Gastroenterologists in private practice find themselves working in a time of unprecedented transformation. Pressures are high as they make important management decisions that profoundly affect their business future, their private lives, and their ability to provide care to patients. The ACG Practice Management Committee has a mission to bring practicing colleagues together in order to explore solutions, overcome management challenges, improve operations, enhance productivity, and support physician-leadership. It was in this spirit that the Practice Management Toolbox was created.
The Toolbox is a series of short articles, written by practicing gastroenterologists, providing ACG members with easily accessible information to improve their practices. Each article covers an issue important to private practice gastroenterologists and physician-lead clinical practices. They include a brief introduction, a topic overview, specific suggestions, helpful examples and a list of resources or references.
Physician & Provider Wellness
Stephen J. Utts, MD, MHCDS, FACP, FACG, Austin Gastroenterology, Austin, Texas
The ACG Professionalism Committee
Physician burnout is an emerging crisis in healthcare affecting 50% of those in primary care fields and 37% of gastroenterologists1. It is characterized by emotional exhaustion, depersonalization and reduced sense of personal accomplishment. Consequences of burnout include increased medical errors, lower patient satisfaction scores, early retirement with high provider replacement costs, as well as alcohol and substance abuse, depression and suicide. Physician organizations have an opportunity to reduce burnout rates, but this requires a comprehensive strategy and commitment by leadership of each practice or unit.
The Triple Aim in healthcare, introduced by Dr. Donald Berwick in 2008, focuses on improving the patient experience of care while improving the health of populations at reduced cost. Unfortunately, current practice design is often not aligned with these goals, and the added workload to provide quality care coupled with the distractions of EHR documentation with limited interoperability has undermined implementation. Some have recommended a revision of the Triple Aim to include physician and provider wellness to complete a Quadruple Aim2.
The causes of burnout tend to fall in three major categories; organizational culture, practice efficiency and physician resilience. There is mounting evidence that organizational and practice factors such as the burden of electronic medical record documentation and financial pressure to increase volume are key drivers to physician frustration and this erodes physician resiliency.
Practices should develop a culture of provider wellness. The first step is to identify wellness as a focus of quality improvement with commitment from all levels of leadership. Wellness surveys can identify the problem and provide a benchmark. Cultural change does not come easily, but champions within practice leadership can foster wellness by modeling healthy and balanced lifestyle, identifying financial and competitive benefits as well as the value of improved morale among clinicians. Identification of sources of frustration for clinicians can reveal opportunities for intervention.
The four common organizational factors that contribute to burnout are:
- Lack of control over workflow and work conditions
- Time pressure from overbooking and limited patient engagement time
- Chaotic workplaces
- Lack of alignment of values between providers and leadership
To the end of improving a sense of control over workflow, practices should create more flexible schedules for physicians for personal obligations and to improve practice efficiencies through workflow redesign.
Relieving physicians from clerical duties frees time for patient engagement. Medical scribes, medical assistants, nurses and physician assistants are potential resources for data entry. Workflow redesign can offload other routine duties as well as lower level decision making to support staff.3
A highly functioning health care team can provide comprehensive care proactively and efficiently. Studies have shown that team-based care improves resource capacity and frees time for care coordination. This reduces chaos in the workplace and improved professional satisfaction.
Practice leadership should be committed to overcoming cultural resistance to innovation as well as a careful study of practice flow and developing the components of the care team. Physicians usually need additional training in team building skills and leadership.
Physicians can also be trained to become more aware of the warning signs of burnout, and to feel free to speak up when they are experiencing signs of burnout. Practice cultures will need to adapt to this transparency without retribution or judgment. Leadership will need to play a key role in ushering this culture change.
- Recognize that burnout is a serious problem that can lead to medical errors, reduced physician engagement and morale and practice disruption with economic consequences from physicians leaving or reducing hours. Mission and Vision statements should incorporate physician wellness. A change in practice culture requires champions to sustain innovation over time.
- Measure wellness and predictors of burnout through standard surveys and share with physicians (Maslach Burnout Inventory, Mayo Well-being index, or Mini Z burnout survey. A copy of the Mini Z survey is attached)
- Research the resources listed at the end of this paper for practical steps in practice redesign.
- Develop and implement innovations for greatest impact and least effortExamples:
- Hire medical scribes directly or through an agency. Scribes can be virtual (offsite with access to the EHR), or in the room with the physician. Since scribes are often students, there is significant turnover in this position. Agency hires reduce the burden on human resources.
