Podcast Episode Transcript: Physician burnout: How can we improve the work of care?

With L. Gordon Moore, MD

Gordon Moore: Welcome to the Inside Angle podcast from 3M Health Information Systems. I’m your host, Gordon Moore, and today I’m going to be talking with Dr. Christine Sinsky, who is someone I’ve known from the past who has just a phenomenal book of work around what brings joy in the workforce. And we’re going to talk about why that’s important.

She is the vice president of Professional Satisfaction at the American Medical Association. She’s a board-certified internist, and she also practices at the Medical Associates Clinic and Health Plans in Dubuque, Iowa. We’re going to talk a lot about the work that she’s done in joy of work, but we’re going to reference also her bio and her work and provide links to interesting and useful resources because she’s just prodigious and has done amazing stuff. So, Dr. Sinsky, welcome.

Dr. Sinsky: Thanks so much, Gordon. It’s a pleasure to be with you.

Gordon Moore: And thanks so much for coming on. What inspired me to reach out is I think the two sides of the coin of joy in work and physician burnout and frustration and even beyond that, just clinician burnout. And what I read all the time, what I experienced in my own practice with the frustration of what it takes to get through a typical day and the kinds of effort and then thinking about technology, which should be an enable but is often not. It often seems to actually frustrate and add to the work burden. And also in that context, thinking about quality measurement and how appropriate and reasonable that is but the manifestation of that in what I have to do to satisfy that, adding to the burden in a way that seems at times to be insurmountable.

So that was the context of why I thought it would be interesting to talk with you today. And so what I’d love for folks to hear is your interest in this work. And where did it start, and how has it evolved? And where are you going with it?

Dr. Sinsky: Great. Wonderful questions. And I’m so pleased to be able to talk with you about these issues. I think if you care about patient safety, if you care about quality, if you care about cost, if you care about human beings, you care about whether physicians and other clinicians have the opportunity for joy in work. And as you mentioned, there are two sides of the coin: there’s burnout and then there’s joy in work.

And I think our goal—my goal is to help create the conditions where joy, purpose, and meaning in work are possible, that getting rid of burnout is good, but that’s just like getting to zero. I think we need to get to the point where routinely clinicians have the ability to thrive in the work that they’re doing. And I think that a number of well-intended initiatives over the last 10 to 15 years each individually make sense, but the cumulative impact has made the work of care, particularly ambulatory care, feel like it’s undoable.

Gordon Moore: Give me an example of that. Are you talking about policy—or what’s the driver, and how does that manifest, then, in the work that people are doing that adds to the frustration?

Dr. Sinsky: Right. We did this study with the RAND Corporation looking at drivers of career satisfaction, and the biggest driver was the ability to provide quality of care. That’s great news, right? That’s what our people get up to work every day to do. Biggest driver of dissatisfaction was our technology. And for people who have been in practice for as long as I have been, that’s sort of a surprise because I spent much of my career looking forward to technology to improve my ability to care for patients. And it has in many ways, but there’s been a dark side, that it has changed the nature of work for physicians and others and added a tremendous amount of clerical work.

Some very interesting studies. For example, one that showed that—one that we participated in—50 percent of the physician’s workday is spent on EHR and other desk work, so basically on clerical tasks. And we know that number shouldn’t be zero, but we can pretty much say that a two-to-one ratio, two hours of EHR and desk work for every one hour of direct face time with patients, is probably not giving society the best value from our training.

Gordon Moore: That’s interesting. When I think about electronic health records, electronic medical records and how they are going to provide terrific advantage, I also hear from people I know who are not clinicians who talk about when they go in now to a doctor’s office that the person with whom they want to connect and have a relationship and talk about deep and scary things sometimes is focusing on a computer, not looking at them, and typing away. And when they relay this story, which I’ve heard a lot, what I’m hearing is a dislocation of relationship. I’m hearing a distancing.

