Physician burnout

[q-school]

MPMD wrote:

The article posted about the dark side of medicine was certainly sad. That said he seemed to be in a terrible practice environment which was the main issue for him. Not sure if it’s just the way it is where he lives the language sounded like the UK? I mean not being able to book your own cases, having an OR control that doesn’t account for time to flip the room, and basically on call 24/7 for ER cases even on a day with OR and clinic? That just sounds like a terrible job. I know lots of sub specialty surgeons who don’t live like that.

Shifting gears: Potentially unpopular opinions about burnout ahead.

1. EMR: It’s really bizarre to me that the EMR is so frequently blamed as a cause of burnout. Do people think that we should still be on paper charts in 2017 when we do basically nothing else on paper? EMR has revolutionized the legibility and portability of patient information. How many older docs out there say the EMR is a big cause of their workplace stress and then go spend the rest of the day on their iPad? There are some good and bad products out there but both Cerner and Epic are actually very decent systems. They both have their own issues but overall they are fine.

2. Loss of autonomy: I’ve never been quite sure what this means. Medicine is a science and things like guidelines exist for a reason — they usually represent the best available evidence. Increasingly we know a pretty reasonable scientifically based treatment option for people and yes, I guess that decreases our ability to make up our own.

3. Administrators in suits ruining everything: I’ve been on staff at 5 different hospitals in my career thus far and this statement has never been accurate. The vast majority of people in hospital admin are a) responding to forces outside their own control and b) nice people who genuinely desire physician input. If you buttonhole one in the hallway to say that things like LWBS from the ED doesn’t matter you’re not going to get a good result. If you spend a few hours learning about the actual things affecting your healthcare system you can understand where they are coming from.

4. New forms, boxes to check etc: Again, never felt like this was a huge issue even in busy EM practice. Yeah it was annoying that we had to fill out the full anesthesia H+P for procedural sedation but it didn’t exactly ruin my day. This complaint always begs the question that these docs, if freed from the chains of paperwork, would be spending all that free time at the bedside being Marcus Welby. Basically every doc I know spends as little time at the bedside of patients as they possibly can. Yeah we try to be nice and make connections and I am as guilty as anyone of sitting in the ED bay with the old lady shooting the breeze for 30 min but for the most part we are in and out. If all the forms go away the vast majority of docs are going to spend the extra time reading Fox or CNN, not forming deeper bonds. Ask yourself, when a patient cancels in clinic or when the ED is dead do you spend that extra time taking a more detailed history?

5. High stress at work: If you’re an acute care doc (EM, surg, anesth, crit care, cards, nicu, etc) this is just unavoidable. No way to change the fact that we have to make tough decisions and see sad cases. Everyone sees sad cases even those in the most benign outpt fields. The secret is to try to have some healthy coping skills I guess. This is one of the reasons I preach the gospel of WCI far and wide b/c you need to have your outside life lined up reasonably well for this not to get to you.

 

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could not disagree with you more. 

except for number 5 I guess.

we have multidisciplinary meetings about burnout, and I wonder if your specialty affects your perception of the relative impact of these changes?

That is not to say that ED hasn't had rough EMR issues forced upon them, certainly they have along with everyone else.

but when we list things that would help reduce burnout, ED (at least in our institution) seems to offer a lot of options to mitigate some risks--more shift like work, no beeper, ability to control schedule somewhat, ability to work part time.  for most specialties who have clinics, the emr has really overflowed and taken a life of its own with constant notes forwarded, staff asking questions, patients asking questions, checking labs, imaging, and no time built in to system to perform these tasks or communicate with other physicians.

every job has tradeoffs, I am just wondering if you have a better job than the rest of us plebes. 

[MPMD]

q-school wrote:

MPMD wrote:

The article posted about the dark side of medicine was certainly sad. That said he seemed to be in a terrible practice environment which was the main issue for him. Not sure if it’s just the way it is where he lives the language sounded like the UK? I mean not being able to book your own cases, having an OR control that doesn’t account for time to flip the room, and basically on call 24/7 for ER cases even on a day with OR and clinic? That just sounds like a terrible job. I know lots of sub specialty surgeons who don’t live like that.

Shifting gears: Potentially unpopular opinions about burnout ahead.

