A different kind of health care crisis - physician burnout

[Boardwalk Jedi]

I know you like to pick out sections of articles, so here's just a few I found interesting...

This makes it sound less like a problem with the software and more with a problem with the USERS.


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At least on our previous system, everyone's charting was their own, so I could read each doctor's notes individually and refer to the charting of (well...) nurses I trust. I could see the ER nurses notes and see how everything started. I could look at the admitting doctor's report and see what the goals are and then I could see progress reports from each day to see where we are at when I begin my shift. This is ideal, but time doesn't always allow a thorough search on a patient's history. Having today's reports at my fingertips are essential for that moment. With everything mixed in, it's hard to sort out.

It adds work on the documentation side too. Now when I chart, an RN from ten shifts ago may have heard crackles in the in the left upper lobe. I don't hear them anymore (makes sense), but I have to now fill that out rather than simply "clear throughout" because they want nothing left unchecked.

As much as you seem to want to pin this on whiny health care workers, this doctor is correct. The software is too overlapping and doctors (users) can't get the clear picture they need whether they have the time to read or need info in a pinch (that last one is usually what's necessary btw).

 

[Southernmiss]

It looks like the software designers and the healthcare providers need to work together to make systems that are more user friendly.

There's not anything those of us on the outside can do to help.

It has to come from those that manage and are in the work of healthcare.

 

[sam_gordon]

As much as you seem to want to pin this on whiny health care workers, this doctor is correct. The software is too overlapping and doctors (users) can't get the clear picture they need whether they have the time to read or need info in a pinch (that last one is usually what's necessary btw).

I'm not trying to pin this on whiny health care workers. Believe me, I will readily admit software can be inefficient also. But as @Southernmiss points out, doctors (users) need to work with the software developers to make appropriate changes. No, I'm sure a given doctor can't call up the software developers, but surely there's a supervisor/contact at their hospital that can forward on suggestions. And, IMO, the "suggestions" need to be more than "this takes too long" or "this sucks". It needs to be "It would be better if I could do 'x' because a, b, c."

 

[longboard55]

We keep hearing we need to more with less money. The answer is yes you do. Figure it out. Health care costs are killing us.

 

[Mackenzie Click-Mickelson]

I'm not trying to pin this on whiny health care workers. Believe me, I will readily admit software can be inefficient also. But as @Southernmiss points out, doctors (users) need to work with the software developers to make appropriate changes. No, I'm sure a given doctor can't call up the software developers, but surely there's a supervisor/contact at their hospital that can forward on suggestions. And, IMO, the "suggestions" need to be more than "this takes too long" or "this sucks". It needs to be "It would be better if I could do 'x' because a, b, c."

I think more places should have R&D departments.

My husband's company had a really good one for a few years but they've since backed off on truly utilizing it at least to the extent that they were. My husband was involved in the department when he was in between projects several years ago. One of the guys on the panel if you will saved the company several hundred thousand dollars by suggesting a different process for something.

When I was at the insurance company it was often a complaint about how long the computers took to load up and for you to sign into all the programs you had to use. Eventually someone suggested we use a Macro, which those were already been more integrated into the process, that would automatically pull up and sign the user into the various programs. It shaved minutes to the whole process which meant the user was then ready to take calls/off the phone requests which in turn translated into higher productivity. That was really one of the few times the company actually took someone's suggestion seriously.

Lots of times companies say "we'd love to hear how we can improve yada yada yada" but they don't actually care to delve into it.

 

[jliehr]

It looks like the software designers and the healthcare providers need to work together to make systems that are more user friendly.

There's not anything those of us on the outside can do to help.

It has to come from those that manage and are in the work of healthcare.

We try, but you have different providers who want different things. Then you have providers who never show up to those meetings.

Case in point, report has been going to practice managers for multiple months with no responses or concerns, report goes out and is tied to a bonus, provider who has been ignoring this reports previously now if screaming at everyone because he won’t get a bonus.

Another point, a large system was transitioning from one EMR to another in a ER, doctors were invited repeatedly to design sessions and never showed. Nurses and admin types ended up making decisions. Days into go live doctors are threatening to quit because the new system doesn’t work the way they want and the whole ER flips back to the old system costing the hospital millions of dollars.

Third point, ambulatory doctors have used a system for 15 years, they have to switch to a new system because of a system consolidation. Doctors are told by default the new system only preloads active patients (seen in the past 12 months) and that modifying this would slow down everything and everyone else. One doctor decides he must have all of his patients preload, and that means 7 years worth. System becomes very slow and everyone else blames the system when it’s really just the doctor doing what he was told not to. But because he is a money maker he gets his way to the detriment of everyone else.

