A different kind of health care crisis - physician burnout

[Southernmiss]

Many jobs are evolving with technology, regulations and a multitude of other new additions to the jobs.

I am hearing the same for pharmacists--I have 2 studying to become pharmacists. Word on blogs, etc. is that that field has changed since those writing the blogs were trained.

I am a church office manager-handling bookkeeping, payroll, secretarial and all other front office work needed at the church. I am the one employee of the church doing all of these things.

I took the job over 4 years ago. I had worked in the church in another capacity for 15 years, so I understood the inner workings of church and could come in and adapt to new technologies. The lady who had it before me had been there 30 years. I immediately knew of things that would modernize the job and implemented them. Quickbooks for payroll, a text messaging/email system to reach parishioners, changing the management of the church website, doing more with electronic and on line tithing, and social media. She knew what she was doing and was good at it. But I implemented newer ways of doing things that were becoming expected and necessary as the younger generations are now digital natives and are not digital immigrants. She was aware of these things, but it her way wasn't (yet) broken so she did not need to fix it.

She often took work home to keep up. After some hiccups and learning curves and long hours implementing the new technology, I have not needed to take work home and can get my work done more efficiently than it was done before.

A lot of jobs have quickly changed due to the internet and computer age. Unfortunately, those who know all the old ways are having to learn new and it's not easy. I get it. My kids switch social media so fast that I find it hard to keep up. But I do it so that I can communicate with them and with younger parishioners in our church.

 

[sam_gordon]

Perhaps younger generations of providers will find it easier to meld patient care with EMR documentation as they've likely grown up in the electronic age and will know going into it that this is how it is. But for many others, it can be a source of great stress on the job. That is all they're saying. I don't have answers other than what they've suggested in the article with having people around to help, indeed, concentrate, on employee wellness, and perhaps better technology support. I don't feel that hiring more help will always be an option, nor will taking less patients on, as the name of the game seems to be not turning anyone away that needs care.

But none of this is new and limited to the medical field. I used to work in television news. When I started, scripts were typed on typewriters on 6ply paper. Rundowns were done by hand. We were at least working on videotape, not film. 30 years later, server based software is used for writing and computers take care of all the math. We went over to PCs almost 20 years ago. There are still people who need almost constant hand holding.

I'm guessing the medical field is still only about 10 years into the "computer age". It will take time to adjust, and those who are used to doing things "the old way" will figure it out.

ETA: I'm not saying "burn out" in the medical profession isn't a thing, but simply that other fields have gone through a similar change in technology and survived.

 

[Sabeking]

This past semester my daughter took a class at college, I think it was called Narrative medicine. The students read many books written by doctors, their experiences,thoughts, etc... She said it was fascinating and learned a lot. She read one story about a doctor that committed suicide partly because of the semantics of the hospital he worked for and how they encouraged him not to do an operation because they were worried about getting sued if the patient endured more harm than good. The surgery was not done, the patient passed and the doctor felt over whelming guilt. She also told me that during an appointment on average the doctor will interrupt you between the first 17-20 seconds. As a result, the patients don’t feel listened to and have a tendency to not relay all their symptoms. The doctors feel pressure to get through the appointment quickly based on their overload. She told me this while we were at the doctors office together recently and the doctor interrupted after the first 7 seconds!

 

[jliehr]

But none of this is new and limited to the medical field. I used to work in television news. When I started, scripts were typed on typewriters on 6ply paper. Rundowns were done by hand. We were at least working on videotape, not film. 30 years later, server based software is used for writing and computers take care of all the math. We went over to PCs almost 20 years ago. There are still people who need almost constant hand holding.

I'm guessing the medical field is still only about 10 years into the "computer age". It will take time to adjust, and those who are used to doing things "the old way" will figure it out.

ETA: I'm not saying "burn out" in the medical profession isn't a thing, but simply that other fields have gone through a similar change in technology and survived.

EMR systems have been in use since the late 70’s, the changes are emphasis on using technology more efficiently and with tighter integration. 10-15 years ago hospitals had teams that scanned all the paper charts and records and that is how those got into the EMR, additionally there were teams of transcriptionists who typed up the doctors dictation. Now the doctors can transcribe directly into the EMR and correct issues on the fly. It takes more time from the physician, but allows hospitals to cut large teams. Also how had large teams of coders who took paper records and entered them into the system, now those are entered electronically. There were teams dedicated to pulling charts and records for patients and other institutions; now those can be accessed online in many cases.