1. EMR: It’s really bizarre to me that the EMR is so frequently blamed as a cause of burnout. Do people think that we should still be on paper charts in 2017 when we do basically nothing else on paper? EMR has revolutionized the legibility and portability of patient information. How many older docs out there say the EMR is a big cause of their workplace stress and then go spend the rest of the day on their iPad? There are some good and bad products out there but both Cerner and Epic are actually very decent systems. They both have their own issues but overall they are fine.

2. Loss of autonomy: I’ve never been quite sure what this means. Medicine is a science and things like guidelines exist for a reason — they usually represent the best available evidence. Increasingly we know a pretty reasonable scientifically based treatment option for people and yes, I guess that decreases our ability to make up our own.

3. Administrators in suits ruining everything: I’ve been on staff at 5 different hospitals in my career thus far and this statement has never been accurate. The vast majority of people in hospital admin are a) responding to forces outside their own control and b) nice people who genuinely desire physician input. If you buttonhole one in the hallway to say that things like LWBS from the ED doesn’t matter you’re not going to get a good result. If you spend a few hours learning about the actual things affecting your healthcare system you can understand where they are coming from.

4. New forms, boxes to check etc: Again, never felt like this was a huge issue even in busy EM practice. Yeah it was annoying that we had to fill out the full anesthesia H+P for procedural sedation but it didn’t exactly ruin my day. This complaint always begs the question that these docs, if freed from the chains of paperwork, would be spending all that free time at the bedside being Marcus Welby. Basically every doc I know spends as little time at the bedside of patients as they possibly can. Yeah we try to be nice and make connections and I am as guilty as anyone of sitting in the ED bay with the old lady shooting the breeze for 30 min but for the most part we are in and out. If all the forms go away the vast majority of docs are going to spend the extra time reading Fox or CNN, not forming deeper bonds. Ask yourself, when a patient cancels in clinic or when the ED is dead do you spend that extra time taking a more detailed history?

5. High stress at work: If you’re an acute care doc (EM, surg, anesth, crit care, cards, nicu, etc) this is just unavoidable. No way to change the fact that we have to make tough decisions and see sad cases. Everyone sees sad cases even those in the most benign outpt fields. The secret is to try to have some healthy coping skills I guess. This is one of the reasons I preach the gospel of WCI far and wide b/c you need to have your outside life lined up reasonably well for this not to get to you.

 

Click to expand…

could not disagree with you more.

except for number 5 I guess.

we have multidisciplinary meetings about burnout, and I wonder if your specialty affects your perception of the relative impact of these changes?

That is not to say that ED hasn’t had rough EMR issues forced upon them, certainly they have along with everyone else.

but when we list things that would help reduce burnout, ED (at least in our institution) seems to offer a lot of options to mitigate some risks–more shift like work, no beeper, ability to control schedule somewhat, ability to work part time.  for most specialties who have clinics, the emr has really overflowed and taken a life of its own with constant notes forwarded, staff asking questions, patients asking questions, checking labs, imaging, and no time built in to system to perform these tasks or communicate with other physicians.

every job has tradeoffs, I am just wondering if you have a better job than the rest of us plebes.

Click to expand...

I probably do have a better gig

That said I mean EM is constantly listed as one of the fields w/ highest risk of burnout.

Can you elaborate on how the EMR made more work in the clinic setting than paper charts? You reference checking labs, imaging, answering pt questions etc but that just sounds like.... clinic?

To me the issue is documentation in general rather than EMR specifically. Documentation is for sure my least fave part of my job.

[Complete_newbie]

EM really with highest burnout rate?

I'd think shift work would help.

WCI seems to be doing fine.

[ifonlyFI]

MPMD wrote:

3. Administrators in suits ruining everything: I’ve been on staff at 5 different hospitals in my career thus far and this statement has never been accurate. The vast majority of people in hospital admin are a) responding to forces outside their own control and b) nice people who genuinely desire physician input. If you buttonhole one in the hallway to say that things like LWBS from the ED doesn’t matter you’re not going to get a good result. If you spend a few hours learning about the actual things affecting your healthcare system you can understand where they are coming from.

Click to expand...

re: #3.  When I first started practice, I joined every committee I was invited to and rubbed shoulders with all the C-suite admins.  I clearly remember a senior doctor, a doctor who I thought lost his edge a little bit, telling me that he sits on no committees and goes to no meetings anymore.  He told me to spend my time in the way that benefits me more.  There is little gain from those directorship positions.  See more patients or go home early.

