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10/26/2015
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Joy in Practice:Reconnecting with the Meaning and Mission of
our Work
19th Annual Management of the
Hospitalized Patient UCSF
Christine A Sinsky, MD, FACPOct 15., 2015
Disclosures
• Advisory board for healthfinch
• (HIT start-up)
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Agenda
• Introduction – Burnout
• Meaning and Mission– Begin to unravel the knot keeping us from meeting our best intentions
– Focus on impact of Documentation/Regulation
– Importance of matching the work to the worker
• Recommendations– High level multiple actors in healthcare ecosystem
– Create space to reconnect
• Discussion
Joy Triple Aim
• Engaging physicians
• Unleash professionalism
• Better care
• Better health
• Lower cost
Quadruple Aim
Take-away: Attending to joy in practice
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Approaches professionals as knaves and pawns, the more kn and pnbehavior
Deep growing dissatisfaction…Imbalance of forces
I
Knights, Knaves or Pawns
JAMA. 2010;304(9):1009-1010 (doi:10.1001/jama.2010.1250)
Core Q: How can we contribute external environment approach physicians more
Nearly ½ of MDs Burned OutArch Intern Med 2012; E1-9
Many physicians would not choose againCalculus: spending d doing wrong work
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Nearly ½ of MDs Burned Out
General Internal Medicine
Arch Intern Med 2012; E1-9
http://www.medscape.com/features/slideshow/compensation/2013/public
Hospitalists ~ GIM
J Hosp Med. 2014 Mar;9(3):176-81
Calculus: spending d doing wrong work
Burnout affects Patients
Physician burnout is associated with…o ↑ Mistakes o ↓ Adherenceo Less empathyo ↓ Patient satisfaction
Sources: Shanafelt Ann Surg. 2010;251(6):995-1000; Dyrbye. JAMA 2011;305:2009-2010.; Murray, Montgomery, Chang, et al. J Gen Intern Med 2001;16:452–459.; http://www.ncbi.nlm.nih.gov/pubmed/10672116
Landon, Reschovsky, Pham, Blumenthal. Med Care 2006;44:234–242.; http://psnet.ahrq.gov/resource.aspx?resourceID=1909
http://journals.lww.com/academicmedicine/Fulltext/2011/03000/Physicians__Empathy_and_Clinical_Outcomes_for.26.aspx
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My health, safety and well-being as a patient in your care are absolutely linked to your own health, safety and well being.
Meg Gaines, founder UW Center for Patient Partnerships, personal communication 8.21.14
Burnout Costs Organizations
Physician burnout is associated with…o ↑ Malpractice risko ↑ Part timeo ↑ MD and staff turnovero $250,000 to replace MD (1999)
Am J Man Care Nov 1999:5(11):1431-1438Am J Man Care Jul 2001;7(7):701-713Health Serv. Res. Oct 2004;39(5):1571-1588Med. Care Mar 2006;44(3):234-242Journal of Applied Psychology, Vol 73(4) Nov 1988, 722-735 http://psycnet.apa.org/?&fa=main.doiLanding&doi=10.1037/0021-9010.73.4.727
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Burnout May Cost US Healthcare
Physician burnout is associated with…o ↑ Referralso Workforce
o $500,000 to train one MD
Social Science and Medicine 1999; (48):547-557 Family Practice doi:10.1093/fampra/cmt060. Arch Intern Med. 2011;171(17):1582-1585http://content.healthaffairs.org/content/29/5/835.full
Burnout Costs Physicians
Physician burnout is associated with…o ↑ Disruptive behavioro ↑ Divorceo ↑ CADo ↑ Substance abuse/addictiono ↑ Suicide (2-4 x)
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Burnout in Hospitalists
1/3 likely to leave w/in 2 yrso “Glorified resident”o Lack of longitudinal care
Depressiono 40%o 9.2% suicidal
J Hosp Med 2014 Mar;9(3):176-81
http://well.blogs.nytimes.com/2012/08/23/the-widespread-problem-of-doctor-burnout/
1 in 2 US physicians burned out implies origins are rooted in the environment and care delivery system rather than reflecting weakness on part of a few susceptible individuals.
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50+ organizations
Obs: 70-80% work effort,
Not add value or not need done; surprising #
Finely ingrained, do not see it
½ Re-engineering½ Mismatch policy/tech
Ultimately hopeful
Solvable problems
Individual can’t solve alone
By coming together, understand fitmultiple stakeholders can make a signifimpact.
External environment?
