One of the Star Tribune’s leading articles 8/7/16 is “Doctors Battling Crisis of Burnout.” The article talks about how many health care organizations are recognizing physician stress and burnout as an important issue and taking steps to help providers develop “resilience” in the face of stress. Such steps include offering an exercise room at work, hosting dinners to discuss stress, and sending cleaners to doctors’ homes when the workload is particularly dense.
Pardon me while I try to prevent my brain from exploding.
People ask me at least weekly if I’m going back to work anytime soon. After I completed residency, I signed a contract for ¾ time with one of the major healthcare organizations in the Twin Cities. I had my own dedicated RN – this sounds possessive, but I assure you, I was hers, too. Full-time status was considered to be 28 face-to-face hours with patients per week. This doesn’t include the hours spent on phone calls, charting, paperwork, prescription refills, etc.
I worked one week out of every eight in the hospital, loving the interaction with our clinic’s patients and hospital specialists with whom I’d trained. I took overnight call about three times a month, sometimes more. Those nights were rough, often with little sleep and hours spent at the hospital.
I dictated my patient visits and handed the tape to our site transcriptionist. The notes were filed in the chart in reverse chronological order. The paper-bound story of a patient’s medical life.
When my son was born, we were up to 34 face-to-face hours as the expectation for full-time status. Not including phone calls, charting, paperwork,, prescription refills, etc. Benefits were dependent on your FTE (full time equivalent). I was my own transcriptionist at that point. We had transitioned, painfully, to an electronic medical record. Physicians were encouraged to develop “dot phrases,” generic pre-fab chart note chunks, that could be plunked into anyone’s note and tweaked as necessary. It’s like calling paint-by-number “art.”
We were paid on “production,” how much revenue we generated for the organization. wRVUs is the technical term – “work Relative Value Units.”
RNs were a hot commodity by that time, sequestered into specialized roles like Coumadin management and phone triage. Providers (we were mostly physicians with a couple nurse practitioners) worked with medical assistants, some of whom floated to different clinic sites.
So when the Big E was born, Ace and I each had non-coordinated, independent, overnight call schedules. I asked for some time away from call with a concomitant decrease in pay. The organization turfed the question back to my colleagues. They declined. I can understand it – if I didn’t take call and the organization offered no support, the burden fell upon my partners.
I gave my notice. But the organization contractually required ninety days. Eventually, the ninety years/days were up. I wanted to continue working for the organization in urgent care sporadically but that meant I couldn’t cash in on the physician retention benefit plan. I worked in urgent care twice and haven’t worked for money since. We are fortunate. We can make it on one income.
Last time I checked, “full-time” was considered to be 38 face-to-face hours per week. That still doesn’t include phone calls, charting, paperwork, prescription refills, etc. Part-time employment is not allowed unless you were “grandfathered” in. Patient visits are scheduled at twenty minute intervals. Yes, you’re expected to do a complete physical exam in twenty minutes on that 64-year-old three-pack-per-day hypertensive, dyslipidemic, diabetic who is transferring care from Florida and arrives with an oxygen tank and a wheelchair. Providers work with whatever medical assistant is assigned to the patient care team for that day.
“When are you going back to clinic?” you ask.
After the revolution.
Physicians and mid-level providers are the way healthcare organizations make money. VPs do not generate revenue. Nurse managers do not generate revenue. Presidents do not generate revenue. When organizations find themselves in tough times financially, they whip the doctors. Work more! See more patients! Get us more money!
Pay-for-performance is a particularly devious form of torture. Your pay is docked if your patients’ blood sugar control isn’t perfect or if their blood pressure isn’t within certain parameters. Physicians are held personally responsible for patient outcomes. On one level, of course this is appropriate. Physicians must practice ethical, up-to-date medicine. On another level, I can’t control whether my patients actually take their medication, follow my exercise advice, or smoke right before their appointment.
What would a revolution look like?
1) Medical scribes for all providers. Physicians shouldn’t be typing their notes. This is an unbelievable waste of the specialized knowledge of the sole income generators in a healthcare system.
2) Single-payer, universal healthcare system. You can’t imagine the convoluted mess of human resources necessary to support our idiotic patchwork-payer system.
3) Allow part-time employment and build in support for life circumstances (illness, leave, surgery, birth, family emergency).
4) Reward thinking specialties (family medicine, internal medicine, pediatrics), not just procedure-driven specialties (gastroenterology, surgery, etc).
5) Make medical school free. I graduated from med school in 1997 with $60,600 debt. I paid most of it off during residency. The average medical student today graduates with $170,000 in debt. And we wonder why there is a shortage of primary care docs.
6) Study upper-level administrative pay and figure out a rational approach.
(7)As long as we’re having a revolution, let’s make it possible for a family to live on one average income.)
8) Give some control back to docs. If I want 45 minutes for a complete physical, let me have it. I know I won’t be paid as much. So be it.
9) Pay should depend upon quality and complexity of care as well as production. But figure out the right ways to measure quality.
10) Off-load providers. Providers should only be doing provider-level work. This sounds arrogant to some, I realize. Gee, the poor doctor didn’t want to room her own patient. In terms of office efficiency, though, this is the only system that makes sense. Develop protocols for refills, triage, rooming, updating chart info, etc, AND FOLLOW THEM. PharmDs can do a lot of medication management for chronic disease.
There’s a lot more to the revolution. And I have a headache.
In short, it’s great that more attention is being paid to physician burnout and stress. However, the answers lie not in fixing the physicians, making them more “resilient,” but in fixing the healthcare system that’s burning them out.
PS (8/11/2016): Over 4500 people have read this post since Monday.
1) Thank you for caring about the health of healthcare.
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