A Country Doctor Writes:

Physicians are generally highly motivated to treat their patients well, both in terms of clinically well and in a nice manner. When they don’t do that, it isn’t usually because of personality disorders or character flaws, but because their jobs are robbing them of their enthusiasm and compassion.

Sometimes it is our own fault that we get burned out. I realized this ten years ago today (!) when I read Claire Burge’s post about burnout skills. We are, by nature and by training, fixers and problem solvers. Because healthcare these days is so dysfunctional, many of us feel like we should be heroes and do “the impossible” in spite of limited time, resources, support and so on. When we do that, we get external praise or praise ourselves, so we end up doing it again. That can be a vicious cycle of always fighting uphills battles, ultimately at our own expense.

But many times, we risk getting burned out even when we aren’t over-capitalizing our heroism. Sometimes the everyday, totally routine tasks put us at risk for burnout. A lot has been written about moral injury in healthcare as a cause for burnout. I agree that can be a dramatic contributing factor sometimes, but I firmly believe the most fundamental cause of burnout is that we, trained clinicians, diagnosticians and decision makers, are put in the position of public health nurses and data entry operators.

This is a terrible waste of a medical education and a sure way to job dissatisfaction and burnout.

It is frustrating for physicians to hear that everyone in their organization except them should work “at the top of their license”.

Think about it:

A patient is due for their ten year colonoscopy recall. The surgical clinic sends an electronic message asking the primary care physician to make a referral so the insurance will pay. It isn’t enough to respond or forward a “MAKE IT SO” command. No, the physician has to create a non-billable encounter, locate the correct diagnosis code for screening for malignant neoplasms of colon, Z12.11, click however many times it then takes to indicate the provider or clinic and send the order off to the referral coordinator.

Or:

A patient comes in for a sore thumb and is behind on all kinds of screenings and chronic care. Instead of devoting the visit to making the correct diagnosis, bacterial paronychia versus herpetic whitlow, and then treating it correctly, the physician is now held personally responsible for catching the patient up on things that could have been figured out and handled by an unlicensed staffer under the supervision of a public health type nurse working with practice wide protocols.

If there were “efficiency experts” analyzing what we do in healthcare, would they really recommend that the people with the highest degree of education do the most basic functions of data entry and checking off health screening protocols?

I find the priorities of modern primary care bewildering. I personally feel less burned out when I double book sick patients or stay late to take care of a complex new patient than when I am put in a position of bookkeeper. If I wanted to be an accountant or a public health nurse, I would have gone to school for that.

The Counterintuitive Concept of Burnout Skills

I used to teach photography and dark room techniques. Now that I only use my iPhone for picture taking, I have forfeited many of the tools that used to help me tell a good story within a photograph.

We may only have 15 minutes with each patient. At least in my opinion, that means you always have to make the choice very early in the visit between going narrow and deep or wide and shallow. A sore knee or an annual physical are like a closeup or a panorama. I can take both kinds of pictures with my iPhone.

In primary care it is often necessary to think in terms of including more than our area of interest in our mental picture of our patient. But if we keep everything in sharp focus, we won’t pay enough attention to solve the problem at hand.

So my mental picture of the problem area ends up being like a photograph with everything surrounding the center of the picture a bit blurry. But that’s not what my iPhone pictures or my EMR notes tend to look like.

The way my EMR prods me to document is by default either panoramic or closeup. My system lets me choose whether to import everything or essentially nothing from the patient’s past medical history. And the past medical history reminds me of a bag person, dragging around everything they own in a stolen supermarket shopping cart. It is a hodgepodge of structured and free texted data that seldom gets updated because of our constant time pressures.

The past medical history has historically been abused by other specialty providers using a common EMR. Some of them have chosen to list everything the patient doesn’t have wrong with them, almost like what a primary care provider calls a review of systems, but under the heading originally meant to give providers a snapshot of each patient.

If a patient only has one medical problem and never had any surgeries, why would any reader of their medical record prefer to view one or more full screens or pages of what has NOT happened to this patient, at least not as of some date in the past when that was nailed down as the patient’s medical profile.

The old paper problem list on the inside left of the chart was by necessity brief, because a page can only hold so much information. Computer scrolling changed all that.

In primary care it is usually sufficient to know that a patient has had two myocardial infarctions and one coronary bypass. I don’t really need the details in order to know how to consider this patient’s risk for future cardiac events.

What I end up doing because of the messy bulk of data in the EMR medical history is insert a macro that says the past history was considered in the visit but not included in the note. I then more and more dictate relevant past history in what I call my visit abstract in my aSOAP note.

