Serious work put into making primary care fun again

Innovative clinics say redesigning the flow of care and freeing doctors from administrative hassles may boost physician satisfaction.

By — Posted June 3, 2013

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Amid alarming rates of physician burnout, hundreds of clinics nationwide are redesigning their practices with a goal in mind beyond improving the quality of care. They are aiming to make life as a primary care doctor enjoyable once more.

Twenty-three of these clinics are profiled in a report in the May/June Annals of Family Medicine that describes practice innovations that can ease the chaos, administrative overload, miscommunication and computerized busy work that too often characterize primary care. These clinics find that planning visits ahead of time, delegating more tasks to nurses and medical assistants, holding daily meetings and using standing orders for recurring items not only improves patient satisfaction but also creates happier doctors.

Physician satisfaction is an essential ingredient in transforming the delivery of medical care, said Andrew Schutzbank, MD, co-author of the Annals of Family Medicine study. He also is assistant medical director of Iora Health, a Cambridge, Mass., physician group that started in 2012 and operates several primary care clinics.

“All medical care, and especially primary care, is incredibly complex, creative work that requires willing, engaged participants and strong support to be successful,” Dr. Schutzbank said. “We use silly words like 'joy' and 'love' and 'hope' because that's what we need. We don't need more rules or checklists or regulations.”

Greater focus on physician satisfaction

The Annals of Family Medicine study is just one sign of growing interest in how to address low physician morale. The research project is funded by the American Board of Internal Medicine Foundation in Philadelphia, which hosted a conference in March 2012 that focused on how work flow innovations could improve the efficiency and appeal of primary care.

The American Medical Association also is leading an extensive project on how to improve physician satisfaction across many different specialties, not just primary care. The Association has contracted with RAND Health to help, and researchers have completed nearly two-thirds of their site visits to 30 practices in six states to determine the care delivery and payment models linked to higher physician satisfaction.

RAND Health, a nonprofit research organization in Santa Monica, Calif., is on track to deliver the findings to the AMA in the fall. The Association will use the research to help develop practice-focused tools as well as advocate for payment and hospital partnership models that promote physician satisfaction.

“Taking physician satisfaction seriously does not mean giving physicians anything they want, but it should mean creating an environment where physicians are always able to put patients first,” Francis J. Crosson, MD, who has been hired to lead the AMA initiative, co-wrote in a May 9 post to the Health Affairs Blog. Dr. Crosson is the Association's group vice president, professional satisfaction — care delivery and payment.

The AMA project on professional satisfaction is one of three major initiatives announced as part of the Association's strategic direction in June 2012, along with a $10 million competitive grant program for innovative medical education curricula and a multimillion-dollar, multiyear effort to improve diabetes prevention and blood pressure control.

Less busy work for physicians

In the Annals of Family Medicine paper, a common theme at the innovative primary care clinics was a focus on team-based care designed to improve patient care and free doctors from work that others could do. For example, at the Southern Illinois University School of Medicine's so-called Office of the Future in Quincy, Ill., family physicians are spared much of the arduous task of electronic documentation. Instead, a medical assistant accompanies the patient and physician into the exam room as a “scribe” to electronically enter the physician's findings and treatment plans. The doctor later reviews and signs off on the scribe's documentation.

“That way, I can just move on to the next patient. My charts are done before the visit is over, and I don't have to redo a lot of the stuff later on,” said Joseph M. Kim, MD, who works in the two-physician office and is an assistant professor of family and community medicine at SIU. “My time with the patient is 100% face to face. No matter whether it's a five-, 10- or 15-minute visit, they get personable service from a physician.”

At the Southcentral Foundation, a health system based in Anchorage, Alaska, that employs 115 primary care physicians to serve the Alaska native population, each team of a physician, medical assistant, nurse case manager and clerk is aided by a behavioral-health expert to help care for patients with mental illness or substance-use disorders. Also, each member of these “integrated care teams” sits close to one another to facilitate ongoing communication about patient care.

For example, a patient's cholesterol is slightly above goal. Should she be scheduled for a visit to re-examine medications? With the advantage of sitting close together, the case manager or clerk can run the question quickly by the physician and get an answer, instead of giving the patient inappropriate instructions or sending another email that may go unread for hours, said Steve Tierney, MD, medical director of quality improvement at the foundation. Each team is measured on how well it meets quality-improvement goals such as vaccination rates and the proportion of diabetics with their blood glucose controlled, but they are given autonomy on how to get it done.

