Productivity and Efficiency, Part 3—The Unintended Consequences on Physician Morale
In two previous articles I have considered the tension between productivity and efficiency at a general level and at the specific level exemplified by the care of dialysis patients. This article looks at the challenge to individual physicians and what has been, in my view, a unintended negative effect on physician morale. Evidence for the low morale of physicians in general is widespread, although there is little agreement about either cause or treatment options. It is clear, though, that meaningful improvement in the value of health care will be difficult without the active cooperation of physicians, so thinking about this issue is important.
At the individual level, it has always been true that the stress involved in caring for sick and hurt people can cause physicians to “burn out,” or more commonly, to experience “compassion fatigue.” The distinction is important, because those who burn out eventually drop out, but those experiencing fatigue usually stay active, but do not perform as well as they could. Compassion fatigue is so prevalent, there is now a “Compassion Fatigue Awareness Project.” A short description of the syndrome has been published in Psychology Today, a publication aimed at the general public.
Another confounder is public attitudes toward physicians. A recent article shows that the public’s trust in their doctor is generally higher than in other countries, but their trust in the medical profession as a whole is substantially lower than in those same countries. I will examine this paper in a separate article, but for this discussion it serves to document the decline in esteem experienced by physicians.
Both of these issues are important, but not, I think, the reason for the relatively abrupt, widespread discouragement expressed by physicians. I think the primary issue is the drive for “productivity.” While procedural specialists are also discouraged, I think the better case study is presented by primary care. All the experts decry the decline in primary care services, and there is a vast literature looking at possible remedies. Few of these papers, though, seem to consider the issue from the level of the physician. Procedural specialists may be somewhat buffered, because the institutional drive for “productivity” simply means being busier. But the incremental marginal value of being busier palls at some point, and it is quite possible to become too busy.
In primary care, though, there are few easily measured procedures, hence the development of an elaborate system of relative value units designed to capture the “work” involved in cognitive services. But let us consider what is expected. In my group, primary care physicians are expected to be as “productive” as national norms. While there is some variation, this typically means each primary care physician is expected to produce around 4,500 to 5,000 “RVU” annually. If they are using the coding system correctly, it is difficult to generate this amount unless their office schedule is fully booked, the no show rate is low, and they maximize their availability. The addition of EMR and coding responsibilities, which do not impact the billable RVU, has not only increased the cost of doing business, it has extended the amount of time each physician most devote to the care of each individual patient. This creates a time pressure, or urgency, that few can resist and increases stress levels BEFORE dealing with the patient’s issues.
This pressure can be eased, of course, if physicians simply accept lower salaries. To those colleagues who complain to me about the impact of the EMR on their productivity, I tell them it is part of a clever government scheme. Having realized they cannot effectively regulate medical decision making, they have decided the best option is to just slow doctors down—it saves a lot of money. One might note, parenthetically, that overall health care spending has reach a plateau in the past couple of years. This may not be coincidence.
The other and in my view more pernicious negative influence is the use of clinical performance measures to “improve the value” of health care services. These measures, in themselves, are not the issue. The problem is in how they are applied. Consider the issue of hemoglobin A1c levels in diabetic patients. The measured level reflects the combined effect of the medical regimen prescribed and the patient’s adherence to it and the dietary restrictions. If one’s compensation is tied to getting a certain percentage of your panel to a prescribed level, the easiest response is to eliminate from your panel those who aren’t activated. But from the perspective of improving outcomes, is it more valuable to work with a difficult patient and help them get the A1c from 12 to 8, or to get an activated patient from 7.2 to 6.9? I suspect the incremental value of the healthcare intervention is greater in the former patient, but the physician will be penalized by current “threshold” performance measures.
I suggested earlier there were three different views of health care: the artisanal, the economic, and the scientific. We have now considered the economic and the scientific, albeit briefly, so now let us consider the artisanal. Physicians who choose primary care aspire to becoming a trusted advisor to their patients, and hope to derive a substantial amount of their compensation from the psychic rewards conferred by long-time, appreciative patients. Those patients tend to rate their doctors highly on opinion surveys. There is evidence that talking to patients saves money. Kroenke noted that patients present with symptoms, and at least 75 of the time, the diagnosis is revealed by the history and physical exam alone. But this takes time, and the pressure to be efficient does not encourage taking time. The path of least resistance is to do confirmatory testing and maybe even referral.