Dr. Sinsky: Yes. And I think that that is something that feels bad to patients, and it feels bad to those who provide their care. We are social beings, and we are built for relationship. In fact, one of the themes I’ve been really noodling on a lot lately is the fact that health care has been evolving into something that’s transactional, this transactional notion of care, that it’s all about meeting certain measures and hitting certain click boxes, and anybody will do.

And I think we need to balance that with a stronger notion that health care is at its fundamental core about relationships. And the more that our infrastructures, our policies, our staffing models, our technology supports relationships, I think the better the care will be. Relationships between physicians and patients, relationships between nurses and patients, nurses to other nurses, nurses to physicians—all of those relationships, I think, when strengthened, will result in better care. And there’s some really interesting studies that support that notion.

Gordon Moore: I remember reading Barbara Starfield’s work as a researcher at Hopkins and over decades and decades was identifying high-performing health systems, which have at their foundation high-performing primary care, which has—one of its essential pillars is a person-focused relationship over time. So it’s nice that there’s good evidence behind this notion that relationship is important because, again, I think that goes right back to why people are concerned about this focus on the computer, focus on the keyboard, focus on clicks as opposed to focus on me.

Dr. Sinsky: Yes. In fact, I just reviewed a study that was published a month or so ago, and it was a study in the VA as well as a university setting. And they found that the average visit across multiple specialties, during the visit itself, the physician did 216 clicks and 729 keystrokes, and they spent 45 percent of the visit not looking at the patient but in screen gaze time. And in addition to that, what they found was that those visits that had more screen gaze time on the part of the physician, there was less patient engagement in the interaction.

Gordon Moore: Isn’t that computer work essential to how it is we care for people now? Isn’t that essential to how it is we identify gaps in care because the human knowing of those gaps in care is just impossible at this point given all the things we have to remember for a person for preventive care, for chronic disease management, for drug interactions and things like that? How do—first, I guess what I should ask, is it essential that we use computers in our care?

Dr. Sinsky: I totally agree with you. I would never want to go back to the pre-EHR world, and I don’t think most serious thinkers on this topic would ever propose going back. We just think we need to evolve our tools and our staffing models and our expectations so that the relationship is honored and supported rather than thwarted. And I think there are lots of ways we can do that, and there are some bright spots in the country of organizations that are recognizing that some of the assumptions that we made at the beginning of the EHR era have to be modified. It can’t be just the physician in the room with a patient and the physician doing all the data entry and all the data retrieval. That’s just too much additional work that’s distracting, and we know that distraction and multitasking is unsafe.

Gordon Moore: You’ve mentioned the issue of patient safety several times in this context. Could you unpack that a little bit more for me?

Dr. Sinsky: Sure. Well, I think intuitively for me as a physician, I know that when I can give my undivided attention to the patient that I am giving them better care. I can read some of their nonverbal signals. I can observe them better. I can pull in more from the patient. I think I can help them share with me important aspects of their history that I can’t if I’m really not fully attending to them. So just in that way, I know it is safer.

There have been times when I’ve pushed the computer to the side and said to the patient, “Okay. Tell me again.” And I realized I almost missed that that patient’s nonspecific symptom turned out to be a PE, a pulmonary embolus, and I would’ve missed it if I hadn’t pushed the computer aside and said, “Okay. Start over. Tell me again.”

And then there’s some hard data around the fact that when we’re distracted, we provide less safe care. There’s an interesting study from the University of Wisconsin, for example. They looked at six primary care clinics, and they looked at how much time they were spending in either face-to-face communication or EHR communication. And it turned out that the density of EHR communication—more dense, poor outcomes. Or said the other way, more face-to-face communication, these patients had fewer hospitalizations, fewer urgent care visits, fewer ER visits, and their costs were down by about 600 per year when there was more face-to-face communication among the team rather than when there was more electronic communication. So I think we just need to be discerning about the role of technology and the role of the human beings in care.

Gordon Moore: So what are some of the solutions you’ve seen to this conundrum where it’s important to use it but it can get in the way?

