Podcast Episode Transcript: A return to relationship-oriented health care

With L. Gordon Moore, MD

Dr. Gordon Moore: Welcome to 3M’s Inside Angle podcast. This is your host, Gordon Moore, and with me today is Dr. Christine Sinsky. She is the vice president of professional satisfaction at the American Medical Association, a trustee for the American Board of Internal Medicine Foundation, and practiced internal medicine in Iowa for 32 years. Welcome, Dr. Sinsky.

Dr. Christine Sinsky: Thank you, Gordon. It’s is my pleasure to be with you.

Gordon: The content of our conversation today I think is going to be around a number of factors, about what it means to practice medicine and what it means to practice in an environment that puts an, I think, undue work burden on clinicians to the point that clinicians and physicians feel like they’re being crushed and they burn out, and what that means. You’ve done an immense amount of research and work and talking and thinking about that, and so I’d like to get your thoughts on that. And I want to start though with the idea that medicine is about relationship, but we’ve turned it into transaction. I’d like you to expand on that.

Dr. Sinsky: Gordon, I’m happy to. And I do believe that over the course of the last several decades, we have collectively evolved in our conceptualization of health care into one of a series of transactions. So our mental model for health care is that it’s very transactional, and we have built the infrastructures that support a transactional notion. We have tick boxes and shift work and a notion that anybody can just step in and fill in. And yet I believe at its core, our work is fundamentally about relationships, that our work is relational. And I don’t mean this in a superficial, fluffy way, I mean it in a really deep, structural way.

And I recognize that I’m a better diagnostician when I have a deep understanding of the patient and it’s based on a relationship. But I’m also much more effective as a physician if I have a trusting relationship with the team that I work with, if that’s a stable team, the same people day after day. So I think reorienting our understanding of health care around relationships will help us in this goal of reducing this overwhelming burden and this disconnect that physicians and nurses and others feel between the mission that they started out in their careers with and the daily work that they’re encountering.

Gordon: Yeah. It makes me think of crew resource management, which is the work inside an airplane, which is highly complex behavior and sometimes cited as something similar to what’s happening in the operating room. And the fear and mistrust drive some people to not raise their hand and say, “Uh-oh, I see something not right, I just want to raise that.” If they’re fearful of that, they don’t raise the issue and mistakes happen in cockpits as well as operating rooms. And I can just imagine that must apply as well to a busy office practice where multiple people are working, hopefully in concert, to the betterment of the people who are coming in for care.

Dr. Sinsky: Absolutely. So Jody Hoffer Gittel has done work on relational coordination and indeed, planes land on time more often or surgeries go more safely and effectively when the people within feel comfortable talking with each other. And I believe that we can extend that throughout health care, that when we have trust and reliance as values that we build in, the results for patients are better.

Gordon: I remember reading something as well about the probability of a person, I guess in general, if you look at a group of people who are receiving a recommendation, go have colorectal cancer screening, on its face it’s not a pleasant thing to go through. And so the probability in this study was predicted by trust of the clinician and trust was predicted by continuity of care relationship overtime. And there’s a lot of subtle connection there, and is this the kind of thing you’re seeing as well?

Dr. Sinsky: Absolutely. And I think that the literature on the value of continuity has been under appreciated and under incorporated into our mental model and of health care. But continuity is really the shortcut to a lot of other goals that we strive for. In fact, I would say continuity is really a tremendous shortcut to The Quadruple Aim because costs are lower when care is being delivered by the same people, for the patient, over and over again, quality’s better, satisfaction among the patients and the providers is better. And I would posit, I don’t know that there’s been data on this, but I would posit that burnout will be less in institutions that prioritize continuity, where there’s an opportunity to develop those longstanding relationships with patients. So I think it’s really where we need to go with the next movement in health care is toward relationships.

