Tuesday, August 28, 2012

Physician Burnout News!! or New?

Consider this article from the Archives of Internal Medicine dated 17Jul2001

It considerabily predates the current Archives of Internal Medicine article of Shanafelt et al (http://archinte.jamanetwork.com/article.aspx?articleid=1351351). Physician burnout is therefore not new or news per sae to physicians. However, it is news apparently to the general reader.

Shanafelt's study employed a structured questionaire the Maslach Burnout Inventory (MBI) (http://www.mindtools.com/stress/Brn/BurnoutSelfTest.htm), and canvased physicians via email. A major problem with the study was the dismal return rate for the questionaires. Specifically, 89,831 physicians were contacted by email but only 27,276 physicians actually opened the 1st email request to contribute to the study. Of the 27,276 physicians who actually recieved and acknowledged the email request to participate in the study, only a paltry 7,288 physicians actually replied and submitted a completed inventory response form. Thus the study conclusions are based on a 26.7% overall response rate, something that would have appaled my biostatistics mentor.

However, barring the extreme self selection implied by the overall response rate, the study is of value to highlight something that I believe most physicians recognize, that the professional rewards of medicine are plumetting in a sustained free fall.

The authors of the study make few (as is proper) speculations as to the cause of the high burnout rate seen in their study. However they do make an interesting point with respect to the comparison of physicians with other workers within the US. Specifically, "after adjusting for hours worked per week, higher levels of education and professional degrees seem to reduce the risk for burnout in fields outside of medicine, whereas a degree in medicine (MD or DO) increases the risk." This paradox, finding a protective factor for burnout in the general population (non-MD/DO) related to educational achievement and possessing a professional degree warants my emphasis.

Furthermore the authors comment that ' The fact that almost 1 in 2 US physicians has symptoms of burnout implies that the origins of this problem are rooted in the environment and care delivery system rather than in the personal characteristics of a few susceptible individuals...' again demands my re-emphasis.

What then may be the root causes of this phenomenal 'burn' rate? The usual suspects are the loss of professional autonomy, the proliferation of mindless corporate and governmental regulations/rules and policies, the increased demands of patient's for solutions to the non-medical or social problems that are tightly integrated into their health problems, the maddening 'accountability without authority' crush that has demoralized our educational colleagues, ever expanding demands for paperwork to jusify the care plan and to justify billing, ever expanding specialized paperwork needed to document 'pay for performance' measures, JACHO mandated best practices/core measures, justififcation of the meaningful use of your practices EMR's, the cumulative fatigue related to disrupted sleep with an accompanying limited opportunity to recoup and regroup that characterizes medical work, and the ever declining fraction of time available to spend with patient's are a partial list of contributing factors.

One of the most significant factors not generally acknowledged in the discussion of physician burnout are the consequences of the generally awful system and software design and  poor business process integration that characterizes most office and hospital EMR products and implementations. Quite frankly, I believe that a significant contributing factor to physician burnout is the forced and strained conversion or more aptly the disruption of the conventional physician directed medical processes of history and physical examination as related to its capture by the available information tools. 

As noted in this slide presentation from the slideshare website (http://www.slideshare.net/fmeissner/dining-with-cannibals) some CPOE (computerized provider order entry) implementations have initially decreased provider efficiciency by as much as 20-40% over baseline values. Such a decline in productivity is unheard of in any other industry with respect to their computerization efforts. And too date there is limited, non-existant, or conflicting data to demonstrate that ultimately there will be payback for the time investments made in electronic transformation of professional medical processes.

This then represents what I believe to be the hidden dimension to the current epidemic of physician burnout -- MD/user fatigue and frustration related to the use of poorly designed and implemented information tools and the inappropriate deployment of information technologies that are designed for the benefit of every player/stakeholder in the care environment except for the physician and his patient.

Sunday, August 26, 2012

"Do or Do Not".... Yoda's 1st Law Of Health Quality And Performance Improvement

"Pay For Performance" May Have No Impact On Patient Outcomes.
The National Journal (3/29, Fox, Subscription Publication) reports, "One of the planks of the 2010 health care law, paying hospitals to improve the quality of care, doesn't appear to help patients survive any better," according to a study published in the New England Journal of Medicine. Investigators "compared two hospital systems over six years – one that took part in the so-called pay for performance plan offered by the Centers for Medicare and Medicaid Services, and one that didn't." Altogether, "more than 6 million patients went through the 3,600 hospitals from 2003 to 2009."
        Modern Healthcare (3/29, McKinney, Subscription Publication) reports that the investigators "say they found no significant difference in overall mortality between hospitals that participate in the program and those that don't."
        HealthDay (3/29) reports, "The researchers also found no differences in results for conditions specifically targeted by the incentive program, such as heart attack and coronary bypass graft surgery."

As many know, Bill Clinton's heart surgeon, Dr. Craig R Smith has some of the 'worst' statistics for heart surgery of any surgeon in the country. Why? because he is such a talented surgeon that he is willing to take patient's considered too high risk by less able physicians. Additionally, as the head of an internationally respected department of surgery committed to meaningful experimental surgical research, both he and his department have mortality statistics that reflect the sometime experimental nature of their work.

What this is all meant to emphasize is that all datum are not created equal. Unfortunately, simple measures of quality are simply that, simple. I would characterize anyone who tries to understand a complex system using simple measurements of that system and who expects profound insights on the system, or enhanced decision making from those measurements to be niave or disingenous.

Again, while I understand the drive to measure and the belief that the process of measurement will make things better, the ability to game the numbers and game the system, especially when such games result in superior renumeration makes the goals of the 'health quality' movement practically unrealizable.