John P Erwin III MD FACC FAHA FACP
“In the event that we lose cabin pressure, the captain will release these oxygen masks. Please be sure to secure your own mask before trying to assist others.”
I have been thinking about this in context of the epidemic of physician burnout of late. There has been a great deal written on the subject, but very little actually done to address the underlying issues. Given the estimated 40-50% prevalence of burnout amongst physicians, one cannot walk into any clinic or hospital in the US without encountering someone affected by this problem. The really bad news as it pertains to burnout is the alarming rate of physician suicides (which are the highest of any profession) and the data which shows us the untoward effects on patient care.
The factors most associated with burnout have been discussed at length by
individual physicians,physician groups, and by healthcare administrators. There are many complex discussions that have ensued from the understanding of these factors, but I’m going to sum it up with this simple phrase: Burnout is caused by the “just one more thing” effect. What does that mean? If you are not in healthcare, you may not know that the daily increase in numbers of documentation demands, quality metrics, and regulatory tasks that doctors, nurses, and others on the healthcare team must do regularly has increased exponentially over the past two decades. At the same time, there has been a very needed and concerted effort to reduce errors that may result in patient harm. Despite what I truly believe was done with the best of intentions, this has led to significant unintended consequences and the “balance measure” of physician burnout. Seemingly weekly these days, physicians are asked to do “just one more thing” or a few more clicks/keystrokes to the already mountainous numbers that it takes to document a patient encounter and order necessary tests, prescriptions, etc.
The end result of the “ just one more thing” is that it has now been estimated that physicians spend two hours of computer work for every one hour that we spend in seeing patients. This is obviously a recipe for disaster as this pulls doctors away from the real patient care that drew us into medicine as well as pulling us away from our families who are a source for “healing the healer”. Doctors are increasingly spending “pajama time” still wrangling with computer duties even when home. This compounds the likelihood for burnout as family relationships suffer. Beyond the simple documentation needs, patients rightly want more expanded and timely communication with their doctors. These electronic health record (EHR) portals, while extremely convenient, have also led to an increasing number of communications for which doctors feel compelled to respond in a timely fashion. Most of us in medicine spend at least 1-2 hours a day, even on days off and vacation attending to these EHR inboxes.
If you ask any physician about their largest source of frustration, it is highly likely that one of their top two answers will be EHR related.
There is even a new EHR parody account that addresses this which has become immensely popular amongst those who engage in #MedicalTwitter. It is well past time that all people should take interest in this burnout epidemic. It is a simple fact of life that those who suffer from it are not going to be able to sustain the level of clinical care to patients that either doctors want to provide or that patients want to receive. We need EHR’s that are designed by and for the front-end user and we need technology to perform the data entry tasks that physicians have neither the time nor natural inclination to perform. We also need hospital and clinic administrators to realize that the continual “just one more thing” has already gone well past the boundaries of a healthy limit. “Dropping out” of healthcare administrated by government payers has been a solution for many Direct Primary Care practices; however, for those of us left dedicated to the patients who need us who are on government insured plans or commercial insurance plans, it is not a solution for the majority…no matter the joy it brings those few privileged to practice in that very autonomous format. We also know that coordinated care of the complex patient occurs best in an integrated care system, so for the rest of us, it is going to take all working within the system to make sure that we make repairs that will allow us to heed the advice of the sage flight attendant: “Please be sure to secure your own mask before trying to assist others”.
Medice, cura te ipsum
“Physician, heal thyself” – Luke 4:23