There are people trying to fix the issues, many systems are adding shadows to physicians who do the documentation in room to allow the providers to focus on the patient. Others are using the same concept with doctors in foreign countries (cheaper labor) over telepresence.

Hospitals used to allow departments to select best of breed systems to fit each department, the hospital had their EMR, ambulatory clinics had another, lab another, radiology another and then a different admissions/billing system. This may be great for each department, but made the overall system inefficient and slow. Now we get larger, integrated systems that make things better as a whole, but also can slow down the specialized departments who have to get used to change and a system that isn’t as customized for them.

 

[LSUmiss]

I was going to say the same thing! In both health care and education, the data is taking over. Sometimes I think more time is spent tracking what we do than doing it.

That’s 100% the case. Add mental health to that list too.

 

[LSUmiss]

I'd say it's not just healthcare, education, retail, & food, it's EVERYTHING. "Do more with less" means more profit. How do you change that though? Personally, I like the idea of the EMR some seem to be lamenting here. As a patient, I like being able to login to my provider's site and see my test results. As a patient, I like doctors/offices are able to send charts electronically.

So, for those that are lamenting the "paperwork", I wonder what your suggestions are to fix the problem (as you see it).

And those complaining about their doctors on their computers during the visit, that makes sense to me also. If they write on forms, then someone needs to later enter that into the EMR. Why not put the information straight into the EMR at the time?

More profit & hence why the gap between the very rich & everyone else keeps getting wider. That extra profit is rarely spent on improving the product or service or passed down to the employee.

 

[Boardwalk Jedi]

I'd say it's not just healthcare, education, retail, & food, it's EVERYTHING. "Do more with less" means more profit. How do you change that though? Personally, I like the idea of the EMR some seem to be lamenting here. As a patient, I like being able to login to my provider's site and see my test results. As a patient, I like doctors/offices are able to send charts electronically.

So, for those that are lamenting the "paperwork", I wonder what your suggestions are to fix the problem (as you see it).

And those complaining about their doctors on their computers during the visit, that makes sense to me also. If they write on forms, then someone needs to later enter that into the EMR. Why not put the information straight into the EMR at the time?

Seeing your test results is cut and dried numbers or X-ray results. When a doctor or RN is trying to write/type a note on an event or incident, describe an ailment or physical issue it is much easier to describe it orally or written, rather than point and click selected options. To me, that doesn't show detailed thought and analysis. I went from having a huge comment section to detail patient problems and now I feel like I'm "writing" the same thing on every patient.

 

[LSUmiss]

But none of this is new and limited to the medical field. I used to work in television news. When I started, scripts were typed on typewriters on 6ply paper. Rundowns were done by hand. We were at least working on videotape, not film. 30 years later, server based software is used for writing and computers take care of all the math. We went over to PCs almost 20 years ago. There are still people who need almost constant hand holding.

I'm guessing the medical field is still only about 10 years into the "computer age". It will take time to adjust, and those who are used to doing things "the old way" will figure it out.

ETA: I'm not saying "burn out" in the medical profession isn't a thing, but simply that other fields have gone through a similar change in technology and survived.

I would argue, however, there was not as much at stake during the transition for other fields.

 

[Boardwalk Jedi]

But none of this is new and limited to the medical field. I used to work in television news. When I started, scripts were typed on typewriters on 6ply paper. Rundowns were done by hand. We were at least working on videotape, not film. 30 years later, server based software is used for writing and computers take care of all the math. We went over to PCs almost 20 years ago. There are still people who need almost constant hand holding.

I'm guessing the medical field is still only about 10 years into the "computer age". It will take time to adjust, and those who are used to doing things "the old way" will figure it out.

ETA: I'm not saying "burn out" in the medical profession isn't a thing, but simply that other fields have gone through a similar change in technology and survived.

I think you don't see that technology has helped your job, not hindered it. I was excited when we were updating our last system. But this new one is actually MORE work and less effective IMHO.

 

[Toolulu22]

I can relate to this thread first hand. I have some medical issues and see my primary care physician 3 times per year, and some specialists 2 to 3 times a year each. My primary switched from private practice to a group medical company a few years ago. Since then, there have been changes- less time with the doctor/more nurse practitioner visits, staffing changes, and yes, much more paperwork. It definitely irks me to have to fill out paperwork each year when nothing has changed and I’ve been a patient for over 10 years.