Dr. Sinsky: Right. I think one of the first and most important ways to address these issues is to adopt a more advanced team-based model of care. We’ve been doing this in my own practice for about eight years. What we have are we have co-visits where the nurse and I are providing care to the patient simultaneously. In our practice, a nurse stays with a patient from the beginning to the end of the appointment. In the first component, the nurse does the chief complaint, begins to explore the HPI. She closes any remaining care gaps. She does the vitals. She does medication reconciliation. All of those tasks are completely within our nurses’ skillset and don’t require a physician to be doing those tasks.

And then I join, they give me a warm handoff, and then they help with data entry and data retrieval while I’m interacting with the patient. And they too are invited to interact with the patient during that part of the visit. And then when I leave, they make sure that all the orders are in, that the charges are done, that the patient has all the information that they need to adhere to the next steps of care. And in that model, I’m able to give the majority of my time in the room to that patient as undivided attention, and yet we’ve got the power of the electronic health record influencing and impacting that care.

Gordon Moore: Well, that’s interesting. That means, though, that you have to increase staffing. Does that create financial constraints on the practice?

Dr. Sinsky: What we found in our own practice and what multiple practices using different variations on this have found was that typically it takes seeing two more patients a day to cover the cost of that additional medical assistant and nurse. And yet with that kind of in-room support, your capacity is much, much greater than two more patients a day. It’s typically on the four to six more patients a day that you can comfortably see, feel like you’ve given better care, feel less stressed, and actually go home without that two hours of pajama time of work after work that many physicians and many specialties are doing. That is, doing their inbox, doing their documentation at home.

Gordon Moore: Right. And I’ve heard that that’s one of the drivers of professional dissatisfaction and lots of clinicians thinking, “Boy, it would be nice to have some kind of exit strategy just to get out of this because it’s become untenable.” Beyond your practice, have you seen this sort of teaming work effectively?

Dr. Sinsky: Absolutely. That’s what gives me optimism. In fact, Mark Linzer’s work from Hennepin County has demonstrated that improvements in workflow—which I would consider this kind of team-based care to be a massive improvement in workflow—have an odds ratio of six of reducing burnout. And of the improvements in workflow that I’ve seen, this is the most powerful improvement. There are other things practices can do as well, but I think there’s just too much important work to be done. It’s too important to leave to chance, but it’s too much for one person to do on their own, and that’s why having additional team members makes a big difference.

Gordon Moore: I wonder about electronic medical records, if they are per se dysfunctional and, therefore, we have to have other humans providing the interface because of their poorly designed workflows and things like that. I believe you’ve been able to look not just at the US but models in other countries as well. Is it true in other countries?

Dr. Sinsky: I had this wonderful opportunity to go to the UK and shadow four different GPs as they did their work and look over their shoulders at their electronic health record with them. And I think the electronic health records are different both in design but I think more importantly in terms of implementation and regulation and what they’re used for. The EHRs that I saw in the UK were designed by other family physicians or other GPs and seemed very fit for purpose.

In addition, it wasn’t used as a billing documentation and justification tool, so that made a big difference in terms of how much was documented. The notes in the UK were really brief. In fact, you could get multiple notes on one page. Can you imagine that in the US, where our notes for an upper respiratory infection can go on for three or four pages? To have multiple visits on a single page is interesting. Actually, Epic has some data that notes in the US have doubled in length from 2009 to 2016. And I think as interestingly, notes in the US are four times as long as notes in international countries using the same vendor’s product.

Gordon Moore: That’s an interesting statistic. I’ve certainly heard from many that the electronic note building has created so much verbiage that it’s difficult sometimes to weed through that to find out what’s actually really happening for a person, as well as the issues around copy and paste where past medical history may be completely appropriate to copy and paste, but sometimes we’re finding things like history of present illness or vital signs copy and pasted. And that’s just kind of scary as we’ve gone too far with enabling technology and turned it into something not useful.

Dr. Sinsky: Yes. And I think copy and paste is a coping strategy that many, maybe most of us, have adopted as a way of handling the volume of data, but it’s fraught with opportunities for error. But I don’t see the EHR and specifically not the EHR vendors as the villains here. In fact, I don’t think there are any villains or victims. I think that we are in this conundrum because of many well-intended efforts, again, that cumulatively have created a work environment that just isn’t sustainable any longer.

