Tuesday, January 30, 2018

Burnout Returns to Center Stage

A recent Mayo Clinic Proceedings guest editorial, by Yale University physician Kristine Olson, asks the question--to some of us it's far from a rhetorical one--whether burnout among her fellow physicians is in fact "A Leading Indicator of Health System Performance?"

Seems to me that her gist is: yes, it surely must be just such an indicator. If she's right, then our system's performance is in a heap of trouble.

What is burnout? Our fearless editor, Dr. Poses, has addressed it repeatedly, including a few months ago here in these pages. But burnout is actually hard to delineate and hard to quantify. People quitting? People getting a lot less efficient once they see they're on the hamster-wheel? Getting lousy performance ratings because they're forced to hang in? (Wishing they had another option?) Leaving front line medicine to go to industry? Leaving to clip coupons and bicycle in Provence?

Well, to quote Justice Potter Steward in his inimitable pronouncement for his short concurrence in the 1964 SCOTUS obscenity proceedings, "I know it when I see it."

I know burnout when I see it. So do you. You want a physician who loves her job enough to get good at it, because lives depend on that. How's that going for you?

I've watched my best and brightest colleagues--or those who could find a nonclinical job or afford to retire--leave in droves. Now the waves of new investigations of burnout are coming at us thick and fast. What's striking about the latest spate of writings on burnout is what it doesn't try to say. Which is to say: back at the turn of the century, or just before that, or just after that, the preponderance of published sentiment was on reinforcing providers' resilience. Essentially, pep talks disguised as exegeses on "professionalism." "Stiff upper lip, remember your values and for heaven's sake, keep your professional wits about you.

That's now changed. The surfeit of real, serious challenges--external threats--from HIT FAN (Health IT FAke News) to the opioid crisis to maldistributed resources, are now finally being examined. We'll come back to whether it's too late for any of this. So here are some recent chances for readers to get, usually without a paywall, a look-see.

  • The redoubtable New England Journal has several recent entries in its 25 January 2018 number dealing forthrightly with the "crisis level" of the problem, beginning with a perspectives piece from National Academy of Medicine authors Victor Dzau et al., including colleagues from most of the major national organizations involved in training and accrediting physicians and their organizations. I hope they read this blog.
  • The article cited above embeds an excellent and downloadable audio interview with Tait Shanafelt, MD, of Stanford University, also on burnout. He helpfully points out how front line doctors--those in primary care fields like internal medicine, family medicine and pediatrics--bear the brunt of the burden. That is, they bear the burden reflected in the alarming rate of especially experienced practitioners peeling off rather than continuing to put up with the (now my words) losses of autonomy and coherence. More later on autonomy and coherence.

    (At Stanford, Shanafelt holds the title of "Chief Wellness Officer." That tells us something right there. At a website tied to fitness, the CWO is defined as somehow hired  to "create work culture for employees to not only show up and perform, but thrive." Hey, any port in a storm. If removing noxious threats such as those above can be compared to wellness threats on exercise machines, like coach-driven anabolic steroids, then we're all for it. Let's get rid of the bullying managers along with the bullying coaches. Can Chief Wellness Officers effect such a change?)
  • In the same number of the Journal, one finds another superb piece by the now long established team of physician-journalists Alexi Wright and Ingrid Katz. Gott sei dank for the impact of young persons and women on health policy around medical worklife. Wright and Katz title their piece "Beyond Burnout -- Redesigning Care," not the shopworn twentieth century "Be More Professional" meme. They go on at length on the cost of losing experienced doctors, and describe one means of addressing the crisis created at the University of Colorado. In the so-called Colorado APEX project, which started (as many innovations do) in Family Medicine, then spread to other departments and institutions, they show how certain burnout measured were cut dramatically.

    They conclude, though, with an admonition: "how [can] physicians can reclaim joy in the practice of medicine?" They're not sure, nor am I, whether managerial redesign of care, by itself, can "restore meaning and sanity" to the lives of providers.

    And this is not just about--in the main this is not about--making doctors' lives better. Not the real point. Doctors flake off, patients have longer wait times then have access to less and less experienced ones when they finally get to see them. Doctors lose that passion for the art when they're overwhelmed with prescriptive guidelines around the "science." Unclear which is more dangerous: doctors who burn out and leave, or those who burn out and stay behind.
  • Wright and Katz and a number of other observers cite what's turning out to be a seminal study published last fall in Mayo Clinic Proceedings. Authored by a team led by prominent internist Christine Sinsky, the piece provides all the evidence anyone will ever need to understand the magnitude of the crisis as well as some of its causes. Chief among those causes, a topic repeatedly and eloquently underscored (most recently here) in these blog pages by our own InformaticsMD, is the Electronic Health Record, or EHR. The blog post just quoted actually harks back, through a report in Medical Economics, to the same Sinsky piece mentioned at the start of this bullet.
There's been a lot of inkshed lately about the EHR as a cause of burnout. But what seems most likely is a murkier picture that means we have to look both across the causal spectrum and across the political spectrum.

Does having your practice swamped by addiction-crisis patients contribute as well to burnout? In an earlier blog we pointed to the phenomenon of physicians across the country "learning" about opiates, first becoming "convinced" of the non-addictive properties of drugs like OxyContin. In a word, later, realizing they'd been snookered--a real blow to the joy and coherence of medical practice. Not to mention the end-effect of whole practices being consumed by drug- and doctor-shopping by patients totally convinced that they "needed" continued use of these drugs to avoid pain relapse.