 

[sam_gordon]

I think more places should have R&D departments.

So it makes more sense to you to have multiple user interfaces? I think it's an easy assumption that every place with it's on R&D will come up with a different "fix" to the same problem.

 

[Mackenzie Click-Mickelson]

So it makes more sense to you to have multiple user interfaces? I think it's an easy assumption that every place with it's on R&D will come up with a different "fix" to the same problem.

Huh? You completely took my comment incorrectly .

I was actually agreeing with you especially on the "there's a supervisor/contact at their hospital that can forward on suggestions. And, IMO, the "suggestions" need to be more than "this takes too long" or "this sucks". It needs to be "It would be better if I could do 'x' because a, b, c."" aspect of your comment.

 

[Pea-n-Me]

I know you like to pick out sections of articles, so here's just a few I found interesting...

This makes it sound less like a problem with the software and more with a problem with the USERS.


Is this because of the software, or because HIPPA regulates who can see what?

Said by Gregg Meyer, Chief Clinical Officer at Partners HealthCare.


Said by a number of people in this thread.

Yes, I do like to pick out sections of articles because I feel they help the reader understand what I'm trying to say. So I appreciate you took the time to do the same. That way I can see where you're coming from.

This makes it sound less like a problem with the software and more with a problem with the USERS.

As Dr. Guwande explains, the systems have gotten too complex, and instead of helping make providers' jobs easier, they've made them more difficult. I don't know how many more doctors need to say that same thing, perhaps in different ways.

These systems have added a lot more painstaking computer time to their already hectic days of dealing with other people's lives and well-being, so their care has become less efficient. Are there user issues? Sure there are. But doctors haven't time to become experts in using complex software while they're simultaneously taking care of patients. I think those are the points. As patients, we we want them to be with us and hearing us, tending to us, figuring out what's going on, helping us. As it stands, they don't have a lot of time for that. It's rush, rush, rush.

And that was my purpose to starting this thread - not to necessarily figure out how to solve these problems, but to help make people aware that your health care providers are under tremendous pressure and burning out, with many leaving, and if you notice they're not as attentive as they previously were, this could be why. I think it's an important thing to understand. I've noticed it with my own providers. Last week I had to put in a call about something and the provider didn't let me get a word in edge-wise. It was a useless call.

Is this because of the software, or because HIPPA regulates who can see what?

No, it is not because of HIPAA. It is because each person has a role which gives them only a certain screen. "Stay in your lane" means an administrative assistant, say, can not access the same pages the physician, or the nurse can; they can only access the administrative page. This is how the systems are built and part of why it's difficult for the physicians to have help with some of their busywork. In the article he mentions that some are hiring other physicians (from India and other places) to remotely input information, and that systems are being developed for this. The reason being because they can understand the information being said to patients and can (hopefully) input it correctly on the physician section of the program. That's an interesting concept, but there are medical/legal/financial implications, all of which will have to be hashed out if something like that were to take off. I can tell you as a consumer it's important to me, obviously, that the information in my record and that of my family, is accurate and all encompassing as it should be by a health care provider. Whether something like this makes things better or worse remains to be seen, I guess. But to answer your question, office and ancillary staff need to access information so it's not a HIPAA issue.

Said by a number of people in this thread

Which is good to know and partly why I wanted to have this discussion!

 

[sam_gordon]

Huh? You completely took my comment incorrectly .

I was actually agreeing with you especially on the "there's a supervisor/contact at their hospital that can forward on suggestions. And, IMO, the "suggestions" need to be more than "this takes too long" or "this sucks". It needs to be "It would be better if I could do 'x' because a, b, c."" aspect of your comment.

My apologies. I thought you were saying more hospitals (health care facilities) should have their own R&D to develop their own software. We use a lot of 3rd party software. We don't have an R&D department, but we do have people who can make suggestions to the 3rd parties. Is every suggestion implemented? Of course not. But some are (those where the software people think can help multiple sites, not just a specific one).

 

[Mackenzie Click-Mickelson]

My apologies. I thought you were saying more hospitals (health care facilities) should have their own R&D to develop their own software. We use a lot of 3rd party software. We don't have an R&D department, but we do have people who can make suggestions to the 3rd parties. Is every suggestion implemented? Of course not. But some are (those where the software people think can help multiple sites, not just a specific one).

It's ok. I was more or less just saying companies should encourage, pay attention to and actually give some thought to suggestions that come from people that actually use them. Not that they should actually develop their own software. Whether that's an R&D department or a suggestion box at least be open to people who voice their concerns with helpful information and actually take it seriously.

