Crossroads Between Physician Productivity and Burnout
By Nancy Gagliano, MD
The scenario is all too common. Practice expenses are rising while physicians are asking for reduced clinical sessions and productivity requirements. Everyone is worrying about physician burnout. Increased and shifting regulations have dramatically increased the complexity of delivering patient care. MACRA, EHR adoption and usage, coding compliance, quality monitoring, and prior authorizations have all amplified the administrative burden that has fallen disproportionately into the hands of physicians. Physicians, particularly, primary care doctors, are spending close to half of their time performing administrative tasks including documentation. This article reviews physician motivators and dissatisfiers, and provides concrete suggestions for improving physician satisfaction while setting up a foundation to enhance productivity.
Physician burnout has three core components – emotional exhaustion, depersonalization, and a low sense of personal accomplishment. It is estimated that close to half of physicians today are burned out. Burnout is associated with depression, substance abuse, suicide, and divorce, as well as reduced patient satisfaction and quality.
Understanding core motivators that affect physician satisfaction is essential to enhance the work environment to support physicians. We all have intrinsic and extrinsic motivators that contribute to our job satisfaction. The intrinsic motivators for physicians are the “Why I went to medical school.” A typical physician finds satisfaction in providing high quality care, learning and discovery, delivering excellence and “making a difference.” Certainly, all healthcare organizations value these core elements, which are often highlighted in mission statements. However, is it possible that these values are not communicated and reinforced frequently enough to providers? Instead, is communication from business lines focused on regulations, revenue, quality reports, and the multitude of demands facing healthcare today? Organizations should step back and commit to a balance of communications focusing on business imperatives and embracing, highlighting, and recognizing its core mission.
In addition, business units should be aware of these attributes when working with physicians. For example, the revenue cycle team may think of EHR documentation as a tool to support compliant coding and charge capture. However, physicians value their documentation as a mechanism to share clinical information with their colleagues to enhance patient care, and view coding and charge capture as a burden. It is important for coding experts and the billing staff to acknowledge and reinforce documentation’s core purpose when working with physicians.
Let’s move on to external motivators that affect physician satisfaction. These factors include autonomy, resources, community, leadership, and appreciation.
Autonomy
Autonomy should be broken into three areas – financial, environmental, and clinical. We have come a long way from the independent physician running their own practice, determining how hard they want to work, where they work, who works in their practice, and the care that they deliver. Today, many physicians work in practices managed by administrators and arrive for their assigned session hoping that the same medical assistant is there to support them. Standardization is essential for efficiency. No longer are diplomas or family pictures hanging in exam rooms. Physicians have lost their environmental autonomy.
Although physicians can impact their earning potential through specialty selection, many physicians are now salaried with only minimal ability to control their earnings. Overall, they have lost their financial autonomy as well.
Finally, they are losing their clinical autonomy in having to deal with quality programs reports, guidelines protocols, and prior authorizations. We are telling physicians that the quality of care they provide, without these programs, is inadequate. Given that a typical physician spends a decade on education and training, we should be careful when communicating these programs and requirements, as they can be perceived as insults. When working with physicians and asking them to change behavior, it is important to be aware that autonomy is important and standardization is not cherished. Prioritizing those activities that truly require standardization and presenting the value of standardization is critical.
Resources
Unfortunately, with the complexity of healthcare increasing, tasks falling onto physician shoulders have increased. In addition, the EHR, because of increasing documentation requirements and inbox tools, has increased the time physicians spend doing tasks previously done by others. There are numerous opportunities for organizations reduce the administrative burden and increase productivity, including:
- Clinical workflow and EHR optimization.
- Virtual scribes.
- Centralizing access.
- Appropriate use of clinical support staff.
Community
Although many physicians are independent by nature, the importance of community is often overlooked. Gone are the physician-only lounges and lunch rooms, which were eliminated for political correctness. Dining with colleagues has been replaced with catching up on notes and paperwork before the afternoon session. We have lost sight of the fact that these venues gave physicians opportunities to discuss emotionally and intellectually challenging cases. Physicians no longer have easy access to their colleagues to unburden themselves from the weight of patient responsibility, which, arguably contributes to burnout.
Look for opportunities to reinforce this in the physician community. Consider holding physician team meetings to share information, whether it is coding review, financial reports, or other administrative issues. It provides an opportunity to support physician community as well as learning from one another. While a physician group meeting may be viewed only as opportunity for venting and could potentially be difficult to manage, the venting may, in the end, result in greater buy-in.
Leadership
While organizations acknowledge needing excellent physician leaders and champions, many physicians do not excel in leadership roles given their autonomous and independent nature. Typical challenges include consensus building, active listening, inspiring, dealing with conflict, and mentoring. Organizations should resist putting the “physician IT geek” in technology roles or solving a productivity reduction request by giving a leadership position. Another common mistake is selecting a physician leader based on how their peers perceive them. While it is vital that their peers respect their clinical leaders, being respected for high quality care, research, or productivity are not necessarily the attributes that make the physician an excellent leader.
Once physicians are selected to be leaders, organizations need to focus on leadership development through external and internal programs. There are numerous external programs available that can provide a boost in learning. However, for larger healthcare organizations, it is advantageous to develop an ongoing internal leadership forum that will provide physician leaders with skills reinforcement and an opportunity to interact with peers in leadership roles across the organization.
Appreciation
Physicians are similar to others in valuing appreciation. Although a full waiting room provides a sense of satisfaction, appreciation from colleagues is very gratifying. While balloons, candy, and flowers may not be appropriate recognition tools for physicians, peer and colleague recognition programs are. Regularly highlighting and celebrating clinical excellence, compassionate caring, teaching, and research should be an integral part of an organization’s culture.
In summary, physician burnout is a real phenomenon that we should all take seriously, particularly in an era of physician shortage. Understanding internal and external motivators of physicians is important when working with physicians. We should reflect on how we work with physicians to make sure our approach taps into their intrinsic motivators. In addition, there are numerous opportunities to create a positive environment to maximize physician productivity and satisfaction.
Nancy Gagliano, MD is CMO at Culbert Healthcare Solutions in Woburn, MA.
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