W

hy did the idea of dismantling Obamacare resonate with voters in the election? The answer may lie in “Your New Health Care System,” the utterly incomprehensible flow chart (above) created by the Congressional Joint Economic Committee in 2010. It diagrams a complicated web of interrelationships that crisscross between hundreds of government offices, departments, and programs in a maze of boxes, circles, triangles, and other assorted shapes.

The chart gains additional complexity when we layer in even more interrelated complex systems: insurers; medical and specialty societies, state medical boards, and medical examiners; medical schools, academic medical centers, and graduate medical education programs; along with a multitude of corporate players and constituents like the biotech, pharmaceutical, medical device, and health information technology sectors. Caught in this web are some 900,000 practicing physicians, as well as millions of other health care workers and the populations they serve.

The complexity of this system leads to what we consider to be an epidemic of burnout in today’s medical profession. A study from the Mayo Clinic showed that between 2011 and 2014, the physician burnout rate rose from 45 percent to 54 percent across all medical specialties.

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Burnout and dissatisfaction with work-life balance are particularly acute for adult primary care physicians — the central figures in our unsystematic health care “system.” A system that was already teetering in 2011 has been stressed by the addition of 20 million covered lives by the Affordable Care Act. It’s little wonder that in Massachusetts, where near-universal coverage has filled up the offices of primary care physicians, malpractice claims against them are rising. Patients and physicians alike complain about the unsatisfying brevity of office visits, and many harbor intense feelings of antipathy towards cumbersome electronic health records and growing administrative burdens.

We believe that to alleviate the stress and burnout in the medical professions, we must pay attention to system factors that lead to what we call the “occupational health crisis in medicine.” We recently surveyed 425 practicing physicians and health care leaders and executives, seeking their opinions on the importance of eight approaches to transforming health care. We presented the results this fall at the International Conference on Physician Health. (You can see a PowerPoint of our presentation here.)

Those who completed the survey agreed that a variety of proposed system-level changes were important to consider in combating physician burnout. Here are the eight transformational approaches we asked about, in descending order of perceived importance and ease of implementation. Leading the pack was overhauling the cumbersome electronic health record systems that require physicians to make thousands of clicks every day.

  1. Improving electronic health records and related technologies to enhance the experience of patients and their clinicians
  2. Restructuring physician work-life to promote better self-care and work-life balance, especially for physician parents in dual-career families
  3. Reorganizing the funding of medical education to diminish burdensome debt for early-career physicians
  4. Placing more emphasis on identifying emotional intelligence in medical school admissions
  5. Modifying systemic factors (e.g. reimbursement, medical malpractice) that impede genuine, multidisciplinary team-based care that will unburden physicians
  6. Rebalancing the funding and focus of graduate medical education to produce more primary care physicians and fewer hospital-based specialists
  7. Enhancing the reimbursement of physicians who focus on health maintenance and primary care
  8. Accelerating migration away from utilization-driven fee-for-service care to so-called “value-based care”

Electronic health records were intended to usher in an era of standardization and high quality care. Ironically, our survey respondents view electronic health records as a major cause of distress in the medical profession. A study in the most recent issue of Annals of Internal Medicine demonstrated that office-based physicians spend significantly more time interacting with their computers than with their patients. In a September commentary in the Wall Street Journal, Drs. Caleb Gardner and John Levinson advised doctors to turn off their computers and listen to their patients.

Doctors responding to this article wrote that there’s “very little conversation in the office”; that they contemplate quitting the practice of medicine because of being “forced to be a secretary and only allowed to practice medicine ‘on the side’”; and “it’s past time we stop turning our backs on patients.”

These sentiments resonate with what we hear repeatedly from colleagues throughout the profession across a variety of practice settings.

There’s no question that it’s easier to hypothesize, survey colleagues, and write opinion pieces than it is to disrupt and transform the complex US health care system. But let’s recognize that a key contributor to this complexity is a clunky and time-consuming electronic health record infrastructure that is taking an enormous toll on the well-being of physicians and the vitality of medical practice. Patients are well aware that computers are diverting their doctors’ attention from the human, interpersonal dimension of the care experience, and this may contribute to a variety of undesirable and unintended outcomes.

The remedies won’t be easy to accomplish. But one place to start would be for the next Bill Gates or Steve Jobs to create a compelling, user-friendly health care electronic health record platform that delights physicians and patients alike.

Steven A. Adelman, MD, is director of Physician Health Services Inc. and a clinical associate professor of psychiatry at the University of Massachusetts School of Medicine. Harris A. Berman, MD, is dean of Tufts University School of Medicine, where he is professor of internal medicine, public health, and community medicine. He previously served as the CEO of Tufts Health Plan.

Adelman-Berman-presentation

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  • I’m an RN in an ICU. I’ve been a nurse for almost 19 yrs. I used to be soooo happy with my career choice. I loved being a nurse and taking care of people. I can truly tell you that my job takes all the energy I physically and mentally possess at this point in time. The only think anyone cares about now are Hcapps and costs. No one cares about the patient. Everyone around them and their opinions are more important. I dread going in to do a job I used to love and cherish. I am all about doing the right thing for the patient but am not allowed to do what I know is the right thing to do. It’s very stressful and disheartening besides the hours of documentation that take you AWAY from the bedside where you belong as a nurse. It’s a very sad and dangerous state of healthcare that we have to be a part of

    • Donna, I feel your and your colleagues pain points. We are all endebded to RN’s MD’s & Medical profession mission, dedication, practice and collaboration in saving lives. Above mentioned impact everyone directly or through family membership.
      Mind maps, diagrams, workflows, are beautifully constructed and carefully thought out. These visuals provide overall detailed level of participant involvement and relationships.