Three Studies and an Email
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Physician Career Satisfaction
• Quality: Major Driver of Satisfaction– Dissatisfaction: Early warning sign of dysfn
http://www.rand.org/news/press/2013/10/09.html
Physician Career Satisfaction
• EHR: Major Driver of Dissatisfaction– Too much time per task, clerical
– ↓ Face-to-face time
– ↓ Quality of visit note
http://www.rand.org/news/press/2013/10/09.html
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JGIM 2014 29(Supple 2):S555-62
Top 3 of 4 Challenges: EHRVA
↑ EHR Functions MD Burnout and intent to leave practice
http://jamia.bmj.com/content/early/2013/09/04/amiajnl-2013-001875.short?rss=1
Fn’s: CDS, alerts, reminders, e-mail w/pts and colleagues
JAMIA 2013
4
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“I am no longer a physician but the data manager, data entry clerk and steno girl. I am frustrated, unhappy and I am unable to do my best in caring for my patients. I became a doctor to take care of patients. I have become the typist.”
physician, Boston 2013
Burnout is the sum total of hundreds and thousands of tiny betrayals of purpose, each one so minute that it hardly attracts notice.
http://www.theatlantic.com/health/archive/2014/02/for-the-young-doctor-about-to-burn-out/284005/
Tipping pointPerfunctory workUnsustainable
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The EHR has been devastating. We can no longer teach medical students due to the time it takes to enter (primarily useless) data; I now see half as many patients and I actually spend less face time with these fewer patients. Working in clinic has become so painful that I have decided to leave my beloved patients—unbearable to think about.
Betrayals of purpose
• 18 clicks to do one fn• EHR “so cluttered w/ non-information, hard to review past, so don’t”• “I used to leave at 6:30 and feel good about work; now leave several
hours later and spend time on weekends catching up.”
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ER physicians
• 10 hr shift
• 44% data entry
• 4000 clicks
• 28% pt care
Hospitalist
• 23% direct pt
4000 clicks per day
Am J Emerg Med 2014;31(11):1591-1594J Hosp Med 2010;5(6):353-9
Tiny betrayals of purpose
Clinical Documentation
The patient presents with palpitations. The onset was just prior to arrival. The course/duration of symptoms is resolved. Character of symptoms skipping beats. The degree at present is none. The exacerbating factors is none. Risk factors consist of none. Prior episodes: none. Therapy today: none.
– Six pages, no meaning; Pt’s story? Dr’s thinking? Care?
– Like many barriers, etiology complex– End result: compromise of clinical quality and efficiency
Billing templatepseudotext
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The patient’s story matters
More than waste
More than sum of drop down boxesHx generic, see pt genericStop fully listening
Listen to your patient, he is telling you the diagnosis.
Sr Wm Osler
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Matching Work to Worker
Worker is over trained for the task
Worker is under trained for the work
Complexity of work
Training
Unsafe
Inefficient (Waste)
Sweet spot: worker and work are well matched
Modified from A. Mulley
Y
X
calculus: wrong work
Current Work Distribution
Complexity of work
TrainingMA RN RN NP PA MD
Med rec
Data entry
Inbox mgmt
Relationship bldgComplex chronicDx and Rx plan
Shared decision making
Script renewals
Prior authorizationData gathering
VitalsPAs
“Production Line”
High value
Good match
“Solution Shop”
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“In few other sectors of the economy is the highest-level professional responsible for the majority of production, customer service, and clerical work.”
SGIM Blue Ribbon Panel Report. Redesigning the Practice Model for General Internal Medicine: A Proposal for
Coordinated Care. J Gen Intern Med 2007;22:400-109
Matching Work to Worker
Complexity of work
Training
Med rec
Prior authorization
Data entry Script renewals
Inbox mgmt
Data gathering
Vitals
Allows greater MD focus on high
complexity tasks
E/M acute sxChronic illness ca
Bio/psycho/social Shared decision m
MA RN RN NP PA MD
“Solution Shop”
“Production Line”
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Documentation specialist?
Round with nurse, pharmacist, SW
David ReubenUCLA
• “Physician Partners”– COE
– Charting
• JAMA IM 5.14– Pt satisfaction
w/MD time ↑
– Save 1.5 hr/4hr
• Training Academy
Innovation
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Brilliantly gifted doctors forced to run patients through an electronic treadmill
http://www.medscape.com/viewarticle/847711?src=wnl_edit_specol&uac=93495FK&impID=844582&faf=1
Malcolm Gladwell
Reduce Burnout in Hospitalists
• ↓ Time pressure• Teams: documentation specialists
• ↓ Chaos• Checklists
• ↑ Control over work• Flexible scheduling
• ↑ Values alignment with leadership• Swartz conference
• Administrators join rounds
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Be BoldAction Step: Institutions
We have developed a new mental model:
Pull the doctor out of the infrastructure (typing, EHR, etc) and get them back to being present to the patient.