The other thing is that I’ve had to see a cardiologist to monitor my heart since about 2009. He is in his early 50’s now and has always been trustworthy, down to earth, and the best doctor you can ask for. During my last appointment in October, he acted uncharicteristically light-hearted. He told me not to worry so much about xyz, that he had faced some of the same issues in his life. I was a little surprised because while we had talked casually in the past, he was always pretty hard on me about my health. Well, I recently got a phone call from his practice saying that he left. I wanted to see if I could move to his new practice and did some digging and found out he is not practicing anymore- he is packing up and moving out of state. Sinanara. His patients, including me, left testimony of how beloved he is on his webpage. What would drive a young, well-liked doctor out of practice? I can’t imagine.

 

[sam_gordon]

Seeing your test results is cut and dried numbers or X-ray results. When a doctor or RN is trying to write/type a note on an event or incident, describe an ailment or physical issue it is much easier to describe it orally or written, rather than point and click selected options. To me, that doesn't show detailed thought and analysis. I went from having a huge comment section to detail patient problems and now I feel like I'm "writing" the same thing on every patient.

I would hope any system allows room for "custom" notes that don't fit into any pull down/select & click preset.

"Back in the day", how did it work? Patient X goes in to see the doctor. Doctor takes notes during the visit? Afterwards, who typed up the notes? Were they legible? Were they dictated back by the doctor (who can presumably read their own handwriting/knew what they meant) into a machine?

The impression I'm getting from this thread (whether intentional or not) is those in the medical profession are complaining because they have to do more with less. They're forced into this electronic system which is terrible when compared to the old physical notes/dictation way. Maybe I'm reading it totally wrong.

 

[longboard55]

When I started as an engineer 40 years ago everything was done with pencils and paper. I can not even imagine going back to that.

The local hospital hired scribers who follow the doctor to type up his orders. There are so many ways to do things better. We just can not afford old school medicine

 

[Pea-n-Me]

I don't think anyone wants to go back to the "old ways". That is not what this is about.

It's just that there have been a LOT of changes over the past decade or so that have made it hard for practitioners to keep up. More stringent insurance and government regulations. ACA changes. Exorbitant Medicare fines. Relentless EMR documentation. Increased acuity and comorbitidies of patients. Shorter stays. Less time to spend with patients. Less time to document. Etc.

EMR may have simply been the thing that broke the proverbial camel's back.

What they are saying is that it is very difficult for physicians to keep up with everything that's required of them today. (And other health professions are feeling it, too.)

I always find the Comments almost as interesting as an article. These were from the Globe article:



Croesor

01/17/19 06:18 AM

I really resent that this article states that healthcare professionals should seek help to cope with symptoms of burnout-- it's a little like blaming the victim of domestic violence for provoking an attack.

The real culprit in the this mess is CMS (medicare) and organizations that accredit hospitals like the Joint Commission-- those systems in addition the nightmare the creation of electronic medical records have created. Those are the entities that need to change!

Don't get me wrong, I am in full support of doctors and other healthcare folks getting all the support services and self care stuff they need for their demanding jobs-- but don't put the onus of the problem on them. Burnout is not the disease, but a symptom of the disease that is really over zealous accrediting agencies and our mindlessly ushering computers into the medical world...not to mention hospital CEOs and insurance companies being overly in love with gathering data and making endless policies that doctors have to follow if they want to be doctors.


LCLCLC

Exactly to everything Croeser has said. I am a physician and I couldn't agree more.

Burnout is a symptom, doctors are the canaries in the coalmine, and their struggle indicates that the system is broken. We need to be looking at and rectifying the systemic causes of burnout, one of which is the electronic medical record, but there are others as people have noted above. Let's hope that practices and hospital systems begin to look upstream at the root causes, and that this latest study by the MMS will motivate change.

 

[Boardwalk Jedi]

I would hope any system allows room for "custom" notes that don't fit into any pull down/select & click preset.

"Back in the day", how did it work? Patient X goes in to see the doctor. Doctor takes notes during the visit? Afterwards, who typed up the notes? Were they legible? Were they dictated back by the doctor (who can presumably read their own handwriting/knew what they meant) into a machine?

The impression I'm getting from this thread (whether intentional or not) is those in the medical profession are complaining because they have to do more with less. They're forced into this electronic system which is terrible when compared to the old physical notes/dictation way. Maybe I'm reading it totally wrong.