Now, a decade later, I stopped all positions and I am so much happier.  I have more time. I drive my kids to soccer practice in the evenings.  That senior doctor who I thought lost his edge is definitely one of the happier ones on staff.

 

Our decades of training teach us to grind forward to reach certain goals, get into college, med school, residence, job, etc.  When I finished training, I still kept on grinding.  I thought it was my responsibility to help the hospital and grow the program.  I used to tell the new hires "don't worry what you are going to get paid.  I don't even know how we bonus."

 

Now, my advice has changed a lot.  I tell the new hires to concentrate on your family and your finances.  The "system/hospital/admin" doesn't really care about you.  You are just a health care provider who has a license that can sign a script or do a procedure.

 

When I had that thought shift, I was no longer on the path of being burnt out.  I gained control of my career and life.  Now, if I could get financially independent, I would have complete control

[Hatton]

Advice on burnout.  It happens to us all.  Get to financial independence ASAP.  Then work part time.  Do not take on extra administrative roles unless the hospital pays you for your time.

[VagabondMD]

hatton1 wrote:

Advice on burnout.  It happens to us all.  Get to financial independence ASAP.  Then work part time.  Do not take on extra administrative roles unless the hospital pays you for your time.

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Wiser words on the matter were never so concisely spoken. My burnout story will be told soon.

[Lithium]

Don't talk to your employer about burnout and expect them to do anything about it.  If they really valued you in the first place, you probably wouldn't already be feeling that way.  It is more likely a notion they just pay lip service to, but ironically acknowledging it only makes them value you less.

The best way to handle burnout with an employer is keep the cards close and lay low until you're ready to deliver an ultimatum.... or just quit.

[Rando]

MPMD wrote:

 

1. EMR: It’s really bizarre to me that the EMR is so frequently blamed as a cause of burnout. Do people think that we should still be on paper charts in 2017 when we do basically nothing else on paper?

 

Click to expand...

 

I'm a solo FP and have had an EMR (Amazing Charts) that I am overall happy with.  I would never go back to paper.

 

The problems come in when I am forced to use the EMR in ways that do not benefit my practice but instead to comply with MIPS, etc.  This is time-consuming and frustrating at times.  If I could just use my EMR as I see fit it would be great.

 

I'm lucky since I selected my EMR and am invested in it both financially and personally.  I had total control over the choice.  Contrast that with the doc that has to use an unwieldy system geared more towards supporting large medical systems as compared to generating good notes.

 

I do have to add most of the local ER EMR notes I get are total crap.  Notes like "The location of the pain is chest.  The character of the pain is none.  The mitigating factors are none.  The timing of the the pain is days.  The contributing factors are none. The radiation of the pain is none.  The other symptoms are none," etc, etc followed by 9 pages of things I don't care about.  I have to search for the sentence or two that tells me what the ER doc thought was going on.  My local hospital uses Cerner by the way.

[StarTrekDoc]

+1 Hatton -  this is Key and second only to finding time balance: work/life

-  As physicians, we are TERRIBLE at asking for appropriate compensation -- administrators and insurers know this and take advantage of it.

EHR - it's not so much the EHR, but how it's utilized to create compliance and issues and ultimately downstream lands on physician's to do since it's the path of least resistance.  That's the problem.  Legacy compliance that made sense for paper charts but stay on (eg abbreviations).   Additional documentation that's redundant.    alerts/reminders that's turned on with limited true benefit aside from a compliance person saying, yeah, that's a good idea.

Messages/Phone calls -  these aren't the EHR issue, but how care is delivered (and many times no compensated time).  So delivery models and time utilization also needs to be mitigated.   Ironically, in salaried positions like Kaiser where there is a heavy physician involvement at all decision making levels; the frustration at the EHR appears to be much lower compared to fellow colleagues in VA and other EPIC institutions.   Or perhaps my fellow docs there are just too tired to complain

[q-school]

Perhaps you guys have better EMR implementations than I have.

Some of the difference between paper charts and EMR (clinic) for me include:  bloated, terrible notes instead of concise (possibly barely legible), and the ease of sending the notes encourages lots of extraneous notes that clutter the chart.   people cc a lot more than with paper.  Lots more notes to read.  because it is so much easier than calling, physicians and patients also send more messages.

with paper, my MA, nurses, NPs could filter all the information before it got to me.  checking labs, reviewing imaging, etc.   With EMR, everyone who has access to the EMR can send you a message--instead of receiving only necessary information, it gets sent to physician to have to filter down.  the inbasket police are constantly chasing you-with the paper chart you could manage your own time.