It may look something like this:

40 year old male has a normal routine physical. His 10 year cardiovascular risk is average but his BMI is approaching 30. Dietary strategies reviewed.

What more do you really need to read next time you look through his chart?

Or it may look like these examples:

60 year old male with hypertension, COPD and anticoagulated atrial fibrillation returns for followup. No treatment changes made but he has noticed a lump in his lower abdomen and altered bowel movements. Labs and CT scan ordered, anticipate diagnostic colonoscopy.

(The rest of the note is more for billing and prior authorization purposes.)

72 year old female with diabetes and heavy atherosclerotic burden presents with two weeks of increased dyspnea and weight gain as well as increased thirst and episodes of blurry vision. In-house HbA1c is 9. Revisited diet, increasing basal insulin and furosemide dose. Recheck 2 weeks.

(The rest of my note serves little purpose under normal circumstances. If anyone wanted to know that there were bibasilar rales or that the EKG was normal or that the last potassium was fine or that the patient had changed her diet against medical advice, it would be there, further down the screen.)

So, I am again making the case that, by necessity, we often need to compensate for the exaggerated comprehensiveness of the charting tools we are made to work with. The aSOAP note can bring the best aspect of the paper chart into the EMR.

My nurse regularly gets at least 50 voicemails every day, many saying “please call me back”.

I have one patient who frequently tests the patience of our clinic staff by calling multiple times for the same thing. He is the most dramatic example of what seems to be a widely held belief that physicians, nurses and medical assistants sit at their desks and answer phone calls all or most of their time. But when we do, we are often hampered by busy signals, phone tag or “voice mail not set up”. Electronic messaging isn’t a panacea, because patients don’t necessarily know what we need to know in order to answer their questions correctly and efficiently at first contact.

Pharmacies, too, create duplicate requests that bog down our workdays. In my EMR, if an electronic refill request doesn’t get a response the day it comes in, the “system” sends a repeat request every day until it gets done. This is one reason I look like I am further behind on “tasks” than I really am. To top it off, every single refill request generated by the “system” comes with a red exclamation point next to it. This happens even when a patient has just picked up their last 90 day refill – a case where I theoretically should have 89 days to respond. Meanwhile, my system has no way of flagging truly urgent refill requests. This “alarm fatigue” is common in EMRs today.

The business model in today’s healthcare is that reimbursable activities (seeing patients in person or via telemedicine) are scheduled back to back, all day long. There is a universal assumption that this will still provide enough slack to deal with prescription refills, phone calls, incoming reports and the further ordering and feedback to patients prompted by them. And did I mention EMR documentation? Multitasking, or rather, constantly switching between different kinds of tasks, is not a sane or efficient way to work.

Providers, as salaried employees, are universally expected to get their work done on their own time (jokingly called “pajama time”). This creates varying degrees of stress and burnout. But nurses and medical assistants have a different stress. As hourly employees, they are theoretically entitled to overtime pay if they can’t finish their work during their normal working hours. But that is expensive for healthcare organizations and often discouraged or forbidden.

In Sweden, known for its somewhat stodgy bureaucracy, clinics almost universally have “telefontid”, a portion of the day when patients can call, or when staff are not seeing patients but returning calls – the details can vary. This may not be ideal customer service, but it at least acknowledges that multitasking in healthcare isn’t always necessary and certainly not healthy.

A growing trend in this country, mysterious to me and a generator of patient frustration and employee stress, is that in spite of all our expensive computers and phone systems – or perhaps because of them – most clinics, even large organizations, can’t afford to have someone answer the telephone.

St Joseph Hospital in Bangor usually answers on the first ring, and the main operator (I know her voice well) is efficient and helpful. My mother worked as an operator for a big hotel and also at one point the phone company. I remember watching her efficiency plugging in those little cables to transfer callers to the right department. Most clinics and hospitals tell you to hang up and call 911 if you’re in trouble and make you “listen carefully” to all the options, threatening that they “may have changed” and eventually you end up in somebody’s voicemail.

When everybody is talking about patient centeredness, customer experience and such things, why isn’t it obvious that incoming calls and other types of requests need to be prioritized as they arrive and not just dumped, unsorted, in someone’s voicemail or inbox?

Organizations appear to be paranoid about being held responsible if non-clinicians are put in a position to “triage” incoming calls. But it isn’t rocket science – everybody does it at home, with their kids, pets and themselves. I believe it may be an even greater liability to have an automated telephone system people get lost or stuck in.

Here are two slides from a staff education talk I gave 10 years ago about common sense telephone triage.

The telephone used to be a powerful tool, connecting people with businesses, services and each other. It no longer works like it used to, because nobody’s answering.

