Our Physician Informatics Group at University of Colorado Health has a book club. We read a book every couple months, and a recent book we read together was Patients Come Second. It is a provocatively titled book, but also timely, in the setting of physician burnout in our country.
There are lots of goals we have in informatics. We have aspirational goals, with lofty thoughts of building or partnering with Deep Mind or IBM’s Watson to have the machine learn about healthcare and build predictive models and seek and destroy wasteful non-productive treatments. These are like building the upper floors of a would-be skyscraper.
We have “keep the lights on” goals: squashing software bugs, seeking out reasons for “slow performance,” upgrading to the new software version, and fixing various things as they stop working. One wonders, exactly how many lines of code are required to run an enterprise EHR? Two million? Ten million? It’s a wonder more doesn’t happen day-to-day. This is like keeping the first floor of a building running smoothly.
Our foundation is crumbling, however, and this puts the entire structure at risk. I’ve been in informatics since 1998, and seen 3 major and countless minor EHRs come and go at our institution. I’ve played the cheerleader for years, setting the vision to modernize healthcare, one doctor, one clinic, one patient, one organization at a time. We’ve all held our breath, hoping that “the next version of software” will finally reduce the burden on our physicians. I’ve implemented major changes in the system for the benefit of patients (Open Notes, Open Results, online communication between patients and physicians), and physicians (Dragon speech recognition, remote access to charts, eliminating shadow paper charts, unifying many clinics around a single EHR database, establishing APSO notes as a default standard for improved readability, building EHR Genius Bars, creating EHR Sprint teams — more on this another time).
Between the burden of increasing federal regulation, the burden of increased documentation to justify the hard work that physicians do (“I certify that I personally updated the past medical, surgical and family histories in this patient’s chart”), and the requirements from the Joint Commission, interpreted from Medicare regulation:
The patient’s smoking status is … the patient’s fall risk is … the patient’s main concern today is … the patient’s score on depression screening is … the patient’s vital signs are … the patient’s past medical, surgical, family history is … the patient’s substance abuse history is … I certify I have reviewed the patient’s State Opiate Registry to ensure no inappropriate opiate use by the patient … the patient’s “exercise minutes per week” are … the patient’s answers to the 40 Review of Systems symptom questions (not related to current visit) are …
And then after being grilled like this, the patient can finally tell us: “why I am here today.”
On top of that, there are RAC audits: The Recovery Audit Contractor, the wolf-hounds contracted by Medicare to sniff out fraud, with the explicit arrangement that any inappropriately Medicare-billed visits in the past will be labelled fraudulent, and the monies returned to the Feds, often with penalties in the $$ millions, with a substantial fraction “earned” by the obviously highly motivated RAC auditor.
The joy of medicine has a smaller and smaller corner of the office to thrive in. Burnout.
Fast Company writes about it here.
JAMA writes about it here.
It is a stake through my heart that EHRs are commonly cited as the reason for burnout. Many of my major decisions of the past decade have been in the service of reducing this burnout, balancing what is best for patients with what is best for doctors.
Maybe it is time to ramp up the care-and-feeding of doctors, and let Patients Come Second, so that patient care can be joyful again, and patients can enjoy better relationships with their docs, and better overall healthcare. Sometimes a shakeup in attitude helps us look at the world differently.
I hear that some organizations are giving their docs the gift of time with certificates that can be spent asking a “gofer” to shop, to buy groceries, to help with laundry or dry cleaning, to shuttle kids to/from child care, to put gas in the car. Some are flexing their docs’ work hours to match family obligations (school children), while others are finding other ways to give back valuable time to harried docs.
How can we help Patients Come Second (so that everyone does better)? What can we all do to think outside the box, and bring joy back to medicine?