Why 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.
- Improving electronic health records and related technologies to enhance the experience of patients and their clinicians
- Restructuring physician work-life to promote better self-care and work-life balance, especially for physician parents in dual-career families
- Reorganizing the funding of medical education to diminish burdensome debt for early-career physicians
- Placing more emphasis on identifying emotional intelligence in medical school admissions
- Modifying systemic factors (e.g. reimbursement, medical malpractice) that impede genuine, multidisciplinary team-based care that will unburden physicians
- Rebalancing the funding and focus of graduate medical education to produce more primary care physicians and fewer hospital-based specialists
- Enhancing the reimbursement of physicians who focus on health maintenance and primary care
- 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.