!

7 Ideas in 7 Minutes

!Sanaz Cordes, MD, COO

healthfinch: The Doctor Happiness Company

Traditional Primary Care Model

Cannot Survive

½of physicians are

burnt out

ORIGINAL INVESTIGATION

Burnout and Satisfaction With Work-Life BalanceAmong US Physicians Relative to theGeneral US PopulationTait D. Shanafelt, MD; Sonja Boone, MD; Litjen Tan, PhD; Lotte N. Dyrbye, MD, MHPE; Wayne Sotile, PhD;Daniel Satele, BS; Colin P. West, MD, PhD; Jeff Sloan, PhD; Michael R. Oreskovich, MD

Background: Despite extensive data about physicianburnout, to our knowledge, no national study has evalu-ated rates of burnout among US physicians, explored dif-ferences by specialty, or compared physicians with USworkers in other fields.

Methods: We conducted a national study of burnoutin a large sample of US physicians from all specialty dis-ciplines using the American Medical Association Physi-cian Masterfile and surveyed a probability-based sampleof the general US population for comparison. Burnoutwas measured using validated instruments. Satisfactionwith work-life balance was explored.

Results: Of 27 276 physicians who received an invita-tion to participate, 7288 (26.7%) completed surveys.When assessed using the Maslach Burnout Inventory,45.8% of physicians reported at least 1 symptom of burn-out. Substantial differences in burnout were observed byspecialty, with the highest rates among physicians at thefront line of care access (family medicine, general inter-nal medicine, and emergency medicine). Compared witha probability-based sample of 3442 working US adults,

physicians were more likely to have symptoms of burn-out (37.9% vs 27.8%) and to be dissatisfied with work-life balance (40.2% vs 23.2%) (P! .001 for both). High-est level of education completed also related to burnoutin a pooled multivariate analysis adjusted for age, sex,relationship status, and hours worked per week. Com-pared with high school graduates, individuals with an MDor DO degree were at increased risk for burnout (oddsratio [OR], 1.36; P! .001), whereas individuals with abachelor’s degree (OR, 0.80; P=.048), master’s degree (OR,0.71; P=.01), or professional or doctoral degree other thanan MD or DO degree (OR, 0.64; P=.04) were at lowerrisk for burnout.

Conclusions: Burnout is more common among physi-cians than among other US workers. Physicians in spe-cialties at the front line of care access seem to be at great-est risk.

Arch Intern Med. 2012;172(18):1377-1385.Published online August 20, 2012.doi:10.1001/archinternmed.2012.3199

A LTHOUGH THE PRACTICE OFmedicine can be incred-ibly meaningful and per-sonally fulfilling, it is alsodemanding and stressful.

Results of studies1-3 suggest that many phy-sicians experience professional burnout, asyndrome characterized by a loss of enthu-siasm for work (emotional exhaustion),feelings of cynicism (depersonalization),and a low sense of personal accomplish-ment. Although difficult to fully measureand quantify, findings of recent studies4-8

suggest that burnout may erode profes-sionalism, influence quality of care, in-crease the risk for medical errors, and pro-mote early retirement. Burnout also seemsto have adverse personal consequences forphysicians, including contributions to bro-

ken relationships, problematic alcohol use,and suicidal ideation.9-11

Despite the extensive data on physi-cian burnout, to our knowledge, no na-tional study has evaluated rates of burn-out among US physicians. Although therehas been much conjecture about whichmedical or surgical specialty areas are highrisk, this speculation has primarily beenbased on comparisons across studies ofphysicians from individual disciplines, forwhich differences in sample selection,study size and setting, participation rates,and year of survey administration con-found interpretation. The literature onphysician burnout is also hampered by alack of data about how rates of burnoutfor US physicians compare with rates forUS workers in other fields.

Author AffilDepartmentMedicine, MRochester, M(Drs Shanafeand Sloan anAmerican MChicago, Illiand Tan); DOrthopaedicSchool of MOrleans, Louand Departmand BehavioUniversity oSeattle (Dr O

Author Affiliations:Department of InternalMedicine, Mayo Clinic,Rochester, Minnesota(Drs Shanafelt, Dyrbye, West,and Sloan and Mr Satele);American Medical Association,Chicago, Illinois (Drs Booneand Tan); Department ofOrthopaedics, Tulane UniversitySchool of Medicine, NewOrleans, Louisiana (Dr Sotile);and Department of Psychiatryand Behavioral Sciences,University of Washington,Seattle (Dr Oreskovich).

ARCH INTERN MED/ VOL 172 (NO. 18), OCT 8, 2012 WWW.ARCHINTERNMED.COM1377

©2012 American Medical Association. All rights reserved.

Downloaded From: http://archinte.jamanetwork.com/ on 01/06/2014

CONFIDENTIAL

Forth-five percent (45%) of the physician’s day is spent outside of face-to-face patient care.

ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 3, NO. 6 ✦ NOVEMBER/DECEMBER 2005

488

Time Spent in Face-to-Face Patient Care and Work Outside the Examination Room

ABSTRACTPURPOSE Contrary to physicians’ concerns that face-to-face patient time is decreasing, data from the National Ambulatory Medical Care Survey (NAMCS) indicate that between 1988 and 1998, durations of primary care outpatient visits have increased. This study documented how physicians spend time during the workday, including time outside the examination room, and compared observed face-to-face patient care time with that reported in NAMCS.

METHODS Using time-motion study techniques, for each of 11 physicians, 2 patient care days were randomly selected and documented by direct observa-tion. Physician time spent on face-to-face patient care and 54 activities outside the examination room were documented. Data represent 12,180 minutes of work and 611 outpatient visits.

