Human Capital—Physician Burnout
When I first got into medical management, burnout was not a concept we applied to physicians—it was more typically used to described why ICU and ER nurses left after being on the front lines too long. It was generally assumed physicians, having more control over their work, were protected from the worst impact. Sure, there were physicians who got into trouble with drugs and alcohol, but this was not considered a sign of burnout. I knew a few physicians who probably did have burnout in that they became unable to make decisions and retired early. Now, though, I can think of many physicians who are in various stages of at least disenchantment with the practice of medicine if not overt burnout.
A recent opinion piece noted that a 2011 study reported burnout in 41% of US physicians, which was higher than in the general working population, and by 2014, the rate had increased further, without a concomitant rise in the rates for the general working population. This current paper was a report from a conference designed to examine the phenomenon, and the work group came up with six recommendations.
The first recommendation, not surprisingly, was research to establish the links among physician burnout, well-being, and health care outcomes. The link is asserted on thin evidence, but it is common sense that a physician who has burned out will not be able to deliver empathetic care, even if he/she can still deliver technically correct care. Of course, this gets at a key question—do we want physicians capable of delivering empathetic care or do we want physicians who check the right boxes without much concern for the individual? Many organizations want physicians checking the boxes, but most physicians, I still believe, really do want to be more than technicians.
The second recommendation was to estimate the economic cost of burnout. Thirdly, they recommended building alliances to address physician burnout. Fourthly, they recommended using common metrics (like all good researchers should.) Fifth, the recommended developing a comprehensive framework for intervention with both individual and institutional components. And lastly, they recommending sharing best practices.
In contrast to this research-oriented agenda, which ignores virtually all issues of funding, Arabadjis and Sullivan have just reported observations from the Southern California Permanente Medical Group, which has had a program in place since 2004 designed to “unburden” their primary care physicians. Since they have 8,500 physicians in the group, their sample size is large. Their starting point was the recognition of two things. First, having a primary care physician implement all of the recommended preventive medicine practices for an average size panel is a full time job requiring 7.4 hrs/day. If acute and chronic care are added in, it would take 21.7 hrs/day. Clearly neither of these workloads is feasible. The second observation was that pushing on primary care physicians to meet quality metrics worked for awhile, but soon a plateau was seen. When they investigated, it became clear that many of their enrollees were not being seen in primary care offices from year to year, but did get seen by specialists and in urgent care settings. In response, they developed a “Complete Care” program that has four key components which the authors postulate keep physician satisfaction high (and burnout low) in this very large group.
The first, was to recognize that meeting care goals was everyone’s problem, not just the primary care physician. To make the point, incentive pay for everyone was tied to performance on quality metrics, not just the “PCP.” Second, they realized they had to unload the physicians, moving tasks to clerical and nursing staff where appropriate. Third, they used their computer system to handle a lot of routine advisories to patients. Fourth, they standardized their care processes so medical assistants and licensed vocational nurses could enter large amounts of routine data into the computer, rather than expecting the physician to do all the work.
Contrast this to what is happening in most medical institutions. Physicians are expected to do all the work they always did, plus make sure all the data elements are entered the way the billers and coders need it done, plus getting all the bullet points and buzzwords just right so the institution is not subject to “quality” penalties. Instead of unloading physicians, most organizations have gone in the other direction. Maybe this is why Permanente has not experienced the rapid rise in burnout rates noted elsewhere.
It is instructive, though, to consider one key element on the Permanente structure—it is prepaid. Budgets are established based on the number of members, not based on the number of services. Money can be spent standardizing routine processes and training lower level staff to help take care of the patient, leaving the physician free to do what he/she does best—practice medicine. In most organizations, though, money spent in these areas has to be freed from other commitments. Organizations experiencing financial stress often don’t make good long-term decisions—if a physician burns out, go hire someone else. The issue not addressed in either of these papers, then, is who benefits and who pays. Physicians benefit, and by implication their patients. Can systems see this as an investment in the most expensive human capital in their organizations. At the moment I am not optimistic.
8 June 2017
 Drybye LN, Trockel M, Frank E., Olson K, Linzer M, Lemaire M, Swenson S, Shanafelt T, and Sinsky CA. Development of a Research Agenda to Identify Evidence-Based Strategies to Improve Physician Wellness and Reduce Burnout. Ann Intern Med 2017;166(10):743-744, 16 May 2017.
 Arabadjis S, Sullivan EE. How One California Medical Group is Decreasing Physician Burnout. Harvard Business Review, 7 June 2017. Accessed 7 June 2017 at https://hbr.org/2017/06/how-one-medical-group-is-decreasing-physician-burnout.
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