Time Sucked Away from Patients by EHRs

Sticking results from this descriptive study – on an average physicians are spending 16 minutes per encounter working with electronic health record. Now you know why your physicians are spending little time with you and always appear in a hurry. They are still very busy, reviewing the chart, ordering tests, and documenting the encounter. Machine has taken over the space between a doctor and a patient.

Obviously, very few (likely none) physicians enjoy spending time away from their patients. However, the regulatory burdens, some national mandates,some state mandates, some regulatory body mandates, and some institutional mandates require increasing documentation. All this increased documentation requirement has been placed without providing any additional time to a physician. As a result, physicians decreased the only discrete time they had – time with the patient.

Most of these mandates are there to make sure that the quality of care delivered is adequate. However, these mandates have worsened physician burnout and are perhaps not improving overall care except only those processes that are being measured.

Physician Burnout and Self-perception of Medical Errors

Another study was just published examining the relationship between surgeon burnout and self-perceived medical errors. As expected, they found a strong correlation between the two. It is pretty well-known that when a physician is burned out, his/her own perception of quality of work goes down.In other words, finding a relationship between burnout and self-perception of medical errors is an issue of physician’s perception and not that actually medical errors occurred. To be confident, we need to objectively measure medical errors.

Maintaining Competency and Physician Responsibility

Santen et al wrote a viewpoint in JAMA and propose the following 5 considerations to address competency decline with age and with introduction of new technology and/or procedures.

1. Lifelong learning and mechanisms to ensure maintenance of certification.
2. Responsibility to keep training.
3. Choosing practices that involve less exposure to procedures or content for which physicians are no longer expert
4. Self-assessment and reflection.
5. Responsibility of the health care system to ensure competency of physicians and surgeons for performing procedures.

These proposals are common sense or a no-brainer. However, the devil is always in the details. For example, how to assess lifelong learning? What is the evidence behind certain methods of lifelong learning? Is it possible that the physicians who self-reflect and self-assess are the ones who need it the least? If so, how to encourage physicians to self-reflect? One can go on and on but I hope I made the point. But I want to make a larger point. Medical education obsessively teaches evidence-based medicine, however, very few, if any, medical education methods have even a weak evidence to support them (as long as we do not include expert advice into evidence). It will be rare to see any medical education methodology that has been rigorously studied like we study medical interventions. No wonder we have increasing burnout among medical students, residents, and physicians; it is time we face the fact that our prescriptions for teaching medicine lack scientific evidence.

Physician Burnout & Patient Satisfaction/Experience

There have been concerns that physician burnout leads to lower patient satisfaction. In fact, some studies have found that patient satisfaction is lower among physicians with higher levels of burnout. A meta-analysis published in 2018 assimilated data and reached to the same conclusion. However, the quality of data, and studies, is questionable and there is a need for better conducted studies to examine this relationship.

A recently published article, by Howell et al., in the Journal of Patient Experience found no relationship between patient satisfaction and physician burnout domains of exhaustion and disengagement. This is an interesting finding and has strong implications. What it shows is that despite having high levels of burnout, physicians are able to function in a way that their patients don’t see a difference based on their burnout level. The brunt of burnout is faced by physicians and they shield their patients from its effects, likely at high personal cost.

Obviously, there may be other explanations – for example, the tools used to measure physician burnout are not reliably measuring burnout or that the tools to measure patient satisfaction with physicians are inaccurate and have large measurement bias. Both of these two explanations are possible but less plausible.

Sleepiness after work, Burnout, and Empathy

Tiredness after work, particularly shift work is common. How this relates to burnout and empathy is poorly explored. This study assessed the effects of shift (Day, Night), time of day (AM, PM), and gender (Male, Female) on sleepiness, empathy, and burnout in medical students. Working a 12 h night shift resulted in increased sleepiness as compared to a 12 h day shift. Sleepiness after a night shift resulted in differences in empathy. The sleepier the participant after working the 12 h shift, the lower their emotional empathy score.Similarly, sleepiness was associated with higher levels of burnout and females were affected more than men.

Burnout among Nurses

Dyrbye et al conducted a national survey of the US nurses (response rate 26.2%) and found that 35.3% had burnout symptoms. Interestingly, 30.7% of the respondents also had symptoms of depression. Quite interestingly, authors found that nurses who had higher burnout were more likely to have been absent 1 or more days during the last month and had poor work-performance.

Critique: Authors need to be commended for conducting a national study of nurses. However, this study has the same issue that we find in other burnout literature; person who is burnout is also the one who determines if they have poor performance or not. At least theoretically, one would assume that a person who is burnout will look more negatively towards themselves and their work than a person who is not burned out; we would expect a high correlation between the two. On the other hand, a study in which nurses’ superiors could have been asked to comment on performance would have generated more reliable data, however, such study would have been quite expensive requiring significant external funding.

Burnout in Healthcare–A systems approach

Interesting and thought-provoking analytical piece by Montgomery et al which correctly points out that the responsibility of mitigating burnout lies with the institution and that the practice of putting the responsibility on healthcare workers should be abandoned. Currently, most places try to focus on the healthcare worker – asking them to take better care of themselves, be resilient, cope with stressors on their own, etc. They propose the following:

1. Provider burnout should be added to the current assessment of healthcare quality
2. Burnout should be assessed at the departmental/unit level (and I would add that it should be measured at least annually).
3. Development of health workplaces should be a major goal
4. Key questions concerning research and practice should not be coming from researchers alone.