The Art of Medicine is such a common phrase because, for many centuries, medicine has not been a cookie cutter activity. It has been a personalized craft, based on the science of the day, practiced by individual clinicians for diverse patients, one at a time.

Unlike industrial mass production, where everything from raw materials to tools to manufacturing processes are standardized and even automated or performed by robots, physicians work with raw materials of different age, shape and quality in what is more like restoration of damaged paintings or antique automobiles.

The Art of Medicine involves knowing how and with which tools to take something damaged or malfunctioning and make it better. There are general principles, but each case is different to at least some degree. In many cases there are different ways to improve something that is malfunctioning, but patients may prefer fixing certain aspects of a complex problem because of their individual needs.

Restoring a very old car may be a different process depending on its intended use, like parading it in car shows or driving cross country. Patients’ desires and expectations can vary just as much.

The view on optimal treatment of high blood pressure has become a vision of automation to the degree that many have proposed letting pharmacists follow protocols, actually prescribing and dispensing medications for better control.

But patients don’t usually fit into such manufacturing mode paradigms. Some hypertension patients also have swollen legs, rapid heart rates or blood pressure spikes when feeling stressed. Some have naturally low potassium levels or cold feet in the winter. A careful and individualized choice of blood pressure medication can make the whole person feel and function better, treating more than one thing at a time. Knowing all the available medications intimately is infinitely more valuable to the patient than blindly following the treatment algorithm of the day – because we have all seen them come and go.

To paraphrase Hippocrates: The Life of algorithms is short, the Art of practice is long.

My recent post about weight loss myths generated more page views than anything else on my blog (9,394 and counting) and more comments, many arguing back and forth between them. A few were by board certified obesity experts who made the claim that fighting obesity is pretty much like rocket science – not something you should dabble in with just a regular MD degree.

Now, I’m just a Country Doctor (I imagine saying this with a slow drawl), but I have trouble understanding why this should be so.

I don’t think it’s rocket science to start with the premise that over the last few hundred years the human genome has not changed, but our habits and environment have. Sometimes those things have direct consequences and sometimes they change gene expression (epigenetics).

So if we look at what has changed parallel to the obesity, diabetes, cardiovascular and autoimmune epidemics, it is hard for me to accept the comment someone made that food has nothing to do with obesity.

We, as a culture, eat differently from one or two hundred years ago, and much has been written about the health benefits of eating a less processed, more natural diet. From Paleo to what the Functional Medicine movement calls “ancestral diet” these shouldn’t be shocking, radical or controversial ideas, yet they seem to be. I can understand that the food industry is fighting this movement vigorously, but I wonder why parts of the clinician community also are.

I live next to an Amish community, where children play in the dirt and with barn animals. They have fewer allergies than urban children in highly sanitized environments. The rate of obesity in the Amish is 4%, compared with 36% in the general population. The Amish typically walk 14,000 to 18,000 steps per day – far beyond the idealized 10,000 typical goal. They also do more manual labor beyond just walking. Their diet is not Paleo or ancestral, but quite high in meat, bread and root vegetables; you’d have to emulate more old fashioned habits than theirs to fit into those categories. But the differences between their statistics and ours are startling according to BMJ, the British Medical Journal:

Prevalence rates for diabetes, hypertension and hypercholesterolemia were 3.3%, 12.7%, and 26.2% in the Amish compared with 13.2%, 37.8% and 35.7% in NHANES (p<0.001 for all).

The Amish are a powerful illustration, with the caveat that they are a fairly homogenous genetic group, that a physically very active lifestyle (beyond the goals of many of the rest of us) is linked to low levels of obesity, and its related conditions. But if we don’t have that activity level, what impact does diet have on the prevalence of these diseases?

The Mayo Clinic states plainly:

Although there are genetic, behavioral, metabolic and hormonal influences on body weight, obesity occurs when you take in more calories than you burn through exercise and normal daily activities. Your body stores these excess calories as fat.

Most Americans’ diets are too high in calories — often from fast food and high-calorie beverages. People with obesity might eat more calories before feeling full, feel hungry sooner, or eat more due to stress or anxiety.

So, if the Mayo Clinic says so, I’ll simply start with the premise that food matters. It may be fascinating to some clinicians exactly which endocrine mechanisms are involved in the causation of obesity, diabetes, heart disease and so on. Again, I’m just a Country Doctor and it’s enough for me to ask, first, are you planning your meals in advance and consciously choosing portion size and, second, are you eating a lot of things that weren’t invented a couple of hundred years ago?

That’s a good start, in my humble opinion. It often leads to a plan for reversal of these disease processes right then and there. Even if the details of exactly how that happens may require another board certification or even a PhD.