Taking Steps to Restore the Doctor-patient Relationship

The contours of the physician-burnout crisis are becoming clearer.

In early September, Dr. Christine Sinsky and colleagues reported on the results of a time study in the Annals of Internal Medicine. Reading the study, I experienced déjà vu: I once conducted a similar study in a factory in Philadelphia the summer before I started medical school, following assembly-line workers with a stopwatch to document how they spent their time. Sinsky and her colleagues clocked the activities of 60 physicians in 16 practices during the course of 430 hours of office practice. It is telling that we are applying to the medical field research techniques practiced in the manufacturing industry.

Attention must be paid to Dr. Sinsky’s results. She and her colleagues discovered that, during office hours, doctors spent 27{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of their time with patients. Thirty-seven percent of the time was devoted to electronic health records (EHR) and desk activity, as opposed to time actively interacting with the patient. When the patient was not in the room, two-thirds of physicians’ time was spent on additional EHR activity and desk work. Outside of office hours, the doctors studied spent an additional 1.5 hours per day on EHR and related administrative tasks.

Let’s put the findings in a historical context. When most of us were in training, the doctor-patient relationship was at the heart of medical practice. Subsidiary administrative activities like record keeping were a peripheral sideshow. This ratio has since flipped: electronic record keeping and other administrative activities have crowded out time spent interacting with patients. In many practice situations, the doctor-patient encounter is now the sideshow.

Little wonder that Dr. Colin West et al., who performed a comprehensive meta-analysis of “Interventions to Prevent and Reduce Burnout” (published in the Lancet), commented that “physician burnout … has reached epidemic levels.” It seems clear that the emotional exhaustion, depersonalization, and reduction of personal accomplishment that characterize burnout thrive in the atmosphere of industrialized administrative tedium that Sinsky’s time study documented.

West and his colleagues reviewed nearly 3,000 studies on burnout and summarized what they learned from the 52 best studies. Fifteen of them were randomized trials; 37 were cohort studies. They found that interventional strategies that focused on the individual physician reduced burnout. Effective approaches included mindfulness training, stress-management training, and small-group discussions (“misery loves company”). Although the data for organizational interventions did not include randomized trials, the reviewed cohort studies suggested that duty-hour reductions and local clinical process-improvement initiatives both reduced burnout.

Overall, their review suggested that burnout countermeasures had the potential to move the 2014 overall burnout rate of 54{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} back to the 2011 rate of 44{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}. None of the reviewed studies looked at a combination of individual and organizational interventions, and there were no data on the sustainability of demonstrated improvements.

Recently, Dr. Harris Berman and I surveyed the attitudes of some 450 practicing physicians, medical leaders, and healthcare executives. We presented our findings at the International Conference on Physician Health. We asked physicians to consider a number of system-level approaches to diminish burnout and enhance joy in practice. Of the eight approaches considered, respondents selected the following as the most important and implementable: “improving and upgrading electronic health record and related technologies to enhance the care experience of patients and their clinicians.”

In order to restore satisfaction in the practice of medicine again, the various stakeholders should prioritize doing everything possible to prevent burnout, restore the doctor-patient relationship, and get the current EHR monkeys off the backs of practicing physicians. Revolutionizing electronic medical records to enhance the experience of physicians and other team members so we can put priorities back to where they belong should not be rocket science — let’s do it!

Dr. Steve Adelman is director of Physician Health Services Inc. (PHS), a program of the Mass. Medical Society. PHS is a confidential resource for physicians, residents, medical students, group practices, HMO networks, and hospitals with medical student or physician health concerns. This article first appeared in Vital Signs, a publication of the Mass. Medical Society.

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