“We tell you what the mission is, but we're not going to tell you how to do it,” Dr. Tierney said. “As long as you've found a creative way to do it and get it done without breaking the law, I don't care.”

The overall employee-satisfaction rate at the foundation is 94%, he said. A breakout on doctors' satisfaction was not available by this article's deadline.

1 in 3 doctors is burned out

About a third of physicians are suffering burnout at any given time, said an April 15, 2003, study in The American Journal of Medicine. And nearly half of doctors say they have at least one symptom of burnout, according to a nationwide survey of more than 7,000 physicians published Oct. 8, 2012, in JAMA Internal Medicine, formerly Archives of Internal Medicine.

Low physician satisfaction can degrade the doctor-patient relationship and lead to physicians leaving practice. For example, a February 2000 study of 2,620 Boston-area patients and the 166 internists treating them found that patients were twice as likely to be pleased with the care provided by extremely satisfied physicians compared with patients treated by less-satisfied doctors. Physicians who are “very dissatisfied” are more than twice as likely as other doctors to retire and nearly four times as likely to cut back on their hours, said a March 2006 study of nearly 17,000 physicians in the journal Medical Care.

Stuart M. Pollack, MD, a general internist, said he often has thought of his daily routine as a giant dump truck of work being unloaded in front of him, while he slowly shoveled the pile the rest of the day. As medical director of another of the clinics studied — Brigham and Women's Advanced Primary Care Associates, South Huntington, in Boston — that load has been eased by social workers and pharmacists who engage patients in time-consuming activities such as addressing psychosocial barriers to care and reconciling medication regimens.

“Every morning I get up, and I'm excited to go in,” Dr. Pollack said. “I get to do what I love, but I'm doing it in a way that's not leading to physical and emotional exhaustion. It's still 10 to 12 hours a day, but you go home feeling it's a job well done.”

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13 fixes for common primary care hassles

Patient visits that run too long, communication gaps, a shortage of time to meet patient demands, and too much energy spent on documentation on compliance are just a few of the problems that frequently exasperate primary care doctors. A study in Annals of Family Medicine details how some physician practices have eased the pain through care redesigns. These clinics:

  • Plan ahead for patient visits in such ways as having patients get lab tests done before the appointment so results can be discussed in the office.
  • Expand nurse or medical assistant rooming protocols to help cover elements such as administering vaccines or scheduling preventive screenings.
  • Use standing orders to let nurses treat simple problems.
  • Extend responsibility for health coaching, care coordination and integrated behavioral health to nonphysician members of the team.
  • Have the entire team take responsibility for panel management through such actions as sending reminder letters to patients about overdue preventive services.
  • Use a medical assistant or other team member as a “scribe” to help complete electronic documentation.
  • Standardize and synchronize 12-month prescription renewals for patients with stable chronic conditions.
  • Use a nurse or medical assistant to help manage the physician's email inbox by filtering out normal lab results, regular prescription renewals and other things for which the doctor is not needed.
  • Talk to other team members face-to-face to get questions answered more efficiently than through email.
  • Sit close to team members to facilitate communication.
  • Use daily huddles to help anticipate problems.
  • Hold regular team meetings to review quality and other performance data.
  • Map the flow of work in the office to spot where effort is wasted and devise more efficient ways of operating.

“In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices,” Annals of Family Medicine, May/June 2013 (link)

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External links

“In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices,” Annals of Family Medicine, May/June (link)

“Physician Practice Satisfaction: Why We Should Care,” Health Affairs Blog, May 9 (link)

American Board of Internal Medicine Foundation initiative on finding joy in primary care (link)

American Medical Association on shaping delivery and payment models (link)

“Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population,” JAMA Internal Medicine, formerly Archives of Internal Medicine, Oct. 8, 2012 (link)

“Leaving Medicine: The Consequences of Physician Dissatisfaction,” Medical Care, March 2006 (link)

“The well-being of physicians,” American Journal of Medicine, April 15, 2003 (link)

“Is the Professional Satisfaction of General Internists Associated with Patient Satisfaction?” Journal of General Internal Medicine, February 2000 (link)

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