Personally, I do believe that there are not enough researchers examining the interventions needed to address burnout. There is lack of funding from national funding agencies and from locally from institutions.

Some Recent Physician Burnout Literature

An abstract, presented at the the annual meeting and published in the Journal of American College of Surgeons’ supplement examined relationship between burnout and involvement of surgeons in medical device development/innovation.

As is often found in medical students across the world, New Zealand’s medical students also appear to have high levels of burnout. Farrell et al surveyed one of the two medical school in New Zealand and found that the prevalence of exhaustion was 77% while of disengagement was 68%. Another proof that burnout in medical profession is a worldwide phenomenon.

A study examined burnout among Egyptian ICU physicians and found interesting results. The level of exhaustion was 38.8%, somewhat better than generally found in the West. However, the level of depersonalization was 70.1%. This is really surprising; do Egyptian physicians really feel that much disconnected or disengaged from their patients?

Issues with Current Physician Burnout Research

The relationship of physician burnout with patient outcomes has been often reported but the studies have been of poor quality and/or report the outcomes as perceived by physicians. Obviously, using physician’s perception of burnout and physician’s perception of patient outcomes is circular in nature; a burnout physician may be likely to think that the patient care provided by her is of lower quality.

A systemic review, in Annals of Internal Medicine highlights the similar issue. Moreover, it also shows that where a relationship is shown, the effect sizes tend to be larger suggesting that publication bias may be contributing to preponderance of studies showing an effect (because studies showing no effect are not getting published.

The physician burnout research (and researchers) should start using rigorous scientific methods to define outcomes, predictors, associations, and evaluation of interventions. Otherwise, such an important topic will get a poor reputation due to low-quality research.

National Academy of Medicine Talks about Physician Burnout

In response to concerning rates of depression, stress, and burnout among US medical students and clinicians, the National Academy of Medicine (formerly Institute of Medicine) launched the Action Collaborative on Clinician Well-Being and Resilience in 2017.

Incorporating input from experts in human factors and systems engineering and health informatics, as well as medical, nursing, pharmacy, and dentistry experts and educators, the committee took a systems approach to clinician burnout.

The committee’s systems model for professional well-being and clinician burnout has 3 levels: frontline care delivery, health care organization, and external environment, which together influence the work system factors that contribute to clinician burnout and professional well-being. The work system factors often extend across more than 1 system level (care delivery, health care organization, and external environment), and improvement can occur at every level to relieve workplace stress. The recommendations from the report, organized under 6 overarching goals, reflect the crosscutting nature of the identified factors contributing to clinician burnout and professional well-being.

1. Create positive work environments

2. Create positive learning environments

3. Reduce administrative burden

4. Enable technology solutions

5. Provide support to clinicians and students

6. Invest in research

Proliferation of Risk Factors for Physician Burnout

Several authors have promoted various risk factors for physician burnout. Below are some that I noticed in my email:

Moral Injury:

Kopacz MS, Ames D, Koenig HG. It's time to talk about physician burnout and moral injury. Lancet Psychiatry. 2019 Nov;6(11):e28. doi:10.1016/S2215-0366(19)30385-2. PubMed PMID: 31631880.

Low or lack of Mindfulness:

Lebares CC et al. Key factors for implementing mindfulness-based burnout interventions in surgery. The American Journal of Surgery (in Press)

Lack of Resilience and Grit

Shakir HJ, Cappuzzo JM, Shallwani H, Kwasnicki A, Bullis C, Wang J, Hess RM,Levy EI. Relationship of Grit and Resilience to Burnout Among US NeurosurgeryResidents. World Neurosurg. 2019 Oct 16. pii: S1878- 750(19)32658-0. doi:10.1016/j.wneu.2019.10.043. [Epub ahead of print]  PubMed PMID: 31629138.

Attacks on the Calling of Medicine

Stewart MT, Serwint JR. Burning without burning out: A call to protect thecalling of medicine. Curr Probl Pediatr Adolesc Health Care. 2019 Oct 17:100655. doi: 10.1016/j.cppeds.2019.100655. [Epub ahead of print] PubMed PMID: 31631025

Above are some of the examples of risk factors cited in literature and the list continues to grow with each passing day. There are folks who have developed ‘Burnout Prevention Programs’ around these risk factors. Some even market these programs and make money.

My concern stems from the fact that while there may be strong conceptual underpinnings for at least some of these risk factors, rigorous studies examining the relationship are missing. The current state of evidence is so poor that a clinician will not take seriously risk factors with such limited evidence when managing a patient. Then, why, physicians doing this to themselves.

In particular, the worrisome part is the so-called prevention programs. Where is the evidence to support that such interventions work? If we don’t accept evidence for our patients without randomized clinical trials or at least strong observational studies, why we accept such intervention programs without evidence of efficacy?

Longitudinal Study of Physician Burnout

Here is the study

The most interesting part is “burnout trends among staff tended to move in the opposite direction from trends among clinicians.”