Gordon: Yeah. It sounds challenging though, to me, because we want to measure quality, we want to get to better person and population outcomes, better experience of care, and by so doing, reduce unnecessary costs and do it while having a stable, empowered, and engaged in low burnout workforce, those are those being the elements of the quadruple aim. And I’m thinking, it’s so easy for me to think about measuring is a person with diabetes, is their blood sugar level less than X? Did this person who’s eligible for a mammogram or a flu shot get those things done for them? That seems so easy.

And it’s not unimportant. I don’t want to set those aside and say don’t bother to do that, but there’s something that’s more profound, I think, in that relationship. So I’m thinking as like a relative importance, is that something you or others have looked at?

Dr. Sinsky: Well, so I have conceptualized a continuity index and a comprehensiveness index, and I believe we’re starting to get to the point where we can extract some of that from the audit log data within an EHR. And once we can do that, then we can correlate that with other outcomes. So continuity index would indicate, for example, how often did the patient receive care in a given specialty from the same physician. And the higher that is, then the higher the continuity index. So did you get most of your primary care from your personal physician? Did you get most of your secondary care? Maybe it’s your cardiology care from the same physician.

And my belief is that when that continuity index is higher, we will probably see more cost-effective care and safer care, and probably more satisfying care to both the patient and physician. And then a comprehensiveness index, I think would get at the notion of how much fragmentation are we putting patients through. So if you as a primary care physician manage—you do the patient’s GYN care, and if they have post-menopausal bleeding, you’re skilled to do an endometrial biopsy. And if they have a polymyalgia rheumatica, you’re skilled to manage that, and you’re skilled to go in a few steps into some of the different organ system specialties.

And particularly if you’re supported in that with co-management from a colleague who is in that specialty, so that you can provide comprehensive care to the patient. I believe that that also will be shown to be cost-effective and more satisfying and result in better outcomes.

Gordon: Are those things you’re studying now?

Dr. Sinsky: The continuity index and the comprehensiveness is aspirational, but what we are doing is we have joined a movement, if you will, maybe even help to spur that movement of using the power of audit log data from the EHR to characterize the work environment. And so with others, we were able to publish a paper in JAMIA on proposing seven core metrics for extractions of data from the EHR. Looking at total time on the EHR for every eight hours of patient contact, looking at pajama time, work outside of work, and looking at how much work outside of work is there for every eight hours of patient scheduled time, and how does that vary by specialty, and how does it vary by team composition?

And a third measure that we have, and it’s our aspirational measure, is undivided attention. How much undivided attention was the physician able to provide the patient? And I think that will be just such a golden measurement, and really a proxy for many other positive outcomes. The more undivided attention that physicians can give their patients, I think the better the care will be. And if we can measure that unobtrusively and begin to manage to that, I think we will see better outcomes.

Gordon: It resonates, as I think back to my own years in practice. And when I felt a lot of time pressure, I was looking for ways to get out of the room to get to the next person who’ve been already waiting, sometimes up to an hour. And I’m feeling really guilty about that, and so I’m trying to rush through, trying to short circuit conversation and things that seem to me to be spurious.

But when I had less time pressure and I let people talk about things to the extent that they needed to describe them, often when I let go of the moment, the stuff that they brought up later into their discussion, which is not much—just minutes later, we’re not talking tens of minutes, there, you started to expose factors and issues and symptoms that were quite profound and important and help solve problems that I had short-circuited and moved around because I hadn’t given them the time to express those things.

And if I think about that in a cumulative way, I’m thinking that that little bit of relaxation around time and letting people talk would lend itself to a better information flow, and as you described, a better capacity to understand what’s happening and diagnose, and maybe make recommendations around treatment that fit that person and help them get to goals.

Dr. Sinsky: Oh, I so agree. I had an experience with a patient that I I’ve written up and titled it, “If not for the Pause.” And it was, if not for the pause in the multitasking that I had been doing, I would have missed the clue that he was giving that led to an important diagnosis. But I was initially a little too busy multitasking and looking for something in the electronic health record with my back to the patient, and he was telling me about a number of symptoms that didn’t seem to add up. And then he said something else, and I was like, okay, put the computer aside, turn to the patient, okay, start from the beginning, tell me all that again.