So in this case if the doctors are saying "it takes too many clicks to get to the screen I need/want what if this was done instead" rather than that suggestion sit with no one hearing or no one able to see it the hospital should have some way of passing that along. An R&D department (or whatever) can act as a defacto screener since obviously not every suggestion out there is feasible or makes a lick of sense. After all the users are the ones using it day in and day out and the powers that be oftentimes aren't actually dealing with the things others are.

 

[Pea-n-Me]

I am not going to have a lot more time today to respond to posts, but I hope the conversation keeps going. I did want to add another Comment from the article, because I think it helps explain the type of pressure that your providers are under. Again, this thread is not intended as a slam to software or EMR people at all. It's just informational. (Sorry, I was unable to access the end of the comment to C&P and I have to move along.)


yogasong44
Physicians are having a normal reaction to an abnormal situation. Mental healthcare will not fix that situation. The health insurance companies are the 10,000 gorillas that need to be reined in with all their documentation requirements. Additionally, the facilities that employ MD’s need to cut down on the number of patient visits required per day. I formerly worked in an ancillary healthcare profession and will never forget one of the MD’s who came to me for treatment. She worked in one of the Boston hospital systems as a primary care. The system required her to see 6 non-annual exams/hour and to squeeze in up to 2 acute patients in each of those hours. It was a crushing schedule which gave her the impetus to work for a new hospital system after just a few years. In my own former profession of PT, in my last job, I was required to see up to 16 patients in an 8 hour day. That basically left 20 minutes per patient as I wrote the simple notes between treatments. The insurance documents needed to be done on my own time after the 8 hour day. It’s no wonder I burned out and left the field after 17 years. I had a classmate who also left the field before I did. Many also leave jobs to form their own cash-only businesses. The patient care improves due to longer

 

[sam_gordon]

These systems have added a lot more painstaking computer time to their already hectic days of dealing with other people's lives and well-being, so their care has become less efficient. Are there user issues? Sure there are. But doctors haven't time to become experts in using complex software while they're simultaneously taking care of patients. I think those are the points. As patients, we we want them to be with us and hearing us, tending to us, figuring out what's going on, helping us. As it stands, they don't have a lot of time for that. It's rush, rush, rush.

But that doesn't explain doctors putting in the same thing three different ways, or not putting enough detail to help the next physician. These are the user problems I'm referring to.

It is because each person has a role which gives them only a certain screen. "Stay in your lane" means an administrative assistant, say, can not access the same pages the physician, or the nurse can; they can only access the administrative page. This is how the systems are built and part of why it's difficult for the physicians to have help with some of their busywork.

So then I ask, WHY are the systems built that way? Can the AA be given more permissions to access other parts of the software? Software that we use also has elements to keep employees "in their lane", but we've found that doesn't work for how WE do business. Do we ask the software developer to change their software (that is used around the globe)? No. We took it upon ourselves to give certain users extra permissions so they could go "out of their lane" in order to get the job done. Maybe that's not possible with the medical software. But couldn't you tell the software that the AA is actually a doctor? Or create a separate login so they can do things on the doctor's screen when they need to?

And I wanted to mention I am VERY cynical about the "2 hours of computer time for every one hour of patient time". That sounds like "every high schooler has two hours of homework for every class every night". I remember when I went through HS, when my DD went through HS (graduated 3 years ago), and my DS is in HS right now. 2 hours/night is FAR from the average.

Last but not least, I apologize for getting HIPAA wrong.

 

[Pea-n-Me]

But that doesn't explain doctors putting in the same thing three different ways, or not putting enough detail to help the next physician. These are the user problems I'm referring to.

What Dr. Gawande was saying is that the same thing that makes these systems great, i.e the ability to have large numbers of people access them and be able to input, also makes them more complex because there is SO MUCH INFORMATION to sort through. In the past, notes "got to the points" succinctly. Now, for a typically relatively complex patient, there might be 30 pages of notes to sort through to get to the really important points because so many providers have given input. I think it might've been in the video that he said that only 40 years ago, patients might see one or two providers, whereas today they might see ten. You have the doctor, the nurse, the NP or PA, the nutritionist, the endocrinologist, the physical therapist, the infection control specialist, etc. Sure, you say, just stick to the physician notes, right? But there's a reason that the patient was seen by all these other people and now the physician has to go searching through all their input to get to the salient points. So a system meant to help streamline care actually made it more complex. As he says, people may C&P information as a way of communicating important information. That's not right, right? But there are only so many hours in a day. They can't sit at home for eight hours of each day pouring through information and writing better notes, it's just not going to happen, realistically. And it doesn't mean necessarily they're lazy or anything like that. They're just trying to do the best they can with what they've got to work with, if that helps explain. (Actually, I think he did a great job.)