      Medical records, treatment materials, therapies, instrumentation and drugs are huge aspects of a complex system. They entail sets of differently regulated data, processes, instrumentation and associated methods, and realtime scrutiny and reporting mechanisms to accomplish mission.
      Under current climate there are security aspects that are critical and must be in place to effectively identify, treat and deliver best health solutions.
      Proliferation of medical and hospital practice systems exist and they are only at times adding to an already complex systems conglomerate.
      Most recently – Some States do not require ER, ICU or Hospitals from reporting adverse events leading to loss of patient’s lives.
      i. Are we learning from historical mistakes?
      ii. Is Ethical Practice meeting expectation?
      iii. Are cost (salaries, facility, equipment, systems….) & treatment (drug/therapy cost…..) taking priority over critical path – “treating patients & saving lives?
      iv. Are advanced drugs, therapies, clinical research keeping pace with emerging disease and pathogens?

  • Many apologies to those who espouse your “point blank” fact driven views of the Medical Industrial complex but, medical professionals are those who will keep working to bail water from the Titanic as long as we get to reduce pain and suffering in the world

    Nothing will change unless we hit the elephant in the room where it hurts, in the pocketbook or, until patients start dying BECAUSE of the system.

  • Nice “Bird View of the Health System as Structured by Obama Care Act” this charts only touches on the surface of an scalating system for which not only Medical profetionals are contributors and are affected by. We all are an infinite cell framework membership and realtime evolving and decaying moving target of a so complex system only the universe can be compared in relativite complexity. It’s an enormity evolving scientific accomplishment challenged by the second by new viruses, diseases, drugs, therapies, robotics, live styles, cultures, environments, all trying to be compressed into policies.
    There is an order to everything and that order shall be followed or it gets out of sequence and creates chaous.
    It’s not the nurse body training patients is the crib, family, school and all ascending gubernamental bodies that are required to make a Health Watch Click and be in time qualified & quantified.
    So much more than a work flow!
    Great article, it puts it in perspective appropriately. Thanks to all involved.

  • They’re burned out because they’re sooo busy counting their money. when I was a youngster people became doctors because they had an affinity to cure, to ease pain. Now they all seem to be money grubbers. I thought that was the realm of dentists, (in God’s name, what bright young person would aspire to having their hands in someone’s mouth all day, yuk), now it seems most docs are following the same motivation. $$$$$$$

    • Humans in general like money. There aren’t really one class of people or profession that if you offered them more money they would turn it down. Many people still do enter medicine because they enjoy taking care of people. They also sacrifice their 20s to do so and some end up with over $300,000 in debt. Now you’re telling them that taking care of a patient brings them less money than their plumber charges just to arrive at the house. It’s about perspective.

    • You’re right, I do count my money. I currently have 1345.67 in my bank account. I also have 378,422.34 in medical school debt with an 8% interest rate. My yearly salary as a resident is currently ~42,000 annually for working 80-120 hours per week. I’m 29 and started medical school at age 23, essentially blowing through my 20s studying to do what I can do. I have 2 years left to finish residency where I’ll finally be done at age 31 with almost 400,000 in debt and I’ll have to start chipping away at it.

      In short, you have absolutely no idea what you’re talking about. Without even the slightest hint of a frame of reference, don’t comment on things you don’t understand. And definitely don’t try and get involved in fixing things if these are the silly things you believe. Younger physicians such as myself are quite sick of dealing with problems that you created for yourself while simultaneously chastising us about “how much you people make,” only to then go home and eat ramen noodles at 9pm. Have a great day.

      You have no idea what you’re talking

  • As long as physicians are put in the position of carrying most/all of the responsibility, but having little authority over their day to day work, the burn out and levels of mood disorders will continue and increase.

  • I am glad people are recognizing this. The way we handle in our office is having scribes (MA’s trained to do so), using nurses to educate patients allowing patients to walk in and giving them the time. this has been achieved over 15 years. NP’s are able to practice independently even in some specialties (like Dermatology and Rheumatology). Why go to Medical school ,
    do a residency and fellowship?

  • It is not just a matter of getting better technology. Now that we are all on computer, CMS requires more and more data submission. As a visiting nurse I now spend about 2 hours of my day doing actual patient care and 4 hours of data entry. We are being used a data collectors for the government. The regulations must be streamlined to make a dent in this problem.

    • Well said. Every time I see a BMI listed to two places past the decimal, I just think about how the keepers of big data are happy, and some poor medical practitioner went through all that training to be a data entry clerk.

  • Here’s two easy ones: (1)Talk to BCBS to eliminate their same day sign off on the day’s records. It is a better note if they can just wait a day or two for the lab and xray results and the doc can go home at the end of the day. (2) Get rid of prior authorizations and other waste of time unnecessary paperwork.

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