RESULTS The average workday duration was 8.6 hours, and face-to-face patient care accounted for 55% of the day. Work outside the examination room relevant to a patient currently being seen averaged 14% of the day. Work related to a patient not physically present accounted for one fi fth (23%) of the workday. The combination of face-to-face time and time spent on visit-specifi c work outside the examination room assessed by direct observation was signifi cantly less than the 2003 NAMCS estimate of visit duration assessed by physician report (13.3 vs 18.7 minutes, P <.001).

CONCLUSIONS Nearly one half of a primary care physician’s workday is spent on activities outside the examination room, predominately focused on follow-up and documentation of care for patients not physically present. National estimates of visit duration overestimate the combination of face-to-face time and time spent on visit-specifi c work outside the examination room by 41%.

Ann Fam Med 2005;3:488-493. DOI: 10.1370/afm.404.

INTRODUCTION

Primary care physicians have expressed discontent and concern that face-to-face time with patients is diminishing and that their adminis-trative burdens are increasing.1-3 Concerns are fueled by data suggest-

ing that shorter visits are associated with lower patient satisfaction4,5 and possibly poorer quality of care.6 Recent fi ndings from multiple data sources indicate, however, that the duration of the visit in a primary care setting is increasing,7 the number of patients being seen during an average week is decreasing, and the number of hours spent working during the week has remained the same.8 Specifi cally, longitudinal data using the National Ambulatory Medical Care Survey (NAMCS) for the decade 1988-1998 indicate that physician-reported face-to-face interaction time has increased 2.0 minutes to an average of 16.3 minutes per encounter.7 NAMCS data from 2003 indicate that among general and family physicians, the average visit duration is 18.7 minutes.9

What could account for the discrepancy between physician perceptions and national data? Data for the NAMCS are based on physician reports at the completion of each sampled visit. Gilchrist et al10 showed that com-

Andrew Gottschalk, BS1

Susan A. Flocke, PhD2

1Case Western Reserve University School of Medicine, Cleveland, Ohio

2Departments of Family Medicine and Epi-demiology and Biostatistics, Case Western Reserve University, and the Case Compre-hensive Cancer Center, Cleveland, Ohio

Confl icts of interest: none reported

CORRESPONDING AUTHOR

Susan Flocke, PhD11001 Cedar Ave, Suite 306Cleveland, OH 44106-7136susan.fl ocke@case.edu

Why physicians are burning out?

Less PCPs

Growing Patient Panels

Traditional Primary Care Model is NOT SUSTAINABLE!

Healthcare today

Who does the work?Physicians

Staff

Protocols & algorithms powered by technology

…and tomorrow

What Challenges Does Primary Care Face?

Challenge: EMR Workflow

• Optimized for Data Collection

• Does not execute tasks based on the data

Idea #1: Workflow Automation

Powered by the EMR

• Transform the EMR from collecting data to executing clinical tasks based on data

Example: Automatic Scheduling

• EX: Patient on tegretol automatically receives serum level scheduling message annually —> lab interpreted by technology —> any additional actions necessary executed

Challenge: Too Many Tasks for a Physician to Complete in a Day

• PCP would need to spend 21.7 hours per day to provide all the recommended acute, chronic, and preventative care to a panel of 2,500 patients!

Idea #2: Task Delegation

Physician StaffProtocols Algorithms

Standing Orders (Technology!)

Example: Refill Protocols

• EX: Nurses relieve physicians of this task by using technology (fueled by protocols) to process refill requests

Challenge: Patient demand for care exceeds

clinic capacity

• Patients experience delays in getting appointments with PCPs

Idea #3: Team Based Care

•Using nurses at the top of their license to provide team based care to patients

Example: Group Appointments

• EX: Nurses provide group appointments to asthma patients (aerochamber, MDI use, peak flow, asthma action plan . . .etc)

Challenge: Traditional PCP Encounter is Reactive

Annual Well Visit

Diagnostics Ordered

Diagnostics Reviewed by MD

Order Sent to Nurse for additional testing

Message sent to scheduler

Patient Notified to get additional test

Test Reviewed by MD

Message sent to nurse to call patient

Nurse calls patient with results

Idea #4: Redesign PCP Encounter

to be Proactive

• Use technology to automate pre-visit planning to queue up routine diagnostic elements ahead of the patient encounter

Example: Pre-Wellness Labs

• EX: Annual blood work is ordered and completed by the patient prior to the physician encounter so that results are discussed real time

Challenge: Healthcare is

Asynchronous

• Primary care offices are flooded with asynchronous requests that use precious staff resources

Idea #5: Synchronize Care

• Technology-enabled batching & consolidating of unrelated care elements

Example: Medication Synchronization

Application

• EX: Using technology to synchronize a patients various medications such that all refills occur simultaneously

Challenge: Primary Care Not Optimally Standardized

• Varying treatment plans for the same patient problem results in staff time wasted and higher rate of errors

Idea #6: Standardization

• Using technology to implement evidence-based and best practice protocols/orders to empower staff and drive efficiency and quality

Example: Strep Throat Protocol

• EX: Standardized protocol in place empowering nurses to diagnose queue up prescription order for strep throat

Challenge: Primary Care Not Optimally Centralizing

Routine Processes

• One nurse may do 10 different types of tasks per day

Idea #7: Centralization

• Create “hubs” fueled by technology where staff is executing the same workflow without interruption

Example #7: Centralized Coumadin

Center

• EX: Hub of nurses using protocols to manage all coumadin patient across the organization

Thank you!

healthfinch: The Doctor Happiness Company !

www.healthfinch.com Madison, Wisconsin

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