David Moen, MDDirector Care Model Innovation, Fairview Clinic MlpsPersonal communication 2.10.10
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Finding Meaning in Medicine Story Telling Sessions: Humility, Compassion, Gratitude
Dr. Rachel Naormi Remen
“Spread like wildfire around our 44 hospitals” Dr. Ted Hamilton, VP Medical MissionAdventist Health System, FL
Swartz Center RoundsAction Step: Institutions
Multi-disciplinary rounds to discuss difficult emotional and social issues; belonging to team, compassion, respect
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Protected TimeAction Step: Institutions
10-20% time on QI projects, patient safety or other passionsJGIM 2013; 29:18-20
ResearchTests Treatment
>$100 Billion/yr
Delivery model to wisely deploy
<$0.3 Billion/yr
Action Step
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Practice Science
Systems Eng.
Human Factors
Action Step: Invest more in
To study innovations and optimize the delivery models
Industry 2.0%Health 0.3%
19th of 22 industries
http://jama.jamanetwork.com/article.aspx?articleid=2089358
Cognitive InterruptionsActivity Timebelt
Pre-CPOE
PostCPOE
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Avoid Compliance CreepAction Step: Institutions
Physicians overwhelmed w/clerical work; origins complex MU CPOE
Rethink SignatureAction Step: Regulators
Hrs/wk, do not add value
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Less is MoreAction Step: Measure Developers
Keep it simple, add it up
New Roles for Nursing WorkforceAction Step: Educators
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Relentless Focus UsabilityAction Step: Vendors
Vibrant community start ups EHR apps
AMA’s Strategic Focus Areas
HealthOutcomes
MedicalEducation
PhysicianSatisfaction &
PracticeSustainability
50
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www.stepsforward.org
• Teams– Expanded rooming– Team documentation– Pre-visit planning/lab– Team meetings– Daily huddles– Hospitalist
• Culture– Preventing Burnout– Resiliency– Wellness in Residency– Transforming culture
Transformation Toolkits
• Value– Panel management– Medication adherence– Burnout Prevention– Diabetes prevention– Hypertension
• Technology– Telemedicine– EHR implementation
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Collective work
IJAMA. 2010;304(9):1009-1010 (doi:10.1001/jama.2010.1250)
Knights, Knaves or Pawns
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Take-away: Attending to Joy in Practice
Joy Triple Aim Quadruple Aim
The Map is not the Territory
Steve Martin MD and Christine Sinsky MD
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The Map is not the Territory
"If you didn't document it, it didn't happen,"
Fresh ears are told in medical school.
But then one day we realize that documenting doing doesn’t make it so,
Experiencing makes it so.
"Visited patient in her basement.
Ascites worsening as she drinks more
after death of son in motor vehicle accident."
What more should I write?
How do you document bearing witness?
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The Code is not the Care
The Pocket Guide:
It folds like origami
and reads like computer code,
this item we received early in residency.
In small font and syllogism,
It tells us what our time with a patient is worth.
It sustains anachronisms
like the review of systems.
Three chronic conditions is the key
that opens a Level 4 lock.
Now we hear these notes are being poorly done.
They have too much.
They have too little.
They don’t have the right elements.
Doctors need better education.
They need more detailed notes.
We also hear there is burnout.
Access problems for patients.
People leaving primary care
or not entering it.
We hear EHRs are good.
We hear they are bad.
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Why don’t we start at the beginning?
The care of the patient is what matters most.
The map is not the terrain.
The code is not the care.
Colleagues have left practice
Unable to keep up
with the note-production complex.
Charting encroaches on caring.
This is what happens when a means
for recording meaning
is alchemized into a tool for billing,
a means for monitoring,
a line of defense.
The patient-doctor “conversation”
becomes an act of distraction,
lapsed eye-contact,
and keyboard tapping.
This is pawn activity.
Finishing a patient session becomes prelude
to converting it into billable accounts.
We rush.
Patients notice.
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The map is not the terrain.
The code is not the care.
Doctors got to where we are
because we follow rules well.
What to do then,
when the rules
erode
our doctoring?
The map is not the territory.
The code is not the care.
Collective work
IJAMA. 2010;304(9):1009-1010 (doi:10.1001/jama.2010.1250)
Knights, Knaves or Pawns
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Take-away: Attending to Joy in Practice
Joy Triple Aim Quadruple Aim
Discussion
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