Yes you are reading it wrong. I don't want to go back to written doctor's notes at all. I prefer the computer. But from this nurse's point of view, the new EMR simply does not cut to the chase. Yes, there are custom notes sections available, but by the time I get down to that area, I have to fill in way too many bubbles to insert interventions and describe the situation. It's a lot of wasted time. And it's so monotonous, that I can fall asleep doing that chart rather than stay in the moment and document what I know is important.

 

[Pea-n-Me]

Seeing your test results is cut and dried numbers or X-ray results. When a doctor or RN is trying to write/type a note on an event or incident, describe an ailment or physical issue it is much easier to describe it orally or written, rather than point and click selected options. To me, that doesn't show detailed thought and analysis. I went from having a huge comment section to detail patient problems and now I feel like I'm "writing" the same thing on every patient.

Right. The section for comments can be rather small, and not all of the pull down menus have exactly what you might want to say on them.

And documentation is not really something that practitioners want to leave to someone else, as they are individually accountable for everything they do, or don't do. If they have to prove they did, or didn't do something, it better be retrievable and accurate.

 

[sam_gordon]

the new EMR simply does not cut to the chase.

OK, I'm confused. Is there a single EMR system that everyone uses for reporting? I'm not talking about the server repository (that doctors can read from), but the user interface doctors use to record.

 

[bigeyedfish]

OK, I'm confused. Is there a single EMR system that everyone uses for reporting? I'm not talking about the server repository (that doctors can read from), but the user interface doctors use to record.

No. There is Centriq, AllScripts, Epic, and lots more. Those are just the three I have used or are familiar with.

 

[Pea-n-Me]

This is a lengthy, but very good and interesting article, by the same author in the video a few posts above this.

He talks about scribes in it, among lots of other things.

https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers

 

[scoutie]

It sounds like every American job. More hours, more duties, more expectations, less down time. A 32 hour four day work week would do a lot to alleviate these issues imo.

 

[sam_gordon]

This is a lengthy, but very good and interesting article, by the same author in the video a few posts above this.

He talks about scribes in it, among lots of other things.

https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers

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

Each patient has a “problem list” with his or her active medical issues, such as difficult-to-control diabetes, early signs of dementia, a chronic heart-valve problem. The list is intended to tell clinicians at a glance what they have to consider when seeing a patient. Sadoughi used to keep the list carefully updated—deleting problems that were no longer relevant, adding details about ones that were. But now everyone across the organization can modify the list, and, she said, “it has become utterly useless.” Three people will list the same diagnosis three different ways. Or an orthopedist will list the same generic symptom for every patient (“pain in leg”), which is sufficient for billing purposes but not useful to colleagues who need to know the specific diagnosis (e.g., “osteoarthritis in the right knee”). Or someone will add “anemia” to the problem list but not have the expertise to record the relevant details; Sadoughi needs to know that it’s “anemia due to iron deficiency, last colonoscopy 2017.” The problem lists have become a hoarder’s stash.

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

Jessica Jacobs, a longtime office assistant in my practice—mid-forties, dedicated, with a smoker’s raspy voice—said that each new software system reduced her role and shifted more of her responsibilities onto the doctors. Previously, she sorted the patient records before clinic, drafted letters to patients, prepped routine prescriptions—all tasks that lightened the doctors’ load. None of this was possible anymore. The doctors had to do it all themselves. She called it “a ‘stay in your lane’ thing.” She couldn’t even help the doctors navigate and streamline their computer systems: office assistants have different screens and are not trained or authorized to use the ones doctors have.

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

“But we think of this as a system for us and it’s not,” he said. “It is for the patients.” While some sixty thousand staff members use the system, almost ten times as many patients log into it to look up their lab results, remind themselves of the medications they are supposed to take, read the office notes that their doctor wrote in order to better understand what they’ve been told. Today, patients are the fastest-growing user group for electronic medical records.

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

And yet it’s perfectly possible to envisage a system that makes care ever better for those who receive it and ever more miserable for those who provide it. Hasn’t this been the story in many fields? The complaints of today’s health-care professionals may just be a white-collar, high-tech equivalent of the century-old blue-collar discontent with “Taylorization”—the industrial philosophy of fragmenting work into components, standardizing operations, and strictly separating those who design the workflow from those who do the work.

Said by a number of people in this thread.