Christine A. Sinsky

Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014.

OBJECTIVE To evaluate the prevalence of burnout and satisfaction with work-life balance in physicians and US workers in 2014 relative to 2011. PATIENTS AND METHODS From August 28, 2014, to October 6, 2014, we surveyed both US physicians and a probability-based sample of the general US population using the methods and measures used in our 2011 study. Burnout was measured using validated metrics, and satisfaction with work-life balance was assessed using standard tools. RESULTS Of the 35,922 physicians who received an invitation to participate, 6880 (19.2%) completed surveys. When assessed using the Maslach Burnout Inventory, 54.4% (n=3680) of the physicians reported at least 1 symptom of burnout in 2014 compared with 45.5% (n=3310) in 2011 (P<.001). Satisfaction with work-life balance also declined in physicians between 2011 and 2014 (48.5% vs 40.9%; P<.001). Substantial differences in rates of burnout and satisfaction with work-life balance were observed by specialty. In contrast to the trends in physicians, minimal changes in burnout or satisfaction with work-life balance were observed between 2011 and 2014 in probability-based samples of working US adults, resulting in an increasing disparity in burnout and satisfaction with work-life balance in physicians relative to the general US working population. After pooled multivariate analysis adjusting for age, sex, relationship status, and hours worked per week, physicians remained at an increased risk of burnout (odds ratio, 1.97; 95% CI, 1.80-2.16; P<.001) and were less likely to be satisfied with work-life balance (odds ratio, 0.68; 95% CI, 0.62-0.75; P<.001). CONCLUSION Burnout and satisfaction with work-life balance in US physicians worsened from 2011 to 2014. More than half of US physicians are now experiencing professional burnout.

From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider

The Triple Aim—enhancing patient experience, improving population health, and reducing costs—is widely accepted as a compass to optimize health system performance. Yet physicians and other members of the health care workforce report widespread burnout and dissatisfaction. Burnout is associated with lower patient satisfaction, reduced health outcomes, and it may increase costs. Burnout thus imperils the Triple Aim. This article recommends that the Triple Aim be expanded to a Quadruple Aim, adding the goal of improving the work life of health care providers, including clinicians and staff.

In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices

We highlight primary care innovations gathered from high-functioning primary care practices, innovations we believe can facilitate joy in practice and mitigate physician burnout. To do so, we made site visits to 23 high-performing primary care practices and focused on how these practices distribute functions among the team, use technology to their advantage, improve outcomes with data, and make the job of primary care feasible and enjoyable as a life’s vocation. Innovations identified include (1) proactive planned care, with previsit planning and previsit laboratory tests; (2) sharing clinical care among a team, with expanded rooming protocols, standing orders, and panel management; (3) sharing clerical tasks with collaborative documentation (scribing), nonphysician order entry, and streamlined prescription management; (4) improving communication by verbal messaging and in-box management; and (5) improving team functioning through co-location, team meetings, and work flow mapping. Our observations suggest that a shift from a physician-centric model of work distribution and responsibility to a shared-care model, with a higher level of clinical support staff per physician and frequent forums for communication, can result in high-functioning teams, improved professional satisfaction, and greater joy in practice.

Electronic Health Records: Design, Implementation, and Policy for Higher-Value Primary Care

