“Connected cogwheels” is an apt description of how our health-care system is supposed to support patients through their health-care journey (with thanks to Dr Laura Desveaux for that analogy).
Physician burnout, however, can clog those wheels.
On April 4, I was invited to take part in a round table hosted by AMS Healthcare in Toronto along with a team from OntarioMD currently working to evaluate many of the digital domains related to physician burnout.
The mission statement for AMS is: “Our work advances a Canadian healthcare system through innovation and technology while remaining rooted in compassion and our medical history. We convene networks, develop leaders, and fund crucial activities in medical history, healthcare research, education, and clinical practice. Our work helps improve care for all Canadians.”
The Mission statement and vision for OntarioMD is: “OntarioMD’s culture is anchored in a clear vision, mission and a set of values essential in delivering next-generation EMR technologies, products and services. Across Ontario, we strive to make a meaningful impact to support physician practices and the patients in their care.”
So, it’s entirely appropriate that these two organizations should finally collaborate on the issues of burnout, potential solutions for health-care providers and address the creep of technology into clinical workflows impacting patient care, threatening compassionate care rather than supporting it.
AMS is hosting an invitational only session April 25. This session is a further opportunity for an exchange of ideas on compassionate care, and a potential “call to arms” to rescue desperate providers from burnout and improve patients’ experiences.
I do not want to pre-empt the work being done by these organizations for this coming session, but I do want to share what I have learned thus far; some of the perspectives I have been exposed to in this journey to reconcile the holistic and compassionate components of care with digital-health technologies.
Here are some thoughts and learned experiences thus far:
- We must consider all actors working within the health-care system to support the patient journey. Adding or changing one component of the clinical workflow – digital or otherwise – no doubt impacts the workflows of all the other actors within that circle of care. What might lessen administrative burden and burnout for one might very well increase it for another. My own experience with the transition from fax to Health Report Manager (HRM) in my Electronic Medical Records (ERM) would be an example. When paper-based, I signed off hundreds of faxes every few days in a mere 10- to 15-minute session; my secretary, however, then needed to file all this data, a task that took hours and required extra staff to assist her. My admin burden was shifted downstream. Now however, those documents come directly into my inbox, creating a significant reduction in administrative time for my staff, but adding hours a day to my own EMR admin time, contributing to burnout.
- Our health-care system and all its digital modalities are pushing toward “high-volume, lower physician touch” – great efficiency and increased throughput. But at what cost? As Ian McWhinney points out in his 1988 article, family physicians are rooted in efficacy and compassionate care, outcomes that may not be captured by the pure metrics of “visits per day” or “disease outcomes.”
“Constraints are always present, but clinical freedom allows practitioners the flexibility to make difficult choices between competing priorities. The choices may range from decisions about how much time to spend with a particular patient to the allocation of the practice’s resources among preventive, clinical and managerial functions. With this freedom goes the moral obligation to do everything needed for the individual patient and to use the least resources necessary to attain this end. Family physicians are notable for their restraint in using resources without impairing the quality of care. At the same time, they strongly resist measures designed to limit services at the point of care in the name of efficiency. To clinicians, efficacy – and not efficiency – has the higher value.”
To clinicians, efficacy – and not efficiency – has the higher value.
Our digital systems focus on “gathering and profiling of data” well beyond what is clinically necessary. Forms and platforms meant to facilitate consults or referrals often increase administrative time but will claim “wins.” Case in point, I recently completed an application for a patient requiring Budesonide oral to manage the patient’s microscopic colitis. This application requires submission on the Ontario Drug Benefit platform under Exceptional Access Program (EAP). The first submission was multiple fields, each one expanding to ask about prior meds used, their stop-start dates, their dosing and their success. The application took more than 15 minutes of chart review and compiling answers. I received a reply in only a few hours –incredible turnaround time and thus very efficient. However, what came to my inbox was a request for more information.
Baseline severity of abdominal pain (e.g., pain scale out of 10): ______________
Severity of abdominal pain while on Entocort (e.g., pain scale out of 10): _______________
Baseline frequency of diarrhea: ________ times per day.
Frequency of diarrhea while on Entocort: ________ times per day.
Provide the patient’s response to an Entocort withdrawal trial. Provide details including the date of discontinuation, description of symptoms and response to restarting treatment. If the patient has not attempted a withdrawal trial, please provide rationale.
Prescriber Signature:____________________ Date:____________
From the Ministry of Health viewpoint, this is incredibly efficient: high-fidelity data with metrics that would make any health analytics person’s mouth water. The cost, however, is incredible administrative burden upon the family physician. A great example of one routine affecting others in the cogwheels of health care.
- We can learn from prior societal experiences when newer technology is about to be introduced. We are on the brink of another technological revolution with AI automation/optimization of clinical workflows. Similar to the industrial revolution of the 1900s, lives of patients and providers will be changed beyond belief in this advance in digital health systems.
Doctors will find their knowledge of certain disease states rapidly become obsolete and may even find themselves competing professionally with the wealth of online data that will allow patients to become experts in their own conditions. One might only prompt a query to ChatGPT and quickly see how easy it is to find detailed, expert online information. Whether that information is validated or unbiased is a whole other issue, but no doubt doctors soon will have to “compete” to prove themselves against AI models. We can only wonder how far the societal desire for immediate medical knowledge will take us in replacing the interactions between patients and their providers.
Ursula Franklin’s descriptions of prescriptive vs. holistic technology may serve us well in understanding how to navigate this next revolution. I would strongly suggest listening to her podcast: The real world of technology. Another excellent read is In the hands of Doctors – Touch and Trust in Medical Care. The author speaks to the idea of “high technologies;” ultimately the challenge is not the technology and its threats of change but how physicians will accept that change.
There will be wins in this revolution.
Recently, I adapted using an AI-based scribe in my clinical workflow during patient visits and it has improved my time with patients. My notes are more detailed and dictated immediately during the encounter, allowing me direct eye contact during the interview. I pause periodically and validate my dictation, seeking a nod of approval from my patients, thus including them as partners in the SOAP (Subjective Objective Assessment Plan) note creation. This technology is an example of giving me back time – time thus spent to optimize compassionate care. Sometimes the interview ends early enough for me to ask patients about their families, their hobbies or their recent travel adventures. I can become a friend with expertise again as McWhinney describes.
There is much to be done to change direction in our failing health-care systems. Some change will be personal and require cognitive realignment. Some change will require rebellious disruption and just simply “insisting on what is right and changing the status quo.” We will challenge the idea that, as Franklin describes, there is “only one way of doing things.”