Gordon Moore: When you think about technology being enabling, you mentioned the work of Mark Linzer. And you’ve participated in work looking at how you distribute work across a team and how you bring others to bear. Have you done any work on the technology side and thought about how that could be modified to fit better?

Dr. Sinsky: I’ve had this experience personally where we used one electronic health record for 12 years, and now in the last four years we’ve used another. And so it’s really interesting to see how your interaction with patients and how your cognitive processing of medical information is so driven by the particular tool that you use. And so I think there are things that have been done and can be done. I don’t have this in my own record, but one of the records that I’m familiar with has an option for a multi-contributor note so that multiple members of the team can enter elements into the note simultaneously somewhat like a Google doc. And that by itself facilitates team-based care.

Gordon Moore: I want to pivot back to this policy issue and how it may be driving work, and I think a lot about the external judgment of clinician quality. And so that tends to be driven on sort of a disease-based model where we’re looking at disease outcomes and processes. And so to get sufficient denominators for a clinician, we need lots and lots of data about did you order this test, what meds are they on, things like that. And I find it a little bit alarming because I believe that it’s accelerated the work burden of having to click a lot of things so that we can have structured data. Is that your experience?

Dr. Sinsky: I absolutely agree with that. First of all, it’s created this expectation that the people doing the three-dimensional work will convert, say, that patient encounter into digital data for the convenience of those who will subsequently audit that information. And I think that’s a burden that’s really difficult for clinicians to bear. But I think more than that, it’s sort of putting the individual responsible for what’s really a system’s factor, right?

I think To Err is Human showed us that the majority of errors in health care are the result of systems factors rather than substandard performance by an individual. And yet in many ways, I think our performance measurement is directed at the individual clinician and, as you said, at the individual disease state and maybe not at the things that are more meaningful to patients, like their functional status and those uber metrics of how much time were they spending at home in the last year of their life or after a surgical procedure.

Gordon Moore: That’s interesting. And just for those listening, To Err is Human is the Institute of Medicine report that came out in early 2000s, identifying pretty significant opportunities in the US health care delivery system to reduce errors with some hundreds of thousands of people dying each year because of potentially preventable things.

Now, I feel a tension, though, when you describe building a record system that can capture information in a way that’s very short and pointed to the note and engines that are not driven towards the billing enterprise, which adds a huge burden to the work that we do. And the other side of that tension is knowing when there are gaps in quality and where there are opportunities. And so I think about sort of an ideal just document for the patient’s care delivery and outcomes. Are we going to miss those opportunities to understand when there are clinicians who could be supported in better teamwork and to get better outcomes?

Dr. Sinsky: I totally agree with you there too. I think there are some things that we really need to have as structured data elements—immunizations, lab values, that sort of thing—so that we can do screens of the population and find out who’s missing having received some sort of prevention work, for example. And this is particularly useful when it’s presented in a user-friendly fashion at the point of care, right?

I don’t have this in my own record, but I’ve observed it in other records. When the patient’s being checked in, the health maintenance care gaps pop up in the corner of the screen, and they’re very easy to close those gaps. You’re due for a colonoscopy. May I schedule that for you? Or you’re due for your diabetic eye exam. Can we take care of that today? That’s really using technology in a great way, and we need to have those care elements as discrete elements if we’re going to be able to deliver that kind of care to patients.

Gordon Moore: When you think about as a clinician understanding how you’re performing, how do you do that? How do you set up indicators, and what sort of things would you want to track? And how would you build all of that?

Dr. Sinsky: Sure. Now you’re getting into an area that I think a lot of other people have more expertise than I, so I’ll be answering it really just as a practicing physician. And I will want to know issues around quality. Like, when I’m seeing the patient, I want to know what their care gaps are, and I think that’s the best time to close those care gaps. And then I would use the registry as the way to capture those people who fell through the cracks on closing those care gaps at the personal visit. Registry being a population database that would say, for example, all of Dr. Sinsky’s patients who are over 65 who have not had these immunizations, and they’re due for them.