Electronic health records (EHRs), and the policies and workflows around them, are inconsistently aligned with the needs of primary care patients and physicians. This results in substantial waste of physician and support resources, high rates of burnout (1, 2), and a decrease in primary care capacity precisely at the time when our nation needs a stronger primary care foundation (3). We propose a set of principles (Table) directed toward vendors, institutional leaders, policymakers, and physicians to support higher-value primary care. These principles draw on our expertise in patient care, quality assurance, industrial and systems engineering, and policy and EHR implementation. They are inspired by discussions with clinicians after more than 100 presentations on redesigning primary care practice and our shadowing of physicians at nearly 50 sites. We hope they will contribute to a multistakeholder dialogue and serve as a call to action. Table. PrinciplesofEHRDesign,Implementation,andPolicy Principles Patient-Centered Design Add Value for the Patient. Technology, regulation, and implementation policies should add net value to the patients care and experience. Current EHR design and use is often visit-based and payment-centered and directs more work to the physician. Therefore, EHRs can paradoxically diminish value for the patient. The Primary Function of EHRs Is Clinical Care. Electronic health records should be designed and used as sense-making and communication tools (4). To be good stewards of information, health care professionals must concisely organize key elements, use structured or copied and pasted text judiciously, and pay close attention to the longitudinal portions of the record (for example, problem and medication lists and the care plan). The optimal person to input information will vary across settings and may not always, or even often, be the physician. Administrative and research activities, although valuable, must be subordinate to the clinical function. Information organized primarily for billing justification or other organizational purposes, including performance measurement and audit trails, can unintentionally undermine its fundamental clinical purpose. Health Care Professionals Well-Being. Patients experiences will not be optimized without consideration of the professional well-being of those who serve them. When nurses, physicians, and other health care workers are overwhelmed or distracted by EHR-associated tasks, patient care can suffer (2, 5). Match the Work to the Worker. All staff should work to the top of their license, especially those with the greatest investment in training. It is not always safer to require that the physician perform a task. Those responsible for complex cognitive work should not also be responsible for routine tasks, such as order entry, billing, and documentation, because they may interfere with higher-level tasks, including synthesizing and interpreting information, balancing risks and benefits, guiding patients in shared decision making, and communicating with others (3, 6). EHRs Are Shared Information Platforms for Individual and Population Health. The entire care team shares responsibility for using the EHR to support coordinated care for individual patients and for population management. Efficiency Minimize Waste. Wise use of health care resources requires minimizing waste. Time matters because it translates into quality, access, and safety. Time per task and time to comply with regulations should be tracked and reduced. Human factors expertise can inform EHR design to minimize mouse clicks and scrolls and screen changes, as well as create better information displays to decrease cognitive workload. A policy environment that reduces documentation requirements and supports team-based care facilitates efficiency. Not every element of care can be captured in the EHR. Not every element of care should require physician signoff. Many signatures in health care do not add value and are a form of waste. Alignment With Clinical Work. Electronic workflows should align with clinical workflows rather than being rigid sequences that physicians must progress through with patients. Medical care is often chaotic (7) and nonlinear, and EHRs must support this complex patient-centered interaction. Various Methods of Communication. The goal is effective and efficient communication rather than to go paperless. The team should be encouraged to use the best method for the situation, including verbal one-on-one interaction in which dialogue is helpful. Asynchronous electronic communication has a role but must be used judiciously to avoid overwhelming the e-mail inbox with messaging that either was unnecessary or could have been handled more effectively by direct conversation (8). Regulation and Payment Sufficient Resources. Higher-value primary care cannot be delivered on a shoestring budget. Many activities in which teams could be engaged (for example, using the EHR to identify and manage high-risk patients) represent new work that requires new resources. The high volume of electronic information in comprehensive primary care cannot be handled with the staffing ratios of the past. In addition, dictated and transcribed notes may communicate the patient narrative and medical decision making more clearly and efficiently than notes primarily comprising structured and physician-entered text. Evidenced-Based Policy. Policies should be explicit about the evidence base supporting them and the time required for compliance, with special attention given to the generalizability of available evidence. In the absence of evidence, a good default strategy is activating professionalism (9) rather than expecting and permitting regulators to fill an evidence gap with additional rules. Regulatory Balance. Regulation is not the only driver of quality and can be counterproductive if applied too heavily. Unopposed emphasis on security, privacy, and performance measurement may come at a cost to quality; efficiency; and the satisfaction of patients, staff, and physicians. The effects on patients and those who care for them need to be considered. Conclusion After a decade of growth in the use of EHRs that has been both promising and painful, we believe it is time to step back and develop principles for their design, implementation, and regulation that support higher-value primary care. Physicians are voting with their feet and abandoning primary care at a time when their expertise is acutely needed. If primary care is to survive as a specialty in which patients receive comprehensive, cost-effective, safe, and personalized care, we need a new generation of electronic information tools and new policies for the sociotechnical environment in which they are implemented (10).

