|
Engaging Burned Out Physicians—Squaring the Circle?
More and more articles these days that talk about the need for health care systems to “engage” their physicians in order to be successful in the transition from volume-based payment methods to “value-based” payment methods. At the same time there are more articles talking about the low morale among physicians. Clearly, people mean different things when they talk about engagement and burnout, but it seems to me the two might be related. What most healthcare administrators mean when they talk about physician engagement is “getting the physicians to do what we need them to do for the good of the organization.” Now this is not an inherently evil position; the organization has a lot of stakeholders. But maybe the cause of the burnout is the increasing frequency where trying to be engaged conflicts with the physician’s primary motive of doing what is best for the patient. Not so long ago, doing well by the patient did not necessarily conflict with doing well by ourselves or our organizations. When deciding what to do for a patient, conscientious physicians considered the costs to the patient and what he or she could reasonably be expected to do. Take a simple example. A patient with multiple chronic illnesses ends up needing a lot of medications—yet the Medicaid program in my state once limited patients to five prescriptions a month. Most of the time that could be done, although patients complained that they had to buy their pain medications and their antacids. Now, most of the patients I see in consultation are prescribed 10-15 different medications. Why? Certainly it is not because we think patients have gotten better at following complex medical programs. Rather, it is because of the ubiquitous guideline programs where everyone is expected to provide “standard” care regardless of the individual facts or be deemed a poor physician. I get form letters every day telling me “experts” think a patient needs more medications to address some abnormality and sometimes letters telling me the patient is not filling the prescriptions, but I never get a letter telling me the patient is taking too many medications. On the other hand, many patient consultations at the hospital involve an adverse drug effect. I suspect more than half the consultations my group does relate to the adverse effects of previous therapies. The conflict has also begun to play out in my local hospital as the small rural hospitals in our area have closed their in-patient facilities, and as the primary care physician base has shrunk to a precariously low level. Now almost everyone who has a serious ailment shows up in the emergency department somewhere and ends up at my safety net hospital. Since there are no outlet valves, these patients end up being admitted to the hospital, usually by hospitalists who are overburdened. They respond initially by increasing the number of specialty consultations to shift the load, but we are now at the point where almost everyone thinks they are “too busy.” Management, responding to other stakeholders, feels compelled to make sure they have a bed available for everyone who qualifies for admission, even if they are not insured. From their perspective, providing no care is the unacceptable option.. Physicians respond that being too busy is bad for everybody, but particularly for patients. We have had contentious meetings where tempers flared over the conflict in viewpoints. For the moment, we continue to muddle through, trying to get the patients cared for, but concerned that we are not being as patient-centered or as efficient as we should be. This situation, which is being common in many hospitals, if decided by management alone, results in physician disengagement and burnout. It also leads to increasing staff turnover, which also has a negative impact on patient care. I contend it also has a negative financial impact. So are we trying to square the circle? If we keep trying to solve the problems from the same perspective we have always used, the answer is yes. When it is clear that a question has no answer, I find it helpful to change the question. In that spirit, I would suggest the way out of the dilemma might lie in asking—how do we get the patient what they need? The answers to that question are likely to lead to solutions that are slow and of uncertain economic value. For instance, we could use existing resources to divert some of the flow of patients with sub-acute problems to an outpatient setting for evaluation and treatment. This would take immediate pressure off the hospitalists, and allow the physicians and management to work together to retool processes that have become strained under the pressure of unexpectedly high volume. It would also put physicians back in charge of controlling their own work, which reduces burnout. Longer term, we need to work out relationships with the existing medical communities in our region to decide what can be done to take the pressure off the emergency rooms. This is even slower and more economically uncertain that the first option. I am sure there are other options I have not named, but first we have to find a forum to address the question in meaningful ways. I actually think this is the challenge facing health care everywhere in the United States. If we think we need to change from “volume to value,” how to we re-organize our institutions to do that? Hospitals and hospitalists can’t do this by staying hospital-focused, but community-based physicians can’t do this by ignoring the problems of the hospital. Can we rebuild the commons? I think getting past burnout and getting re-engaged requires it, but I don’t see many organizations putting their institutional muscle into the process, probably because the risk is evident and the benefit is not. Sort of reminds of the problem doctors face in the office when they try to talk a patient into taking medicine for a disease that is not causing symptoms now, but can be expected to be important later. For health care in the United States, that later is now. 12 February 2016 |
Further Reading
Are We Too Task Oriented? The number of tasks doctors must complete grows exponentially. Have we become too task oriented at the expense of our patients? Patient-Centered Care A consideration of the interactions of patient preferences, evidence-based medicine and peer review. Productivity in Healthcare Part 1 Many are focused on efficiency and productivity in healthcare without a clear understanding that the two are not interchangeable. This article introduces the two concepts as they are commonly used. Productivity in Healthcare Part 2 The conflict between productivity and efficiency is examined from three perspectives using the care of dialysis patients as the case study. Productivity in Healthcare Part 3 The conflict between productivity and efficiency is contributing to widespread physician malaise, which has negative implications for health care improvement. Restoring the Commons A consideration of the interactions of patient preferences, evidence-based medicine and peer review. |