Gordon Moore: Dr. Sinsky, where are you going next with this?

Dr. Sinsky: I think we have this wonderful opportunity to continue to enable conditions where patients can get care from people who are thrilled with their work, right, because that’s what I want as a patient. I want my physician to be excited about coming to work. I want the staff that works with that physician to be excited about it.

And I think if we start to collect data not only about one’s joy in work, their satisfaction, their wellbeing—the flip side being their burnout scores—collect that data, collect some interesting EHR use metrics. How much time are you spending after work or on vacation doing EHR? And then we look at some other practice variables—staffing ratios, compliance environment, strict or more balanced—and look to see what are those associations, I think we will start to recognize what the variables are that lead to conditions where patients can get care from people who really love the work that they do.

Gordon Moore: As I think about all the work that you’re doing, you are interacting with entities across the country. The AMA is, obviously, doing significant work in this, as well as the Institute for Health care Improvement. Tell me something about what the AMA is doing to help further this joy in the workforce.

Dr. Sinsky: Sure. Happy to. Well, about five years ago, the AMA actually reorganized all the work they were doing and got rid of about 140 initiatives and boiled it down to just three. One of those three initiatives is improving the practice environment, reducing burnout, improving professional satisfaction. All of the work at the AMA supports three initiatives, one of which is thriving practices.

And so one of the things we’ve done is we’ve created now 50 different toolkits that are free and available online for physicians, for practice managers, for anyone. You don’t need a username or password. And all of those toolkits are at stepsforward.org. And some will teach how to have a team meeting, how to do a daily huddle, how to implement team documentation and advance team-based care in your practice. And we have sample policies. We have sample checklists. For many of the toolkits, we have brief video clips showing how organizations across the country have implemented particular innovation that the toolkit is about. So that’s one of the things that we have done to help encourage practices to adopt efficient and satisfying workflows that improve care.

Gordon Moore: If I’m a hospital CEO, would I care about this aside from I just want to be a nice person and have a happy workforce?

Dr. Sinsky: You know what? You definitely should care about it, and the reason you should care about it is because a happy, healthy workforce helps you achieve all the other outcomes that you’re responsible for. And just to address one aspect of that, if you’re a group of 500 physicians and you have average rates of physician burnout, you will lose 13 physicians every year who leave your organization because of burnout, not because they’ve got another job someplace else or they’re moving for their spouse. They’re leaving because they’re burned out in your organization, and it costs between $500,000 and $1.3 million to replace each physician.

So if we use the conservative 500,000, that organization of only 500 physicians every year invests $6 million just to replace the docs who leave because of burnout. So if I’m a CEO and I’ve got 500 or 1,000 or 3,000 doctors, I can very easily calculate what that’s costing me and decide whether that’s how I want to invest our money. And, of course, that’s only part of the cost because there are additional costs when physicians are burned out: cost in terms of patient satisfaction and loyalty, cost in terms of errors and quality gaps. So yes, I think CEOs should be interested.

Gordon, you might be interested to know that last year we brought together 11 CEOs from some of the largest health systems in the country, from Mayo and Cleveland Clinic and Kaiser and others, to address joy in medicine through the CEO consortium. And they published a Health Affairs blog where they publicly committed to a number of actions, and it’s a call to action to their fellow CEOs to also commit to these actions.

Gordon Moore: That’s terrific. And we’re going to make sure we can link to that Health Affairs blog. I also would like to link to the AMA resources that you talked about as well because, again, just right back to the beginning, this is an area which is very interesting to me because I believe and see the literature that a satisfied workforce is less likely to create mistakes and errors and improve patient safety. To say nothing of the huge cost of turnover, not just in physicians but across the workforce as people come and ago.

So, Dr. Christine Sinsky, thank you so much for spending time today. This has been a terrific discussion.

Dr. Sinsky: Thanks to you, Gordon.

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