By Brad Zehr (BUSM '18)
Feb 8, 2017
Medicine is by nature a field in flux, but we are entering medicine during a period of historically intense disruption that can feel chaotic.
The digital revolution, having radically transformed and improved so many facets of modern life, has been conspicuously tardy in hospitals and medical schools. Inelegant, inefficient electronic medical record systems abound, rote memorization of endless factoids remains dominant in medical education, and the use of mobile phones is actively discouraged throughout medical training despite the emergence of many potentially game-changing apps.
Simultaneously, the speed of information and knowledge creation has accelerated to a degree that can feel unmanageable. The daily crush of patient data is dizzying. The burgeoning genomic revolution, "precision medicine" movement, and "Big Data" developments will further compound the information glut. Documentation requirements are expanding, while time allotment per patient is decreasing.
National health care reform, meanwhile, is systemically disrupting the delivery of health care. New models of care, new incentives, and new rules often complicate the workflow of physicians. Byzantine requirements for reimbursement, conflict with insurance companies, and soul-crushing administrative tasks erode morale. And perpetual political conflict surrounding health care imbues the field with a sense of instability, uncertainty, and tension.
An editorial last December by Steven Adelman, MD, the director of Physician Health Services, Inc., and Harris A. Berman, MD, the dean of Tufts University School of Medicine, captured the zeitgeist in its title: "Why are doctors burned out? Our health care system is a complicated mess."
These major stressors on the health care system and disruptions in the practice of medicine exacerbate the inherent pressures of being a doctor -- avoiding any error that could harm a patient, witnessing human suffering and injustice, contemplating death and dying, prioritizing patient care over self-care, and balancing competing demands of the clinic, research, teaching, leadership, and advocacy, not to mention time for family, friends, and solitude.
Traditional media and social media are saturated with stories about the epidemic of burnout among physicians and physician trainees, a phenomenon well documented in the academic literature. In fact, a new journal titled Burnout Research launched in 2014, and a 2015 JAMA editorial argued that depression among medical trainees had reached a "crisis level." Recognizing burnout as a worsening problem, the National Academy of Medicine recently announced a clinician wellbeing and resilience initiative.
Given this worrisome atmosphere, and given my own personal experience of losing a friend and medical school mentor to suicide, I decided to attend the International Conference on Physician Health this past September in Boston. Al Nadjarian (BUSM '17), a steering leader of the BUSM Wellness Initiative, also attended.
(Moment of Zen / Fun Fact about Al and I: One time, for the sake of achieving comedy excellence at BUSM Skit Night 2014, Al took pictures of me walking around the South End in a cat head costume.)
Below is an outline of the key take-home points and resources I gathered from the conference.
Major Themes of the Conference
-- Identifying trends and root causes of burnout among physicians and trainees
-- Sharing practices to increase physician work satisfaction and joy in medicine
-- Discussing the role of EMRs, technology, and changing regulatory environment in physician dissatisfaction
-- Cultivating time and space for humanities in medicine (literature, poetry, art, music)
-- Incorporating mindfulness into the practice of medicine
-- Addressing physician/trainee mental health and suicide
Top 10 Cited Causes of Burnout Among Physicians
From the Medscape Lifestyle Report, 2017.
1. Too many bureaucratic tasks
2. Spending too many hours at work
3. Feeling like “just a cog in the wheel”
4. Increasing computerization of practices / bad EMRs
5. Income not high enough
6. Too many difficult patients
7. Insurance issues
8. Maintenance of certification requirements
9. Lack of professional fulfillment
10. Threat of malpractice
Preventing Burnout Requires These Key Ingredients
Stephen Swensen, MD, Senior Fellow, Institute for Healthcare Improvement
— feel physically and psychologically safe
— appreciate meaning and purpose in work
— have choice and control over time
— experience camaraderie with others
— perceive work life as fair and equitable
Institute for Healthcare Improvement Recommended Reading for “Creating Joy in Work”
1. curriculomegaly -- phenomenon of incremental expansion of the medical school curriculum over years-decades, creating untenable amalgam of material that may no longer be essential to 21st century medical education; see how Dell Medical School (UT-Austin) addressed this issue with their EDGE curriculum
2. documentology -- study of how to improve the efficiency and flow of medical documentation; note, this is not an official term in the literature, but instead was used as shorthand among some researchers at the conference)
3. cognitive load -- NASA and the FAA always consider pilots' "cognitive load" when creating new work flow items or tasks, with an understanding that there is a finite limit even among the most gifted minds; health care systems research could benefit from incorporating this concept to improve physician wellbeing
4. compliance creep -- phenomenon of over-interpretation and misinterpretation of federal regulations at the local hospital or clinic level; this is a major barrier to innovation in health care
5. Quadruple Aim -- take the classic health care policy Triple Aim (Better population outcomes, Improved patient experience, Decreased cost), and add fourth component, Increased physician satisfaction (http://www.annfammed.org/content/12/6/573.full)
6. pajama time -- time spent by physicians at home finishing or prepping EMR documentation in the late PM / early AM
"Have you noticed how intoxicating momentum is?"
-- Saki Santorelli, EdD, MA, executive director of the Center for Mindfulness in Medicine, Health Care, and Society at UMass Medical School
Plenary session by Dr. Christine Sinsky (http://www.drsinsky.com), VP of professional satisfaction at American Medical Association
Innovations to improve physician satisfaction in outpatient clinic setting:
1. Pre-visit planning / pre-visit labs arranged by nurse (e.g. ThedaCare in Wisconsin, MGH Point-of-Care testing: https://www.ncbi.nlm.nih.gov/pubmed/23669184)
2. Annual prescription renewals: renew all of patient’s chronic/stable meds once annually (“90 day x 4 refills”)
3. Sharing care: 2:1 or 3:1 allied health professional to MD ratio, allows for between-visit health coaching, care coordination, panel management, immunization, cancer screen, patient education, health coaching, HTN visits, DM eye apps, DM foot care, etc.