Patients want their physicians to be good listeners, to be caring and compassionate, and to be competent. However, there are no metrics for these attributes. Yes, Medicare and insurance companies are doing patient satisfaction surveys, but these really don’t get at the root issues. Those of us who have dealt with these for a long time know that waiting time and the interaction with the billing office have more to do with reported satisfaction than the performance of the physician herself. In other words, the desire to be efficient, providing only the care the patient needs in the way the patient wants, conflicts with the drive to be productive.
So what can be done? The question is urgent, at least in my area. Many of our most effective primary care physicians are past full retirement age, and the number leaving is much greater than the number of new physicians. The local family practice residency produces only eight graduates yearly, but we have more than that leaving practice. I have said many times that primary care delivered by physicians outside of a few privileged ZIP codes is a thing of the past. Yet 25% of our population is on Medicare and even though our state is not running its own exchange, about 10% are on Tenncare, our version of Medicaid. Few of these people have access to primary care delivered by anybody. As Wal-Mart gets into the primary and urgent care business, access will improve, but whether care will or not is an open question.
I suggest the most urgent need is to restore a balance among the psychic, financial, and intellectual rewards of primary care, but doing so does require a change in mindset. Traditionally doctors have thought in terms of taking care of patients one at a time. I think they must learn to think in terms of taking care of groups of patients and using teams of nurse practitioners and physician assistants to do this. I think this is the intent of the “medical home” concept, but I don’t usually see it discussed this way.
How would this help? First, it provides some relief from time urgency, since payment is partially uncoupled from office visits. Second, it allows the physician to spend his/her time mostly with those who need care the most, and therefore the ones most likely to satisfy the psychic needs that led them to choose primary care. Third, the intellectual challenge of building teams that deliver good health care is substantial and there is plenty of room for innovation. Lastly, it allows the physician to concentrate on the efficiency part of the equation. If compensation is fairly stable, then there is time to think about what the most efficient and effective way to diagnose and treat the patient’s problem should be. There is also time to figure out whether the patient has reached the time to have “the conversation” and be taken off conventional protocols.
It will not be easy. There is a long tradition of individual doctors caring for individual patients, despite all of the additional requirements that have been placed on this relationship. The lack of measures for the “soft,” but important parts of the relationship like empathy and compassion must be addressed, and physicians must learn to think about groups of patients. It won’t be easy, but I don’t see another way, and I am sure a demoralized physician work force is and will remain a serious impediment to improving health care for our public.
14 November 2014
 http://www.compassionfatigue.org/. Accessed 14 November 2014.
 Babbel S. Compassion Fatigue. 4 July 2012. Accessed 14 November 2014 at http://www.psychologytoday.com/blog/somatic-psychology/201207/compassion-fatigue.
 Blendon RJ, Benson JM, Hero JG. Public Trust in Physicians—U. S. Medicine in International Perspective. N Engl J Med 2014;371(17):1570-72. doi: 10.1056/NEJMp1407373.
 It is much more difficult to track incremental gain, so the real reason for using the threshold or cutoff approach is administrative simplicity.
 Kroenke K. A Practical and Evidence-Based Approach to Common Symptoms: A Narrative Review. Ann Intern Med 2014;161:579-86. doi: 10.7326/M14-0461.
Clinical microsystems are composed of front-line clinicians engaged in direct patient care. Despite a lack of formal authority, they are the key to successful healthcare reform.
Nursing Staff Turnover
If empowered teams of clinicians is the key to effective, efficient care, then staff turnover is Achilles' heel. Nationally, RN turnover exceeds the cap needed to maintain patient safety and quality of care. The problem and approaches to a solution are considered.
Is physician engagement a strategy to promote physician leadership, or a code word meaning how do we get the doctors to do what we want?
Strategic Human Capital
Healthcare organizations need to realize the economic value of experienced teams of clinicians able to provide highly reliable care and to recognize the importance of maintaining team integrity in times of surges in patient volumes.