And it was atypical, but he had symptoms consistent with a pulmonary embolus. So I sent him for a D dimer and eventually for the CT angiogram, had the pulmonary embolus, but had it as a consequence of a previously undiagnosed malignancy that we also diagnose that day. And if not for the pause, I would have missed it. And so to me, that undivided attention is just—it’s a critical piece of delivering on our mission.

Gordon: I think about the administrative factors in the way of that as you describe, the attention, I feel like there’s this huge burden of documentation and capturing information, not necessarily for the person and their needs at the moment, but because of requirements of reporting things in a certain way. And I think that’s something that you’ve looked at a lot, and that’s part of—is that what you think is driving this transaction as opposed to relationship?

Dr. Sinsky: Well, I think there’s a lot to that. That is, I think the mandatory but less important work is crowding the important work to the margin. And so when we fill up physicians and nurses days with mandatory low value tasks, we really put them in a moral bind because they know the important work, and yet it’s been pushed off to this very small slice of time. So we know that physicians spend two hours on EHR and desk work for every one hour of direct face-to-face time with patients, and we shouldn’t expect that there’d be no EHR time, but a two to one ratio for most of us seems out of line.

Some of this could be how the EHR is designed, but there have been some intriguing studies that have come out recently looking at the same EHR vendors, clients in the US versus international settings. And U.S. physicians have notes that are four times as long as the international physicians, using the very same electronic health record, or I believe the statistics are on the line of U.S. physicians spend about 50 percent more time on EHR documentation than physicians internationally using the same record.

And in fact, you have to find a physician—the physician in the U.S. at the 50th percentile of time on EHR, that amount of time is at the 99th percentile for international physicians using the same record. So that makes you think, well, it’s not all the record, some of it might be the regulatory environment in which that record is deployed. And so then you can look at what’s different in the US versus other countries that’s leading us to spend so much time on these clerical tasks.

Gordon: Yeah. A lot of this dot the I, cross the T stuff.

Dr. Sinsky: Yeah. And some of it is the regulatory environment, but some of it is that things start at the regulatory level, they’re enabled by the electronic health record, but then out of an abundance of caution, the local over interpretation of regulations adds dramatically to the burden. So a compliance officer who’s only responsible for protecting the organization from an audit failure will more often say no, rather than yes, to whatever it is to improve workflow, improve teamwork, and will take a really tight interpretation of regulation and not really being accountable for the additional burden that that adds.

So we have a website at the AMA about debunking regulatory myths, and we have currently seven myths that are present, they’re common in the medical community, and we clarify those, and we debunk those myths and we say, no, there isn’t actually a federal prohibition against non-physicians or non-providers doing order entry, and here is the place in official language where you can find that, and here’s a link to that. And so we have seven of those kinds of myths that we’re trying to clarify so that local institutions can stop exacerbating problems that may have started with regulation.

Gordon: I can imagine that there are a bunch of people listening now who are saying, “Oh, please, give me another example.”

Dr. Sinsky: Well, there are many. We clarified one about whether ancillary staff or even patients can enter aspects of the visit note and have it count for billing. That was particularly relevant in the pre-2021 era, the evaluation management coding rules have changed. But we have one on pain assessments. Some organizations feel that every patient, every visit needs to go through a pain assessment, and that’s actually not the case. We have a myth clarifying that commercial health plans, in fact, do have to abide by CMS’s new 2021 guidelines that drive level of service determination simply by medical decision-making, or you can go by time, but it’s not driven by history and exam.

So all of that perfunctory, low-value documentation that we’ve all been doing for 20 plus years with bullet points for the history on duration, timing, context, modifying factors for a presenting complaint, that may not be a value from a clinical point of view, but we put it in for billing justification, don’t have to do that anymore. And so we have information about all of those kinds of things on that debunking regulatory myths page.