So then I ask, WHY are the systems built that way? Can the AA be given more permissions to access other parts of the software? Software that we use also has elements to keep employees "in their lane", but we've found that doesn't work for how WE do business. Do we ask the software developer to change their software (that is used around the globe)? No. We took it upon ourselves to give certain users extra permissions so they could go "out of their lane" in order to get the job done. Maybe that's not possible with the medical software. But couldn't you tell the software that the AA is actually a doctor? Or create a separate login so they can do things on the doctor's screen when they need to?

And I wanted to mention I am VERY cynical about the "2 hours of computer time for every one hour of patient time". That sounds like "every high schooler has two hours of homework for every class every night". I remember when I went through HS, when my DD went through HS (graduated 3 years ago), and my DS is in HS right now. 2 hours/night is FAR from the average.

Last but not least, I apologize for getting HIPAA wrong.

More than I have time to delve into right now, but I honestly don't know the answer. I am just a working stiff who takes care of patients myself for a living. (And uses one of these systems, too.) I know my job has gotten more difficult, too, for many reasons. (Sounds like I'm in good company!) I believe health systems have their own IT depts and people from the software companies constantly working to improve things, but improvements are slow, and tedious. I read somewhere that some of these systems cost hundreds of millions - even billions of dollars - so only large healthcare systems can afford some of the better/more popular ones, what have you. (Which is crazy, but they are a necessary evil today.) I thought it was interesting that Dr. Gawande said that a large part of the expense for start up came from pulling staff away from patients for a while and having to upstaff in order to get things off the ground. If that's the case, you can see why changes don't come all too easily. Staff (who may number in the thousands) have to be trained on all new changes to the system and need time to get good at them. So this is way beyond just a software issue. It's really a systems issue. As for the "stay in the lane", there are a lot of rules and regulations in healthcare about who can do what, so changes would be incrementally small, if there are any. A lot of thought already went into systems. Someone mentioned somewhere that changes are difficult. Also, I do believe the two hours of computer time to one hour of patient care because I work beside physicians and see first hand what they have to do. As consumers we want them to get it right. We have to give them the time. Our lives and those of our loved ones depend on it.

 

[g00fy!]

The problem is that reimbursement from insurance is going down. One can't afford to take less patients or hire more staff. DH and I are both medical professionals and advised our kids not to go into health care. I was able to retire in October. (I turn 66 next month.) I couldn't take it any more. DH is trying to hold on a little longer but financially, it is tough. Health care is not what is was when we started in it.

My son had dreamed to be an Orthopedic surgeon from middle school. He tailored all his high school and college courses to achieve that goal. Upon college graduation, he decided to not pursue a medical degree but to go into research with a grad degree. More money, less tuition, and more flexibility. The costs to pursue the medical degree were unbelievable and every one of our physician friends made it their personal missions to talk him out of his goal of pursuing medicine. I know many of our friends whose children are deciding to not pursue their medical school dreams.

It is sad to see all of these talented young adults who would be great physicians to look at other areas in medicine. It is going to affect the quality of our medical care in the future if something does not change.

 

[sam_gordon]

What Dr. Gawande was saying is that the same thing that makes these systems great, i.e the ability to have large numbers of people access them and be able to input, also makes them more complex because there is SO MUCH INFORMATION to sort through. In the past, notes "got to the points" succinctly. Now, for a typically relatively complex patient, there might be 30 pages of notes to sort through to get to the really important points because so many providers have given input. I think it might've been in the video that he said that only 40 years ago, patients might see one or two providers, whereas today they might see ten. You have the doctor, the nurse, the NP or PA, the nutritionist, the endocrinologist, the physical therapist, the infection control specialist, etc. Sure, you say, just stick to the physician notes, right? But there's a reason that the patient was seen by all these other people and now the physician has to go searching through all their input to get to the salient points. So a system meant to help streamline care actually made it more complex. As he says, people may C&P information as a way of communicating important information. That's not right, right? But there are only so many hours in a day. They can't sit at home for eight hours of each day pouring through information and writing better notes, it's just not going to happen, realistically. And it doesn't mean necessarily they're lazy or anything like that. They're just trying to do the best they can with what they've got to work with, if that helps explain. (Actually, I think he did a great job.)


