the hospital) who has been followed by an obstetrician or family doctor might well want and expect to be delivered by that doctor (a point acknowledged by Nelson). While many primary care doctors would like to provide this continuity to their patients, they may be unable to in the system they work in. And if it is not their “fault”, it is a pretty guilt-free way to enjoy the benefit.

If the hospitals and health systems make more money and operate more “efficiently” with separate hospitalist and “ambulists” (yes, this term is being used by some!), and if the doctors are happy with the arrangement because it makes their lives more controllable, the boat on generalist hospitalists and “laborists” has probably already sailed, at least in communities large enough for this to be feasible.

Anyone who has flown in and out of the Kansas City International Airport (KCI) knows what a pleasure it is compared to other airports in even relatively big cities. Built on only one level in 3 almost-circular terminals, there are only a few gates for each security checkpoint so the lines are relatively short (compared to, say, the nightmare at Denver International). Once you come in you get off your plane, walk right out into the hall where your baggage carousel is nearby, and then you walk right out to the street (even sooner if you have no checked bag), where you can be picked up or go to your car in the garage right there. It is a true pleasure for the traveler.

But it is not so desirable for the airport and airlines. I have heard that this setup requires more security people than any airport except Heathrow. There are rumblings about redesigning, maybe rebuilding, the airport to make it more “efficient”. Sure, it will be worse for the traveler, but that’s the way it goes.

So maybe you want to ask your doctor if s/he will see you in the hospital. And let the hospital and health system know that you think it is important, too. It is unreasonable to ask your primary care doctor to work a full day in the office and also care for patients in the hospital; that time needs to be built into their schedules by their employers. It could work; you never know. What’s good for people sometimes actually happens.

And if you haven’t flown in and out of KCI, you should do it soon before it becomes Denver. 

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[1] Nelson JR, Wellikson L, Wachter RM. Specialty hospitalists: analyzing an emerging phenomenon. JAMA. 2012 Apr 25;307(16):1699-700.

[2] Wachter RM, Goldman L., The emerging role of "hospitalists" in the American health care system, N Engl J Med. 1996 Aug 15;335(7):514-7.

[3] Seiler A, Visintainer P, Brzostek R, et al. Patient satisfaction with hospital care provided by hospitalists and primary care physicians. J Hosp Med. 2012;7(2):131–136, pmid:22042532.

GME funding must be targeted to Primary Care

Much of the cost of training physicians is currently borne by Medicare (and, to a lesser extent, Medicaid). This is known as Graduate Medical Education, or GME, funding, and it pays some, all, or more than all (depending upon the hospital and based upon a complicated formula discussed on May 25, 2009, Funding Graduate Medical Education) of the cost of training residents in the various specialties that comprise medicine. For those unfamiliar with medical education, graduation from medical school, while it confers the MD (or DO, Doctor of Osteopathy) degree and the title “doctor”, no longer permits practice in any of the US states. A least one, and in some states two, years of residency (“GME”) is required for licensure, and most doctors complete an entire residency of 3 or more years to make them eligible for certification as a specialist in a field (eg, family medicine, general surgery, internal medicine, psychiatry, etc.). Fellowship training is requires addition years beyond the core residency to become a sub-specialist – for example, those who complete an internal medicine residency can then do additional years to become a cardiologist, gastroenterologist, endocrinologist, etc.

Medicare augments its payments to institutions (usually hospitals, although there are a few consortia and federally-qualified health centers) with two types of payments, Direct GME which is intended to pay residents’ salaries and cost of teaching, and Indirect ME which is for the additional costs that training hospitals bear for a variety of reasons. (In addition to the piece linked above, see also Training rural family doctors, Nov 5 2010; PPACA, The New Health Reform Law: How will it affect the public's health and primary care?, Apr 22,2010; Primary Care and Residency Expansion, Jan 7, 2010.) These payments have been the cornerstones for funding residency education. Because the amount is tied to the percent of Medicare patients in a hospital, rather than the total number of patients cared for in hospitals or outpatient settings, it could be (and has been) argued that funding GME should be done comprehensively and separately from Medicare. The most persuasive argument is that private insurers should also contribute to GME (they don’t, although Medicaid does in some, but not all, states). On the other side, many fear that uncoupling GME funds from Medicare would make it easier for a Congress looking at ways to cut the budget to cut GME than having it as part of Medicare.