Gordon: So you were telling me about a conversation about reducing documentation burden overtime. Tell me, is this all part of that, and who’s sponsoring that, what shape does that have?

Dr. Sinsky: Sure. So there is an initiative with the goal of reducing documentation by 75 percent by the year 2025. And that’s an initiative that is sponsored by AMIA, the American Medical Informatics Association, in conjunction with Columbia University and Vanderbilt University. And there was just a six-week symposium on that and more will come from that, and it was also sponsored by the National Library of Medicine. But the goal is, what are the things we can do that could reduce documentation burden by 75 percent over that period of time? And it gives me hope because I absolutely believe that we can do that if we bring the right stakeholders together.

Gordon: Recognizing that you guys are at the planning and building phase, if you were to toss out an idea that you think might gain acceptance, give me some idea of something you think would reduce burden in that direction.

Dr. Sinsky: Absolutely. Well, first of all, I think we need to rethink documentation and get it back to its primary purpose of clinical communication. So if the documentation doesn’t help with relationship building or medical decision-making, then we need to determine, really, do we need it in the record? And my belief is, if we are asking people to document for the convenience of other stakeholders, we need to find a way to not do that any longer. But we have nurses and physicians who are spending hours every day on documentation for someone else’s convenience, whether it’s the payer or a researcher, or some other audit function, and we just can’t be doing that anymore. Let physicians and others document for clinical purpose, if you need to extract other information from the record, fine, go do it, but don’t do it on the backs of the physicians.

So that would be one. I would say, if you can document it with smart phrases and dropdown boxes and templates, you probably shouldn’t document it at all. That the gibberish that comes out of that kind of documentation gives the appearance of a note, but it is not useful. And Gordon, if you will, I’ll be happy to share an example that came from my own practice of the kind of note that appears to have some content and appears to be compliant with all the external guidelines, but just doesn’t fit the bill for clinical communication.

Gordon: Oh, please do.

Dr. Sinsky: So it begins, “The patient presents with palpitations, the onset was just prior to arrival. The course duration of symptoms is resolved. Character of symptoms, skipping beats. The degree at present is none. The exacerbating factors is none. Risk factors consistent of none. Prior episodes, none. Therapy to date, none.” It went on for six pages, and yet I’m left, as the physician caring for this patient, wondering, what was the patient’s story? What was the doctor’s thinking? What care was delivered? And the end result of documenting by dropdown box I fear is that, if we document by generic dropdown boxes, I fear that that structurally increases the likelihood that we will begin to interact with our patients in a generic way. And that I think is counter to our mission as physicians.

Gordon: Going back to that lived experience of having our backs to people and working on the chart, working on the documentation and not actually paying attention and listening to what’s going on. So as I think about that, I can imagine, let’s say we wave this wand and say, let’s just document for what’s happening to this person, with this person now. Are there fears that, well, then doctors are going to run amuck doing things that are of low quality or unnecessary, or that charges are going to go off the chart, we won’t have any insight into quality? How do we address those fears?

Dr. Sinsky: Right. And I think what you’re getting at is that a lot of what we could consider sludge within the health care system and often unrecognized sludge, comes from a place of lack of trust. And I’m not suggesting that we throw all caution to the wind and have universal trust without any kind of guardrails, but I think our well-intended attempts have, at times, actually made care more hazardous, and so we just need to be brave enough to look at that. So I’m impressed with the American Board of Family Medicine, which has proposed reducing a large number of measures to a single 11-item, person-centered primary care measure, that asks patients questions about access to care, continuity of care, comprehensiveness, my doctor seemed to know me kinds of questions. And to me, that’s moving in the right direction.