But wait. Burnout is multicausal. Physicians trained to practice public health and physiologically-based internal medicine are stymied by loss of control of their practice, as the managers insist on crowding their schedules with all comers. No choice. Firing a patient is well nigh impossible.

They're also stymied by the bizarre contradictions--see above and all the new articles--of the technology imposed by managerialism. Why is it imposed? The physicians know why, and there's nothing they can do about it.
  1. It allows managers to "watch"--using all the wrong metrics--their performance.
  2. It gives managers the illusion of control by means of counting--which in fact EHR does very badly--adherence by clinicians to clinical guidelines, even when the latter are ill conceived.
  3. It allows managers to draw in more dollars through "compliance" with government-imposed standards, out of the Office of the National Coordinator (ONC) for Health Care IT, including the now justifiably much-maligned Meaningful Use standards. Some standards we came to know well, allowing managers to capture more dollars, include things such as the following.
-- pushing out end-of-encounter "Clinical Summaries" that contain nothing but erroneous lists of medications, and no plan, then leaving these near-worthless paper documents on printers when they were destined for patients
-- striving perversely to push out "eScripts"--electronic prescriptions--for a certain percentage of patients during encounters, requiring first the e-prescription followed by a web-page button indicating "I wrote this prescription electronically," followed by billing for an eScript: except that most patients already got their meds renewed outside of in-office encounters
-- push doctors to "upcode" from lower- to high-reimbursement level billing codes for greater charge capture, requiring nothing more than gross importation of macros and text blocks
-- this list goes on and on; this writer knows inside out the perversities of the EHR
So the opiate crisis and the technology crisis have converged with still other forces that now  becoming rampant. Chief among these is the much slower-simmering crisis of hyperspecialism. Students who would become great generalists cannot afford to do so because of crushing debt burdens. Their institutions impose drastic inflated costs on medical students while pushing, through both cultural and institutional pressures, these students to hyper-specialize in procedure-driven specialties whereupon they, too, can become part of the problem.

This last problem has been discussed on occasion over the years in HCRenewal by its editor, Dr. Poses, in his discussions of the secretive AMA-designated panel known as the RUC, the Resource Utilization Committee. RUC exposés are rampant--see here and here--and nothing new. But the result is that the AMA's efforts on behalf of its own heavily specialty-weighted membership have created within medicine an auto-cannibalistic food chain within which the profession, including academic medicine, essentially penalize their own most vulnerable. The most vulnerable who are in fact societally the most valuable. But since the AMA appoints the RUC, it is complicit in this autocannibalism, and therefore in the demise of physician worklife coherence. In his interview, Stanford CWO Shanahan states as much when we speaks of the particularly burdensome consequences of burnout among primary care physicians.

(That Sinsky now spends some significant part of her time at the AMA is a good portent, we have to admit.)

So what are we left with? Earlier we said this is a multi-political problem. Look at the sources of the three causes of burnout discussed above.
  • The opiate crisis clearly stems from industry. Big Pharma, with one company, Purdue, allegedly leading the charge over several decades, gets the nod here. Not, as Wisconsin Sen Ron Johnson seems to think, the availability of Medicaid funds for addicted patients. Score one for private sector iniquity.
  • The EHR crisis clearly stems from Big Government. And probably, equally, industry, although when it started out the folks who brought you all the deficient EHRs were small entrepreneurs, nothing like Big Pharma. Score one for public sector iniquity.

    But Big Government brought them into the Bigs. Using by and large the wrong metrics. Medical managerialism then kicked in, bought the package, and went for the gold in them thar IT hills. That's the story of HITECH and even ACA as they sought out tech panaceas--the classic American technological imperative that brought us everything from the Interstate Highway System to the Moon Shot to the War on Cancer. And now this.
  • The relationship between public clinical needs and physician organizational resource mismatches is internal to the medical profession. "We have met the enemy and he is us." Score one for autocannibalism in a classic profession unable to regulate itself now, if it ever could before, in the face of all these new external forces.
Put all this on a SWOT analysis chart and you have a recipe for disaster. The one thing that both Big Medicine and Little Medicine had going for them in years past was autonomy and coherence. The autonomy couldn't survive in the 21st century, but the coherence--the sense of meaning derived from applying science to the individual patient--could have and should have. It is a flame still not extinguished. But faced with the forces we've discussed here, it is a flame flickering, just barely.

And the solution, like the problem, comes from every part of society. It therefore brooks no easy or solitary solution from either the left or the right extremes of political philosophy.


InformaticsMD said...

Health IT, especially bad health IT, may be the straw that's broken the camel's back.

Unionization - with militant laeadership - is needed to fix that injury and provide the medical profession a spine, in my opinion.

Anonymous said...

Good piece, I still am having issues with staff 30 months after a health scare as the issues covered are moved down stream in the medical community. The drive for financial gain has taken over medicine and management is now in the hands of MBA’s where profit is the goal of every encounter.

In my community we are in the early stages of the battle as a regional medical center moves not only its service but financial and practice standards into the area. As a person treated at one of its hospitals I cannot wait for this institution to make the final move to serve our local population.

Steve Lucas

Afraid said...

Physician, heal thy industry.