More than I have time to delve into right now, but I honestly don't know the answer. I am just a working stiff who takes care of patients myself for a living. (And uses one of these systems, too.) I know my job has gotten more difficult, too, for many reasons. (Sounds like I'm in good company!) I believe health systems have their own IT depts and people from the software companies constantly working to improve things, but improvements are slow, and tedious. I read somewhere that some of these systems cost hundreds of millions - even billions of dollars - so only large healthcare systems can afford some of the better/more popular ones, what have you. (Which is crazy, but they are a necessary evil today.) I thought it was interesting that Dr. Gawande said that a large part of the expense for start up came from pulling staff away from patients for a while and having to upstaff in order to get things off the ground. If that's the case, you can see why changes don't come all too easily. Staff (who may number in the thousands) have to be trained on all new changes to the system and need time to get good at them. So this is way beyond just a software issue. It's really a systems issue. As for the "stay in the lane", there are a lot of rules and regulations in healthcare about who can do what, so changes would be incrementally small, if there are any. A lot of thought already went into systems. Someone mentioned somewhere that changes are difficult. Also, I do believe the two hours of computer time to one hour of patient care because I work beside physicians and see first hand what they have to do. As consumers we want them to get it right. We have to give them the time. Our lives and those of our loved ones depend on it.

First, the bolded... that's exactly what I was referring to when I asked if HIPAA was the cause of some of those problems. You said "no". You neglected to say other rules/regulations prevent it though. If a regulation keeps an administrative assistant from helping a doctor, the problem is with the regulation, NOT with the software that prevents them from doing 'x'.

And again, it comes back to the users, whether doctors, nurses, PAs, whoever, getting back to the software developer things that they think need to be fixed. Have you (or any of your coworkers) gone to any meetings/made any suggestions about what can be done to improve things? I don't think you will ever build a piece of software that satisfies 100% of the people 100% of the time. Go back and read post 46. Sounds like @jliehr has some practical examples of what I'm talking about.

It sounds to me like the problem isn't the software OR the people using the software. It's the communication (or lack thereof) between the two to make a product that will make everyone satisfied (note I didn't say "happy").

 

[yoopermom]

My SIL is an m.d. (first in hospice, then in urgent care, now in a jail), so I have the utmost sympathy of dr burnout, I've seen her going through it the past few decades. She is an *excellent* listener, and wonderful communicator, but gets stressed/burnt out with what all has been mentioned above. When doctors like her leave, who is going to hold your dying grandma's hand and comfort you all? Who is going to be the g.p. who listens to your complex list of chronic and urgent ailments and makes you feel listened to, whether or not she can cure what ails you? Who is going to LISTEN?!?

Before any doctor appointment, I feel like I have to prioritize and outline, since I know that I will only have a brief amount of time with the doctor to explain what is wrong. Same thing with surgeries: I've had two in two years (with a third in two weeks). I saw the surgeon for maybe five minutes at the appointment before, and may or may not see him at some point at a follow up appointment after. At the hospital I will most likely only see the hospitalist, and for follow up care in office I will probably see the assistant or p.a.

I'm in my 50s, and had the same scoliosis doctor from the age of 10 until he retired when I was in my 40s. He knew my life COMPLETELY, and was one of the best doctors (and men) I've ever had the honor to know. I've had no luck finding one since that I feel the same connection with.

So, it's frustrating.... and I feel for them, and their patients.

Terri

 

[LSUmiss]

We keep hearing we need to more with less money. The answer is yes you do. Figure it out. Health care costs are killing us.

But there are still ppl getting rich. That’s where the change needs to happen. Not making nurses work longer hours with more patients per shift.

 

[Happyinwonerland]

But there are still ppl getting rich. That’s where the change needs to happen. Not making nurses work longer hours with more patients per shift.

There comes a point where it is simply not possible to provide adequate care to each patient, regardless of the charting. During a 12 hour shift with 4-5 progressive care patients, each person is allotted slightly more than 2.5 -3 hrs of my time. This has to fit in med passes, at least 3 full asessments, labs, turns, baths, ambulation, dressing changes, sometimes detailed stroke assessments, talking with patients and families, notifying doctors of heart rhythm changes or abnormal lab values, transporting ,etc. There is too much already, and then to get randomly audited and find out you have a "write up" because you missed charting a pain rating every hour for every patient or whether or not a person was wearing their "leg squeezers", its ridiculous and eventually you just can't do it anymore.

 

[RangerPooh]

I work for my states flag ship medical school and we hear about it. Burnout, like physician suicide rates is not something that we shy away from addressing students. Rather we encourage them to seek mental health treatment, to break stigmas, and in the case of burnout, to take take time for themselves. To practice wellness. Unfortunately burnout is going to happen regardless. There is high demand for physicians, and not enough availability everywhere which means they are potentially working more.

Sadly burnout is happening in many disciplines. I work in education where we are accustomed to doing more with less. It's frustrating. It's a reality that needs to addressed more.