- Train current staff of medical assistants in entering data into the medical record and populating the note with essential data and detailing patient symptoms. Empower staff for routine template driven decision making.3
- Create care teams for patients with more complex conditions (see accompanying module for Team Based Care).
- Team huddles prior to a clinic session can assure that essential data are entered in the record and needs of certain patients are anticipated.
- Establish an EHR team to identify software upgrades that add functionality and reduce the burden of data entry. The team should also interface with the vendor to explore improvements in clinical decision support, ease of logging in, creating dashboards for key data, templates for care management, and reducing redundant mouse clicks and data entry.
- Explore outside apps that can enhance inpatient care and charge entry
- Establish a Wellness Officer to champion a compassionate wellness culture and to monitor surveys and interventions.
- Encourage collegiality through social events, team building activities. Restore physician collaboration and discussion of difficult cases and advances in clinical care.
TESTIMONIALS FROM ACG MEMBERS
Dr. Steven Bernick Narrative (Lifestyle Balance to Avert Burnout)
On February 1, 2017 I retired from active duty military service, having enjoyed a long career as a physician in the United States Navy. Over the course of my career, military assignments intermittently took me away from home and my family extended periods of time. Although I found these experiences incredibly rewarding, when I transitioned to the civilian sector I decided that I no longer desired a full-time practice. After considering the options available, I elected to continue serving current and past warfighters and their dependents by accepting a position as a staff gastroenterologist at Madigan Army Medical Center in Tacoma, Washington. I structured my work schedule like that of a traditional hospitalist, where I have blocks of time at work, and blocks of time free. I tailored my practice to focus on what I enjoy most – inpatient consultative medicine and outpatient procedures, thus forgoing an empaneled group of patients and outpatient clinic. This dovetails nicely with the type of schedule I desire. As a member of the faculty of my alma mater, the Uniformed Services University, participation in the education and mentoring of the next generation of physicians remains important to me, and this position has provided me with frequent opportunities to participate in the graduate medical education program as a consultant, attending physician, and lecturer.
During my transition to civilian practice, I also elected to take a six-month sabbatical. I used this time to pursue leisure activities that required a greater time commitment than previously available, such as section hiking the Pacific Crest Trail. I also had the time available to volunteer as a teaching assistant at my children’s middle school, and, as an Eagle Scout myself, to serve as a mentor and role model to my son’s Boy Scout troop. Finally, I launched a second career as a voiceover narrator, something I’d desired to do for years but simply didn’t have the dedicated time to get started. Overall, this was time well spent, and is something I would encourage others to consider at some point in their career.
Certainly, an alternate work schedule such as mine has its fallbacks and challenges. Discontinuity limits the formation of the long-term relationships that I had previously enjoyed with empaneled patients. For similar reasons, clinical research is also limited. Finally, the financial remuneration is less that what would be available with full-time employment in private practice. However, each of these potential drawbacks has a work-around, and the benefits I have enjoyed far outweigh these considerations. I have found that shifting my paradigm and actively taking steps to affect a work-life balance that truly meets my needs has resulted in a greater degree of both personal and professional satisfaction than I would have otherwise believed possible. I started my civilian career re-energized, and even more excited about the practice of medicine and all that it has to offer. With the problem of physician burnout becoming more recognized, I encourage fellow physicians who are facing this challenge to “look outside the box” and consider similar options in their practice.
Dr. Sita Chokhavatia Narrative: (A burnout retreat followed by scheduled meetings to share medical narratives: one model to address burnout.)
Recognizing the importance of addressing physician and provider burnout, the proactive leadership at The Valley Medical Group (VMG), Ridgewood, New Jersey, sponsored a “Burnout Retreat” to encourage Mindful Medical Practice. The goal was to increase the wellbeing of the VMG staff by reducing stress and preventing burnout. This was a voluntary program open to all VMG medical providers. About 50 providers signed up for the day and a half retreat and received CME credits for attending the retreat.
National experts, Dr. Michael Krasner and Dr. Patricia Luck, directed this day and a half Mindful Practice Program which included active participation from all attendees in the practice of mindfulness, stress reduction exercises and meditation. The exercises were deemed helpful in reducing stress (by some, but not all, participants). Four webinars on “Mindful Practice in Medicine” followed the retreat: “Meaning in Medicine”, “Health Professional Grief and Loss”, “Uncertainty”, “Bringing it Home and Moving Forward”. Health providers shared their experiences and medical narratives which helped crystallize their reasons for the joy and satisfaction in medicine.