All the ticky tack clicks and alerts distract from care of the patient.  best practice alerts for things I will never manage.

It forces our work flow to go in order that are not convenient for physician.  It forces us to do data entry instead of allowing us to use our energy on critical thinking.  It interferes with the visit from a history taking standpoint, at least for me.  For whatever reason, I can write things down quickly and maintain conversations with patient.  I cannot do this while typing.  When I had my own home grown EMR, this was minimized, but now that I use EPIC I am forced into its workflow.  I know some of the issues are compliance issues rather than EMR issues.  but for me, EMR has dramatically added to time and energy spent on non clinical activities in the outpatient area.

ymmv.

---------

let me ask you what factors do you think contribute to EM having a higher burnout rate than most other fields (if the data is to be believed)?

pretty much every article I read says their field is at high risk for burnout and projections are for terrible shortage in x years. 

 

 

[StarTrekDoc]

Poor implementation; just like crappy data in; crappy data out.    The only people who know the process well are docs themselves, so if there's no doc at the table directing implementation, you're doomed to failure.   Yes, lots of compliance stuff; and a lot that is completely unnecessarily implemented or poorly thought out.

We don't let technicians of scopes do the actual colonoscopies and determine appropriate use of that scope.  Why abdicate arguably the most important tool we use to nonclinicians?

To say that we're better off with paper charts is like saying seat belts should be removed because they are uncomfortable.

[MPMD]

Rando wrote:

MPMD wrote:

 

1. EMR: It’s really bizarre to me that the EMR is so frequently blamed as a cause of burnout. Do people think that we should still be on paper charts in 2017 when we do basically nothing else on paper?

 

Click to expand…

 

I’m a solo FP and have had an EMR (Amazing Charts) that I am overall happy with.  I would never go back to paper.

 

The problems come in when I am forced to use the EMR in ways that do not benefit my practice but instead to comply with MIPS, etc.  This is time-consuming and frustrating at times.  If I could just use my EMR as I see fit it would be great.

 

I’m lucky since I selected my EMR and am invested in it both financially and personally.  I had total control over the choice.  Contrast that with the doc that has to use an unwieldy system geared more towards supporting large medical systems as compared to generating good notes.

 

I do have to add most of the local ER EMR notes I get are total crap.  Notes like “The location of the pain is chest.  The character of the pain is none.  The mitigating factors are none.  The timing of the the pain is days.  The contributing factors are none. The radiation of the pain is none.  The other symptoms are none,” etc, etc followed by 9 pages of things I don’t care about.  I have to search for the sentence or two that tells me what the ER doc thought was going on.  My local hospital uses Cerner by the way.

Click to expand...

My guess is that these types of notes come from scribes trained to maximize billing capture. It doesn't help you to read but it's easy for coders.

I personally cannot understand the mindset of an ER doc who doesn't spend a few minutes doing some MDM on complex cases. You literally might as well hand out biz cards w/ a plaintiff's attorney's phone number.

[MPMD]

q-school wrote:

 

let me ask you what factors do you think contribute to EM having a higher burnout rate than most other fields (if the data is to be believed)?

pretty much every article I read says their field is at high risk for burnout and projections are for terrible shortage in x years.

 

 

Click to expand...

Work is challenging when you are there, not a ton of downtime.

No ability to predict when you will get hit with terrible case.

Frankly I think the field got a rep it didn't deserve among students as this big lifestyle specialty. It's better than surgery but it shouldn't be lumped in with the really nice ones. Lots of students who aren't really equipped to make really hard decisions at 3am or handle fairly intense scrutiny/criticism from other docs flood in b/c they think they can be part time docs and end up poorly trained and ill-equipped to handle the rough stuff.

[G]

Complete_newbie wrote:

EM really with highest burnout rate?

I’d think shift work would help.

WCI seems to be doing fine.

Click to expand...

I seem to recall from those studies if you got into the weeds, the EM folks "burned out" to do other things...like create a start-up, run a travel/CME business, become a congressman, etc.

[Re3iRtH]

Please do tell. I am suffering from the opposite, too low of a volume in radiology as I would like. I guess I'll enjoy it while it lasts..