I also think we ought to have sludge audits that compliance officers and other leaders should be charged with auditing the amount of sludge and de-implementing policies that are either outdated or not evidence-based. And so, we have that the AMA created, a de-implementation checklist to guide organizations to spur their thinking. These are some of the things you could consider looking at in your organization. We ran that checklist past the Joint Commission, and so we know that it’s consistent with their standards. And so that’s one way an organization can pull out some of that waste and make more space, the breathing room that you had referred to earlier, the pause.

Gordon: Give me an example of what’s on that checklist.

Dr. Sinsky: So a few examples of things that are on the de-implementation checklist, several are under the HER, so minimize alerts. We have so many alerts going on and it’s very noisy and adds to the cognitive workload for physicians. Another is to simplify the login. We have physicians who are signing in a hundred times a day with their username and password, but if we have RFID readers or bio identification that can save all but two of those a day, if you sign in in the morning and you sign in the afternoon, in the usual fashion and every other time is through these much faster technology-enhanced approaches, that’s really great.

I think you can extend the time for auto log out. Some physicians are being logged out of their computer even when they’re in a private space, every five or 10 minutes, and that gets in the way of efficiently doing the work. And another example with respect to compliance that we’ve put on is to allow verbal orders in low-risk and also in crisis situations as are legally permitted. And that can save time and bring the physicians back to recognizing their role as healers.

Gordon: Sounds like there’s just an awful lot of accreted policy at the front lines that drives minuscule behavior with the idea of trying to get to some grand outcome, but we’re actually just bogging ourselves down. A lot of stupid stuff in other words.

Dr. Sinsky: I think so. And the amount of relief that we all feel from even being released from one or two of those pebbles in the shoe, or as someone told me, shards of glass in the shoe, is quite substantial. So getting rid of stupid stuff. You must have seen Dr. Melinda Ashton’s New England Journal of Medicine article called, “Getting Rid of Stupid Stuff.” And so we got in touch with her, I’ve interviewed her, she became an author of one of our Steps Forward toolkits. So these are online toolkits that are free, you don’t need a username, you don’t need a password. And it’s a step-by-step description and guide about how an organization can learn from what she had done in Hawaii at her institution, to get rid of stupid stuff.

And basically, they put out invitations to all of their workforce to nominate things that they might consider stupid that they were doing. Most of these were related to the electronic health record, and they were able to eliminate 10 of the top 12 alerts, for example. Yeah. And one of my favorite things that they did was, a nurse wrote in and said, “I don’t know why I am having to ask every adolescent and document for every adolescent, the condition of their umbilical cord to care.” So there was a pediatric screen that had been created years earlier, and there was a place where you had to document around the cord care, and it persisted and was applied to all pediatric patients. Well, they got rid of that one.

Gordon: That makes a lot of sense. So I think we’re heading towards the close, and I just want to float a general concept and see what you think about that, which is that we have the philosophy of looking at smaller and smaller particles of things to unmask a greater truth and understanding. And as we dive into how well do we take care of people, how well are we taking care of people with chronic conditions, how well are we doing for people with diabetes, how well are we managing blood sugar, what’s their hemoglobin A1C? As we keep driving down to that smaller particle of understanding, we have a net increase in administrative costs in pain, in expense, and in burnout. And we need to back away from the small stuff. What do you think?

Dr. Sinsky: I think you are spot on. And as we go more and more granular with the nature of the measurement, then there is a companion going more and more fragmented in the model of care. So if you measure all of those granular things, then the patient ends up going to one person for their blood pressure, another person for their diabetes, another person for this aspect of their care, another person for that. And no one is caring for the whole person and the issues that are actually more important to this individual, unique person then whether their A1C is 6.4 or 7.1. And it’s critically important that it not be 13, but we have people that are focused so much on the granular and at the level of an A1C of 6.4 versus 7.1., and I think that’s really been disruptive to care.

Gordon: Dr. Christine Sinsky, thank you so much for your time and thoughts today.

Dr. Sinsky: Dr. Gordon Moore, it is my pleasure.

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