Redesigning the practice model for general internal medicine. A proposal for coordinated care: A policy monograph of the Society of General Internal Medicine

General Internal Medicine (GIM) faces a burgeoning crisis in the United States, while patients with chronic illness confront a disintegrating health care system. Reimbursement that rewards using procedures and devices rather than thoughtful examination and management, plus onerous administrative burdens, are prompting physicians to pursue specialties other than GIM. This monograph promotes 9 principles supporting the concept of Coordinated Care—a strategy to sustain quality and enhance the attractiveness and viability of care delivered by highly trained General Internists who specialize in the longitudinal care of adult patients with acute and chronic illness. This approach supplements and extends the concept of the Advanced Medical Home set forth by the American College of Physicians. Specific components of Coordinated Care include clinical support, information management, and access and scheduling. Success of the model will require changes in the payment system that fairly reimburse physicians who provide leadership to teams that deliver high quality, coordinated care.General Internal Medicine (GIM) faces a burgeoning crisis in the United States, while patients with chronic illness confront a disintegrating health care system. Reimbursement that rewards using procedures and devices rather than thoughtful examination and management, plus onerous administrative burdens, are prompting physicians to pursue specialties other than GIM. This monograph promotes 9 principles supporting the concept of Coordinated Care—a strategy to sustain quality and enhance the attractiveness and viability of care delivered by highly trained General Internists who specialize in the longitudinal care of adult patients with acute and chronic illness. This approach supplements and extends the concept of the Advanced Medical Home set forth by the American College of Physicians. Specific components of Coordinated Care include clinical support, information management, and access and scheduling. Success of the model will require changes in the payment system that fairly reimburse physicians who provide leadership to teams that deliver high quality, coordinated care.

Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations

PURPOSE Primary care physicians spend nearly 2 hours on electronic health record (EHR) tasks per hour of direct patient care. Demand for non–face-to-face care, such as communication through a patient portal and administrative tasks, is increasing and contributing to burnout. The goal of this study was to assess time allocated by primary care physicians within the EHR as indicated by EHR user-event log data, both during clinic hours (defined as 8:00 am to 6:00 pm Monday through Friday) and outside clinic hours. METHODS We conducted a retrospective cohort study of 142 family medicine physicians in a single system in southern Wisconsin. All Epic (Epic Systems Corporation) EHR interactions were captured from “event logging” records over a 3-year period for both direct patient care and non–face-to-face activities, and were validated by direct observation. EHR events were assigned to 1 of 15 EHR task categories and allocated to either during or after clinic hours. RESULTS Clinicians spent 355 minutes (5.9 hours) of an 11.4-hour workday in the EHR per weekday per 1.0 clinical full-time equivalent: 269 minutes (4.5 hours) during clinic hours and 86 minutes (1.4 hours) after clinic hours. Clerical and administrative tasks including documentation, order entry, billing and coding, and system security accounted for nearly one-half of the total EHR time (157 minutes, 44.2%). Inbox management accounted for another 85 minutes (23.7%). CONCLUSIONS Primary care physicians spend more than one-half of their workday, nearly 6 hours, interacting with the EHR during and after clinic hours. EHR event logs can identify areas of EHR-related work that could be delegated, thus reducing workload, improving professional satisfaction, and decreasing burnout. Direct time-motion observations validated EHR-event log data as a reliable source of information regarding clinician time allocation.