4. Team documentation: Hire MA to be in room from start to finish of patient visit, documenting “pre-visit” (med rec, chief complaint, HPI, ROS), “visit” (exam, meds, labs, imaging, follow-up), and “post-visit” (review visit summary, script pick-up, health coaching) (https://www.stepsforward.org/Static/images/modules/4/downloadable/Team_Documentation.pdf)
5. Inbox management: nurses/med assistant filter the practice inbox (results reporting, med renewal), only pass a fraction on to the MD; average PCP receives 77 email notifications per day (https://www-ncbi-nlm-nih-gov.ezproxy.bu.edu/pmc/articles/PMC4860883/)
6. Semi-circular desk arrangement to improve doctor-patient relationship (Iora Health: https://www.bostonglobe.com/business/2015/05/03/iora-health-pioneers-new-primary-care-model/kc7V4W5V8OJ0gxFqY4zBrK/story.html)
7. Tap-and-go login to EMR (no username/password, instead tap your card, saves time and mental bandwidth, no multiple user/password combos for different applications)
8. “Flow stations”: Team co-location / huddles; MD, nurse, medical assistant sit in same location to facilitate communication and camaraderie
9. Printer in every room to prevent needless trips to central printer for every patient visit
Other key recommendations from Dr. Sinsky:
— We need to formalize “Practice Science” to improve the 21st century doctor visit
— AMA “Steps Forward” shares innovative outpatient models, future goal to expand to inpatient models
— Changing clinic practices is hard: avoid design/deploy and command/control; instead use empower/encourage
1. UMass Mindfulness in Medicine (MiM): http://www.umassmed.edu/cfm/
2. AMA Steps Forward, collection of online modules on practice innovations to increase physician / patient satisfaction: https://www.stepsforward.org
3. AMA Mini Z Burnout Questionnaire: https://www.stepsforward.org/modules/physician-burnout-survey
4. Abbreviated Maslach Burnout Inventory: https://www.aap.org/en-us/Documents/soim_abbreviated_maslach_burnout_inventory.pdf
1. Meldrum H. Exemplary physicians’ strategies for avoiding burnout. Health Care Manager. 2010. https://depts.washington.edu/fammed/wp-content/uploads/2015/03/ExemplaryStrategiesforAvoidingBurnout.pdf
2. Epstein RM, Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Acad Med. 2013. https://www.ncbi.nlm.nih.gov/pubmed/23442430
3. Dyrbye LN, et al. Burnout among US medical students, residents, and early career physicians relative to the general US population. Acad Med. 2014. http://www.ncbi.nlm.nih.gov/pubmed/24448053
4. Dyrbye LN, et al. Efficacy of a brief screening tool to identify medical students in distress. Acad Med. 2011. http://www.ncbi.nlm.nih.gov/pubmed/21642810
5. Kearsley JH, Lobb EA. ‘Workshops in healing’ for senior medical students: a 5-year overview and appraisal. Med Humanities. 2014. http://mh.bmj.com/content/40/2/73.full
6. Sinsky CA, et al. In search of joy in practice: A report of 23 high-functioning primary care practices. Ann Fam Med. 2013. http://www.annfammed.org/content/11/3/272.full, http://abimfoundation.org/wp-content/uploads/2016/01/Finding-Joy-in-Practice-White-Paper.pdf
7. Babbott S, et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Inform Assoc. 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3957395/
8. Sinsky CA, et al. Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties. Ann Int Med. 2016. http://annals.org/article.aspx?articleid=2546704
9. Shanafelt TD, et al. An interactive individualized intervention to promote behavioral change to increase personal wellbeing in US surgeons. Ann Surg. 2015. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4333681/
10. West CP. Interventions to reduce physician burnout and promote physician well-being. ACGME Symposium, 2015. https://www.acgme.org/Portals/0/PDFs/Symposium/CWestSymposiumPresentation.pdf
Recommended Viewing / Listening
1. "A concert of melody and medicine”, aka “My life as a Guitardiologist.” Suzie Brown MD. TEDMed 2016. http://www.tedmed.com/talks/show?id=528927
2. “The Doctor.” Sir Luke Fildes. 1887. http://www.tate.org.uk/art/artworks/fildes-the-doctor-n01522; Commentary: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2249807/, http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2960915-0/fulltext
3. “The healing power of mindfulness.” Jon Kabat-Zinn PhD, speaking at Dartmouth Hitchcock Medical Center. 2011: https://www.youtube.com/watch?v=_If4a-gHg_I
4. “Why doctors kill themselves.” Pamela Wible MD. TEDMed 2016. https://www.youtube.com/watch?v=qyVAtZ9VZ4Q
5. “Slomo.” Joshua Izenberg. New York Times Op-Doc. 2014. https://www.nytimes.com/2014/04/01/opinion/slomo.html?_r=0. (About Dr. John Kitchin, a neurologist who retired and now skates by the beach while in “the zone.”)
6. “What makes a good life? Lessons from the longest study on happiness.” Robert Waldinger. TED Talk. 2015. https://www.ted.com/talks/robert_waldinger_what_makes_a_good_life_lessons_from_the_longest_study_on_happiness#t-116218
1. International Conference on Physician Wellbeing: Best practices for individuals and organizations, Sept 28-30, 2017, San Francisco, co-sponsored by Stanford Medicine and Mayo Clinic; https://med.stanford.edu/cme/courses/2017/wellmd17.html
2. International Conference on Physician Health, Oct 11-13, 2018, Toronto, to receive updates email firstname.lastname@example.org, if questions email email@example.com