Medical narratives and dialogues with colleagues were considered by all participants to be the most helpful: easy to relate to peers, identify issues that are not unique to single practitioner, provide solutions to situations as we see ourselves in similar struggles. The exercises helped develop resiliency to counter burnout.
To build on the positive feedback, “most valuable practice of shared medical narratives which was learnt at the retreat”, we plan to schedule monthly meetings to continue sharing and discussing medical “stories”. Mindfulness meditation will also be offered at the start of each meeting.
Peer support empowers the individual medical provider in several ways- we relate to our peers’ experiences, we realize that moments of uncertainty in medical encounters are not unique and many of us grapple with difficult situations –medical and personal, there is enhanced appreciation for our career choice, and we learn to cultivate positive responses to our stressors.
Dr. Steve Choi Narrative (Physician Wellness)
After completing my gastroenterology fellowship, I had the opportunity to join the faculty where I trained and pursue my goal of becoming a physician-scientist. A part-time clinical position at the Veterans Affairs hospital seemed to be a natural fit for me at the time as it allowed me the chance to develop my research while better compartmentalizing my clinic effort. Having spent a considerable portion of my training as a resident in internal medicine and then as a fellow in gastroenterology, I developed a natural comfort at the VA so a transition to the faculty made a lot of sense for me.
With the considerable help of colleagues at the VA and at our academic affiliate, I was able to help further develop a hepatology program established by one of my mentors while also trying to balance and grow my career as basic researcher. I was able to see both my clinical and research career grow in parallel; however, as just about every researcher experiences, maintaining momentum can be quite challenging. It was during these challenging moments where clinical effort can serve as a refuge. Indeed, using my research to help inform my clinical care helped maintain motivation for both.
Ultimately, I did make a choice to expand my clinical effort. The arrival of directly-acting antiviral therapies to treat chronic Hepatitis C made the choice easier as it came with the chance to make a direct impact on the lives of veterans long-infected and losing hope for a cure. Being able to reach out to so many individuals and have what may be a lasting impact on their lives served to remind me why I chose a path to medicine in the first place. Additionally, practicing medicine at the VA offered a chance to focus fully on providing care without the constraints that some of my colleagues who practice outside of the VA must face, including time taken away from patient care in dealing with insurance or the possibility that a patient cannot afford a medication critical to their health.
Providing care at the VA can be challenging as we face what seems to be regular criticism and regular leadership change; however, the mission of improving the lives of veterans never changes. Practicing in the VA comes with challenges but it does allow for a purer approach to patient care since no veteran is turned away. While burnout in medicine is a true concern, medicine can also be refuge from other challenges faced in a career.
The AMA Steps Forward modules are excellent and practical and well referenced. The National Academy of Medicine has a great search engine for team care articles and studies.
- https://www.stepsforward.org/modules/physician-burnout (AMA Steps Forward Module: Preventing Physician Burnout)
- https://www.stepsforward.org/modules/joy-in-medicine (AMA Steps Forward Module: Creating Organizational Foundation for Joy in Medicine)
- https://www.stepsforward.org/modules/improving-physician-resilience (AMA Steps Forward Module: Improving Physician Resiliency)
- https://www.stepsforward.org/modules/preventing-physician-suicide (AMA Steps Forward Module: Preventing Physician Distress and Suicide)
- https://www.stepsforward.org/modules/physician-wellness (AMA Steps Forward Module: Physician Wellness: Preventing Resident and Fellow Burnout)
- https://nam.edu/clinicianwellbeing/?utm_source=National%20Academy%20of%20Medicine&utm_campaign=18b3d7fa9e-CR%20July%20meeting%20registration&utm_medium=email&utm_term=0_b8ba6f1aa1-18b3d7fa9e-150936445 (National Academy of Medicine: Clinician Well Being Hub)
- https://www.acponline.org/online-learning-center/wellness-and-resiliency (American College of Physicians Webinar)
- Lacy BE & Chan JL. Physician Burnout: The Hidden Health Care Crisis. Journal of Clinical Gastroenterology and Hepatology 2018; 16:311-317 DOI 10.1016/j.cgh.2017.06.043
- Bodenheimer T, Sinsky C. From triple to quadruple Aim: Care of the patient requires care of the provider. Ann Fam Med 2014;12:573-576. DOI: 10.1370/qfm.1713