Operational improvements are more important than resiliency.
By Rob Schreiner, M.D.
Dr. Carl Goolsby remembers those days. No matter how early heâ€™d arrive at the office to prepare his charts for the dayâ€™s patients or remain in the office after the patients and staff had left, he couldnâ€™t stay ahead of the workload.
He was well-trained, with a disciplined work ethic that attested to his military background, yet the workload of his family medicine practice in east Paulding County seemed insatiable. Moreover, the proportion of his time devoted to the work that only he could do (medical reasoning to reach the right diagnosis in the least amount of time, balancing multiple medications for multiple conditions and managing the patientâ€™s wellness longitudinally) had given way to clerical work, despite every member of his team working hard every day, including his three Advanced Practice Professionals (APPs).
Dr. Goolsby began to feel emotional exhaustion, depersonalization toward his patients and that he was no longer making a difference in the lives of his patients â€“ the telltale triad of physician burnout. He was offered enrollment in a Physician Resilience Retreat. While that experience might have left him better equipped to tolerate the chaos of the workday, it wouldnâ€™t actually improve the chaos of the workday.
At the same time, 20 miles away, Ivy Spencer, chief nursing officer of the WellStar Health System, envisioned a better office flow for primary care offices, one that combined better teaming, optimal EMR use and top-of-scope practice for all team members. But she needed a willing physician partner to refine her design and test its deployment. She found that partner in Dr. Goolsby.
Before I tell you how they did what they did, let me tell you the results of that intervention, sustained for each of the eight consecutive months since roll-out of the office changes:
â€¢ Dr. Goolsbyâ€™s symptoms of physician burnout resolved. He was starting and ending the day on time, with much less after-hours chart completion in the EMR (closing more of his charts during the day). He was spending more time with his patients. He was eating lunch daily with his staff, discussing the sessionâ€™s patients and office flow, rather than finishing charts in his office alone.
â€¢ Quality metrics improved. Rates of pneumococcal vaccination, colorectal cancer screening, depression screening, fall-risk reduction â€“ all improved 9-35 percentage points
â€¢ Patientâ€™s perception of clinician-patient communication (cg-CAHPS Physician Communication Composite) improved by 12 percentage points and continues to rise
â€¢ No office staff have left since the intervention (zero turnover in 8 months, front-office or back-office, whereas turnover rates prior to the intervention, while low, were not zero)
Alright. Hereâ€™s how they achieved that turnaround.
Elevate Everyoneâ€™s Proficiency on the EMR. A team of three clinical informatics nurses spent two weeks in the office training the entire team beyond the basics. (Medical assistants, nurses, APPs and Dr. Goolsby all learned how to make patient flow check-in to check-out quicker with more complete documentation, using menus of ordering preferences, and more efficient patient outreach and resulting of tests.) Specialty-specific physician advisors taught Dr. Goolsby and the APPs better use of time-saving EMR functionality. All too often EMR training is treated as a â€œone-and- doneâ€ at the time of deployment, yet we physicians are, or ought to be, continuous learners in everything we do, including how to best use the current and evolving functionality within the EMR.
Optimize the Staffing Ratio. In an attempt to be as lean as possible, Dr. Goolsby had reduced his staffing to one CMA devoted to his day, with a portion of a shared RN. Adding two LPNs to the practice of four clinicians (Dr. Goolsby plus 3 APPs; 0.5 LPN per clinician) to give injections, do patient education, close care gaps, clean out the InBasket and handle patient paperwork, substantially offloaded clerical duties from the clinicians, enabling them to spend more time with patients and families, with more time to think.
Deliberately Improve Teaming Attitudes and Behaviors. For two decades now, a great deal has been published regarding the benefits of teaming in healthcare, yet we as a profession have not adopted nor spread those teaming best-practices as widely as we should. AHRQâ€™s Team- STEPPS training was used as a template for Dr. Goolsbyâ€™s and Ms Spencerâ€™s cultural enhancement on the team. Teaming can be taught for the betterment of patients, colleagues and staff.
This Solution Works for the Majority of Practice Settings.Â Dr. Goolsbyâ€™s and Spencerâ€™s success at improving office work flow, thus reducing clinician and nurse burnout, canâ€™t be considered unique. But the point is that their three operational enhancements described above are more effective than physician resiliency training. And interventions such as theirs that (1) improve office flow for all, (2) optimize everyoneâ€™s use of the EMR and (3) restore time and space for the physician to do what she/he is best- equipped to do (e.g., medical reasoning and interacting with patients and families) are evidence-based.
We should deploy those operational interventions more reliably. Iâ€™ve got nothing against taking personal accountability for oneâ€™s happiness and using well-facilitated time away from the office to enhance self-insight, self-awareness and self-control. Indeed, my personal and professional maturity have benefited from insight gained with Covey, Myers-Briggs, Herman Brain Dominance Inventory, StrengthFinders, TKI and more. But the idea that physicians are the cause of their burnout (â€œthey just donâ€™t make â€˜em like they used toâ€) is inaccurate and harmful.
For more information about how we physician leaders ought to be changing operational flow for the betterment of our colleagues and the patients and families they serve, consider any of the following recent papers:
Erickson SM, et al. Putting patients first by reducing administrative tasks in health care: a position paper of the ACP. Ann Intern Med 2017;166:659-661.
Olson KD. Physician burnout â€“ a leading indicator of health system performance. Mayo Clin Proc Nov 2017;92(11):1608-1611.
Sternberg S. Do Electronic medical records breed burnout? US News and World Report: diagnosis burnout. 2017. Pages 12-13.
Dr. Schreiner thanks Dr. Carl Goolsby and Ms. Ivy Spencer for allowing him to tell their story.
Dr. Schreiner is president of WellStar Medical Group. He is a pulmonary and critical care physician and a past president of the Medical Association of Atlanta.