The Business Case for Investing in Physician Well-being

Importance Widespread burnout among physicians has been recognized for more than 2 decades. Extensive evidence indicates that physician burnout has important personal and professional consequences. Observations A lack of awareness regarding the economic costs of physician burnout and uncertainty regarding what organizations can do to address the problem have been barriers to many organizations taking action. Although there is a strong moral and ethical case for organizations to address physician burnout, financial principles (eg, return on investment) can also be applied to determine the economic cost of burnout and guide appropriate investment to address the problem. The business case to address physician burnout is multifaceted and includes costs associated with turnover, lost revenue associated with decreased productivity, as well as financial risk and threats to the organization’s long-term viability due to the relationship between burnout and lower quality of care, decreased patient satisfaction, and problems with patient safety. Nearly all US health care organizations have used similar evidence to justify their investments in safety and quality. Herein, we provide conservative formulas based on readily available organizational characteristics to determine the financial return on organizational investments to reduce physician burnout. A model outlining the steps of the typical organization’s journey to address this issue is presented. Critical ingredients to making progress include prioritization by leadership, physician involvement, organizational science/learning, metrics, structured interventions, open communication, and promoting culture change at the work unit, leader, and organization level. Conclusions and Relevance Understanding the business case to reduce burnout and promote engagement as well as overcoming the misperception that nothing meaningful can be done are key steps for organizations to begin to take action. Evidence suggests that improvement is possible, investment is justified, and return on investment measurable. Addressing this issue is not only the organization’s ethical responsibility, it is also the fiscally responsible one.

Key Elements of High-Quality Primary Care for Vulnerable Elders

With the impending surge in the number of older adults, primary care clinicians will increasingly need to manage the care of vulnerable elders. Caring for vulnerable elders is complex because of their wide range of health goals and the interdependence of medical care and community supports needed to achieve those goals. In this article, we identify ways a primary care practice can reorganize to improve the care of vulnerable elders. We begin by identifying important outcomes for vulnerable elders and three key processes of care (communication, developing a personal care plan for each patient, and care coordination) needed to achieve these outcomes. We then describe two delivery models of primary care for vulnerable elders – co-management, and augmented primary care. Finally, we discuss how the physical plant, people, workflow management, and community linkages in a primary care practice can be restructured to better serve these patients.

Texting While Doctoring: A Patient Safety Hazard

Texting while driving is associated with a greatly increased risk for crashing and reduces the amount of brain activity devoted to driving. This commentary asks whether typing into electronic healt...

Professional Satisfaction and the Career Plans of US Physicians

Objective To evaluate the relationship between burnout, satisfaction with electronic health records and work‐life integration, and the career plans of US physicians. Participants and Methods Physicians across all specialties in the United States were surveyed between August 28, 2014, and October 6, 2014. Physicians provided information regarding the likelihood of reducing clinical hours in the next 12 months and the likelihood of leaving current practice within the next 24 months. Results Of 35,922 physicians contacted, 6880 (19.2%) returned surveys. Of the 6695 physicians in clinical practice at the time of the survey (97.3%), 1275 of the 6452 who responded (19.8%) reported it was likely or definite that they would reduce clinical work hours in the next 12 months, and 1726 of the 6496 who responded (26.6%) indicated it was likely or definite that they would leave their current practice in the next 2 years. Of the latter group, 126 (1.9% of the 6695 physicians in clinical practice at the time of the survey) indicated that they planned to leave practice altogether and pursue a different career. Burnout (odds ratio [OR], 1.81; 95% CI, 1.49‐2.19; P<.001), dissatisfaction with work‐life integration (OR, 1.65; 95% CI, 1.27‐2.14; P<.001), and dissatisfaction with the electronic health record (OR, 1.44; 95% CI, 1.16‐1.80; P=.001) were independent predictors of intent to reduce clinical work hours and leave current practice. Conclusion Nearly 1 in 5 US physicians intend to reduce clinical work hours in the next year, and roughly 1 in 50 intend to leave medicine altogether in the next 2 years to pursue a different career. If physicians follow through on these intentions, it could profoundly worsen the projected shortage of US physicians.