While the role of a physician has always been demanding - there's a spike now in doctors who say they're overwhelmed, and spending more time in front of computers than tending to patients. That's contributing to a burnout epidemic, leading to high turnover, early retirement, and greater malpractice risk. We'll find out how doctors in New Hampshire are coping.
- Steve Del Giudice - Retired dermatologist. He has been practicing medicine for over thirty years. In 2015, he founded Northern Sky Healthcare Consultants, which provides stress reduction and resiliency training for healthcare professionals. He is the author of two books: First Patient, Last Patient (Practicing Medicine Mindfully), and I’m Out of My Mind (so why can’t I stay there?).
- Eric Kropp - Practices family medicine at Active Choice Healthcare in Concord. After working at a hospital-owned practice where he says he spent too much time dealing with paperwork and computer tasks, he established his own direct-care practice, which provides care for a monthly fee and eliminates insurance claims for routine healthcare needs.
- Tanja Vanderlinde - Internist at Concord Hospital, where she is also Advisor for Population Health and co-chair of the Provider Wellness Oversight Committee.
How are doctors experiencing stress and burnout?
ERIC KROPP: It was really very gradual. As physicians, with the training that we go through, we are very good at adapting and pooling what's left of our energy and putting it where it needs to be, and I found there was less and less energy to put where it needed to be with patient interactions or at home with family. And you really have this gradually creep up on you and the weight is heavy and you don't recover.
It was almost like a cartoon where you have a frowny face before you walk through the door and you walk through the door and you put on your smiley face and interact with the patient. Soon as the door closes behind you, it drops again.
And for me it really became completely clear when one of my physician colleagues, an office mate of mine, passed away unexpectedly, and I didn't have an ounce of emotional, physical, spiritual energy to be able to deal with that. And the result was that I felt very cynical about his passing, about having to take care of the patients that he left, and I recognized that that can't continue. What went through my head is, This is not me. This is not who I should be.
TANJA VANDERLINDE: I generally have been able to maintain a certain amount of resilience. But over the past few years because of the extra work related to the electronic health records I have found that I was less attentive to my own family and would be spending hours in front of the computer instead of answering their questions. They'd be talking behind me, and I'd be focused on my electronic health record, trying to finish the work that was done that day. And it takes a toll on family life.
Electronic Medical Records, EMRs, are considered a big part of the problem. Why?
STEVE DEL GIUDICE: There's a term that I read recently in a survey called pajama time, and this is where the physician goes to work say 7:00 or 7:30 in the morning, comes home around 7:00 o'clock in the evening and then has dinner, a little bit of time with the family, then they're in front of the computer finishing their notes. This is a common problem. And the point is that the medical group was really not designed so much by physicians or by working physicians. They're designed more as a billing instrument, as a data collection instrument. So I think that's important to understand -- that the electronic medical record as it exists now is not really friendly towards practicing healthcare providers.
It's very demanding. And physicians talk about the broken promise of "only two more clicks." For example, we need to do this extra metric that Medicare needs -- a metric for, say, smoking versus nonsmoking -- even though the person is not there related to a smoking issue. And that's called a click. So you click the computer a couple of times and get to the next step. But the broken promise of "two more clicks" is that the tasks add up.
KROPP: A study came out recently showing that for every hour that is spent in direct patient-care contact, that physician is spending two hours doing electronic health record tasks, and it also demonstrated that during that interaction with the patient, they are directly interacting with the patient only a third of that time. The remainder of that time is spent interacting either with things on the desktop or with that electronic medical record.
To get mad at the EMR or to put all that focus on it, is sort of like getting mad at a car. You know you can buy a jalopy or you can buy a Maserati. If the road is posted for only 25 miles an hour, you're still only going to get there when you get there. I agree that there are issues, but it's not really the EMR. It's more the payments and the insurance companies that are mandating these quality measures and mandating this data extraction and then being forced onto the practices. --Exchange listener, Jen, RN, of Concord
Direct Primary Care is described as one way to reduce time-consuming paperwork generated by health insurance. How does it work?
KROPP: I work directly for my patients. They pay me a flat rat, monthly fee. The national average is $50 to $100. And there's no billing with that. If they come in for a visit, there's no billing, no additional fees, there are no co-pays, no deductibles. That covers the cost of their care. It allows me to take care of fewer patients and take better care of them. It is one reason cited by a lot of the medical students choosing family medicine residences as sort of a beacon of hope for family medicine -- that they may be able to practice in a model where they can have that relationship, be able to take care of people, that Marcus Welby sort of thing.
There's still a role for insurance. People need insurance to prevent catastrophic loss, which is what your homeowners and auto insurance does. Your auto insurance doesn't pay for new tires or a new transmission, but yet we expect our health insurance to pay for everything. And as long as we expect them to pay for everything, they have every right to ask us to do whatever they want to get paid: check these boxes if you want to get paid for this; make sure it's meeting this code if you want to pay for that. Our addiction to third-party payers is really allowing them to drive so many of these factors.
What about expanding responsibilities of other medical professionals in order to distribute the work and reduce the burden on one particular group?
VANDERLINDE: Nurse practitioners and physician assistants are used extensively in New Hampshire and in the Concord area. That's not a new concept for all of us. They also experience the same burnout issues that doctors do. They have the same requirements, documentation, the same expectations for seeing patients. But for building up the workforce, they play a very important role.
As Exchange listener Gisela, an RN for 30 years, pointed out, nurses, too, experience burnout:
I love nursing but I am done because I feel burnt out. I can no longer spend time with my patients because electronic health records are so time consuming, and administration is not understanding of the legal implications nurses have to undergo while charting in electronic health records.