Care Redesign—The Answer for Physician Burnout?
In a recent “Perspective” in The New England Journal of Medicine, Wright and Katz call for redesigning care to restore meaning to physician work.
“Increasing clerical burden is one of the biggest drivers of burnout in medicine…Burnout rates are now twice as high in medicine as in other fields, even after adjustment for factors such as age, sex, level of education, and hours worked in the past week.”
They report the efforts of the Department of Family Medicine from the University of Colorado health system to redesign their care processes, which they called APEX.
“Under this system, medical assistants gather data, reconcile medications, set the agenda for patient visits, and identify opportunities to increase preventive care. After they complete this structured process, they share this information with a physician or nurse practitioner and remain in the room to document the visit. When the clinician leaves, the medical assistant provides patient education and health coaching. This arrangement allows physicians and mid-level clinicians to focus on synthesizing data, performing the physical exam, and making medical decisions without distractions…Within 6 months after the APEX launch, burnout rates among clinicians dropped from 53% to 13%.”
Of course, the business managers were concerned about the cost of the extra personnel and training required, but the improvement in productivty and in metrics used for “value-based” purchasing allowed them to make the change in a cost-neutral manner.
A second article in the same issue reports on a collective effort to confront the challenge of burnout. The authors report formation of a collaborative by the National Academy of Medicine, formerly known as the Institute of Medicine, the Association of American Medical Colleges, and the Accreditation Council for Graduate Medical Education. This collaborative aims to “increase the visibility of clinician stress and burnout, to improve health care organizations’ baseline understanding of the challenges to clinician well-being, to identify evidence-based solutions, and to monitor the effectiveness of implementation of these solutions.”
These articles got me reflecting upon the changes I have observed in the 44 years since I graduated from medical school, and how we got to this point. I remember attending a meeting, probably in my junior year of college, (1968-69), where Dean John Chapman of Vanderbilt University Medical School talked about changes that he was seeing take place in medicine as the result of Medicare being approved in 1966. From his perspective, the changes were positive, as it was now possible to treat older patients, particularly in the hospital, without having to worry about how it was going to be paid for.
As an intern (1974-74), I remember attending a Grand Rounds where a patient with multiple co-morbidities and symptomatic uremia was presented. The older physician argued that dialysis was not appropriate and too expensive. The younger physician argued that the cost of care was not his problem. His job was to get the patient what he “needed.” That same year, I remember an evening discussion with a fellow intern, where he was explaining something called the “CPT book.” His father was a physician, and he was already studying how to bill for his services, something frankly I had not thought about at all.
Shortly after I entered practice (1983) CMS changed the way it paid for physician services provided to dialysis patients from a “fee for service” format to a “monthly capitated payment.” It was only a few years later when reports started appearing that physicians were billing for the payment without physically seeing the patient, so new rules were instituted requiring documentation and changing the amount, depending on how many visits were documented in a month. I also remember having discussions with the Clinic management about how to deal with dialysis patients differently from the usual Medicare patient, as the Clinic did not “accept assignment” as a matter of routine. I also remember they had to sue one of my patients who took the check and did not pay the bill.
In 1993, I was trying to educate my physician colleagues on the new “Resource Based Relative Value System” and the need to document essential elements of the visit to support the level of billing chosen. After I finished the presentation, one of my senior primary care doctors slapped the side of his head and exclaimed: “You mean I have to charge a different level for every patient I see?” Already his life had started getting more complicated. About the same time, we started keeping an electronic health record, but it was basically the old paper chart, kept on the computer.
In 2011, I was Chief of Staff when the hospital went to a complete electronic health record. We had vigorous debates about implementation, but one thing I discovered was that no one was actively concerned about the impact on physician routines except for me and the CMIO. From the hospital’s perspective, the key thing was to get on the computer to capture the money that was available.
Today, as I make rounds in the hospital or see patients in the office, I review many medical records, all generated electronically, but by different systems. I even have occasion to see old notes that I wrote more than twenty years ago. Today’s records are vastly longer than before, but I daresay contain less information. Some of them don’t even contain as much as the pre-Medicare hospital charts, like the one I reviewed for a CPC, which basically said the patient came in for a routine delivery, started bleeding from her mucous membranes on day two post-partum, and died. So why are they longer? Because people are hoping it will make it easier to get paid for treating the patient.
I once heard a speaker ask a group how you boil a frog. The answer is to put the frog in the water, then turn up the heat slowly until the frog is cooked. If you try to put the frog in hot water, it will jump out. I think I have lived through the medical profession get cooked in just the same way. I don’t mean to imply malevolent intent, but the fact that the medical “system” is awash in so much money as caused the “managers” to try to “manage” physician behavior without consideration of the downstream effects. While I am encouraged to see efforts to turn us back to our primary job of caring for patients, I am not hopeful that enough organizations will do it fast enough or effectively enough to keep us from the adverse effects of care delivered by harassed, stressed, burned out clinicians.
7 February 2018
 Wright AA, Katz IT. Beyond Burnout—Redesigning Care to Restore Meaning and Sanity for Physicians. NEJM 2018;378(4):309-311. doi: 10.1056/NEJMp1716845.
 Dzau VJ, Kirch DG, Nasca JT. To Care in Human—Collectively Confronting the Clinician-Burnout Crisis. NEJM 2018;378(4):312-314. doi: 10.1056/NEJMp1715127.
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