Except this year, with exceptionally high pressure to cut the budget, Medicare is not even sacrosanct, although, as I have recently argued, (Medicare: A lifeline, not a Ponzi scheme, Dec 2, 2011) most of the proposals to cut it across the board by tactics such as raising the age of eligibility are poorly conceived. So there are now proposals to cut the funding from Medicare for GME. Unsurprisingly, this has created great anxiety in the community of academic health centers, and the Association of American Medical Colleges (AAMC), which has strongly supported expansion of GME residency slots, is quite alarmed (Preserve Medicare support for physician training, revised Oct 2, 2011). The Accreditation Council on Graduate Medical Education (ACGME), which accredits institutions that sponsor residency programs and, through its subsidiary Review Committees (RCs), each individual specialty and subspecialty, has done a study that shows that cuts in residency positions have already occurred and more major cuts are threatened if Medicare decreases its funding ("The Potential Impact of Reduction in Federal GME Funding in the United States: A Study of the Estimates of Designated Institutional Officials”). ACGME CEO Thomas Nasca, MD, is quoted by AAFP News Now as saying “We will actually reduce the number of physicians who are trained in the United States at a time when all workforce studies are demonstrating a mounting deficit of physicians….That will place us in a position where our physician-to-population ratio in 2020 and beyond is below (that of) most of the developed countries in the world." The study found that “With a 33 percent reduction in GME funding

• 68.3 percent of responders said they would reduce the number of core residency positions,
• 60.3 percent would reduce the number of subspecialty fellowship positions,
• 4.3 percent would close all core residency programs, and
• 7.8 percent would close all subspecialty programs.”

Because there are many more “core” residency positions than subspecialty fellowship positions, these would be disproportionately affected by across-the-board cuts. In addition, residency programs in primary care, which are not as profitable to the sponsoring institution, are even more likely to be cut despite the service that they provide to patients, especially those most in need. Perry Pugno, M.D., M.P.H., AAFP vice president for education, notes in that same article that "…any cuts to GME that go across the board are going to hurt primary care -- especially those of us who disproportionately take care of adults with chronic illnesses….In communities where primary care residency programs are present, those programs become the access point for the poor and disenfranchised of the area.” He says that it's not unusual for family medicine residency programs to see patients who live both in poverty and with numerous chronic illnesses. "The payment for taking care of those patients is so low that the local medical community often doesn't want to provide that care…But residency programs take all comers."

The key issue that Pugno is addressing is one that is very important issue and is not usually made explicit in national policy discussions: our current method of allocating Medicare GME funds to institutions (hospitals) rather than to individual residency programs tends to encourage funding the funding of positions in specialties that most profit those hospitals. The interests of the American people, in regard to the kinds of specialists they need, are not necessarily (and I would argue in fact are not) the same as the interests of the hospitals that sponsor residencies. Hospitals like to fund specialties whose trainees’ work enhances their revenue (e.g., cardiology fellows, who can increase the number of profitable procedures that are done) or at least decrease their loss (e.g., emergency medicine residents, who can fill gaps in seeing patients in emergency departments). Indeed, when hospitals can afford to, they often augment Medicare GME with their own funds to create more such positions. This is about their own financial interest, and does not take into account whether or not the US needs more cardiologists or ER docs, or more family physicians and general surgeons.

This contrast between the interests of the hospital (what kind of residency positions are most beneficial to its bottom line) and the needs of the population, is, of course, a subset of the larger tension. We train doctors in highly-specialized tertiary care academic health centers, while they will mostly practice in the community. There are a number of reasons that this is not brought up more often. For the general lay public, including most members of Congress and their staffs, it seems like a subtle difference. For experts, such as the AAMC, the issue is that they represent the interests of the medical schools, and want to have those interests seen as also representing the interests of the US population. Of course, they do not always, especially the interests of the most rural, poor, minority and other underserved portions of that population.

I think we need to use every opportunity to make this issue more clear and open. While it is probably true that it is a mistake to decrease federal funding for GME, it is absolutely necessary to increase the support for primary care and, in particular family medicine. And this will only happen if GME funding is explicitly tied to requiring it to be spent on primary care programs, and “prevents substitutions”.