Back in the day, coal miners always carried a canary with them in a small cage whenever they would go down in the mine. The canary is a very talkative bird, always singing and tweeting in a constant background noise. Canaries have one more characteristic important to a miner.
When there is bad air in the mine, the canary's sensitive lungs will cause it to drop over dead before the miners notice any shortness of breath. When the bird stops singing, the miners head for the surface -- fast. It is a life saving maneuver.
Here in 2013 as we start to implement the provisions of Obamacare and projections of physician shortages as high as 91,500 by 2020 from respected sources, I believe we have a similar "coal mine" situation in healthcare.
Unfortunately, physicians appear to be the canary in the mine.
Even before the pseudo-shortages of the Affordable Care Act, physicians were not in good shape. Symptomatic burnout is present in an average of one in three doctors on any given office day. A 2012 survey by the Physician's Foundation reported that 60 percent of doctors would retire today if they "had the means."
High patient volumes, the hassles of Electronic Medical Records (EMR), political uncertainty and changing reimbursement rates are all cited in surveys and online forums as new and increasing sources of stress for doctors. Online patient complaints always center on "the doctor seemed rushed, didn't listen or seem to care," which are classic signs of overwork and burnout.
The biggest new burnout threat may be Pay for Performance (P4P)
Healthcare organizations will soon be paid bonuses for reaching certain care quality indicators and patient satisfaction thresholds. Patient satisfaction is incredibly important and should be tracked and rewarded. At the same time, if care organizations simply use these reimbursement changes to dump more stress on the doctors they will actually block the doctor's ability to be present and care for their patients more effectively. Where is the tipping point, where the canary falls off the perch?
How did we get here in the first place?
Healthcare is a classic giving profession. Doctors and nurses learn early that patients come first. Our job is to serve them as best we can, no matter how tired or drained we may be feeling. Their needs come before ours. Simply acknowledging our own needs is a challenge. Finding time and tools to get them met is a struggle for most physicians.
Many healthcare organizations systemize this self care blind spot
It is rare for the physicians and staff to appear in the Mission Statement of a care organization. The patients and care quality will always be front and center in the mission. Any mention of the providers and staff is very rare.
[Take a quick look at your organization's Mission Statement. Does it mention provider or staff health, wellness and satisfaction? If so, is your organization actually doing something about it?]
This creates a double bind where the providers are challenged to get their needs met and their organizations fail to acknowledge we have any in the first place.
The last American sweatshop
As a result, many healthcare workplaces feel like a classic sweatshop environment. There are too many patients to be seen, multiple systems come between the doctor and patient (EMR for instance) there are quotas to be made and no regard whatsoever is paid to the health, wellness or stress levels of the physicians and staff.
The workplace resembles a mine. We are waiting for the physician/canary to drop.
In my work with doctors with career threatening burnout, it is common to hear of hospital departments and group practices where the entire staff is just barely making it through their work week.
Thank god for work hardening
The only reason these toxic workplaces don't implode is the stamina and work ethic of the doctors and staff in the system. On one level, residency is a work hardening program for physicians. We can take a tremendous licking and keep on seeing patients. Our organizations know this and just pile it on. The leaders count on the doctors to carry any load they pile on while taking no responsibility for the stress involved. It is just like putting a canary in a shaft where you know the air is bad and hoping it survives.
Everyone loses
Tragically, unless your group actually monitors for physician health and satisfaction, the toll burnout exacts on the doctors and their patients remains invisible.
Research shows burnout has a pervasive negative effect on every aspect of a physician's practice and life. Physician burnout has been linked to
- Lower quality of care and lower patient satisfaction rates
- Higher rates of medical errors and malpractice risk
- Higher physician and staff turnover
- Higher levels of divorce, alcohol and drug use and suicide for the physician - our Canary.
So how much longer can we simply pile more and more stress on the doctors? When will this canary be stretched beyond its limit and simply topple off its perch and crash to the bottom of the cage? Does anyone care or is this something doctors just have to take care of on their own?
There is a different path available to healthcare organizations.
This path results in a win:win:win situation.
The key is to stop taking the canary down the mineshaft in the first place. Focus the same amount of effort on creating a healthy environment for your physicians and staff as you do on patient satisfaction for one simple reason.
Your doctors cannot produce consistently high patient satisfaction scores if they are not consistently healthy and happy at work.
Happy doctors naturally have happier patients. Put the canary in a sunny window and change the papers in the bottom of her cage. This is a fundamental shift with positive consequences for everyone in healthcare.
The most successful organizations in the near future will be those that acknowledge the universal presence of physician stress and burnout.
There are hundreds of proven ways for both physicians and organizations to make real and lasting changes in the physician experience as soon as this fundamental shift is recognized.
I also predict this type of organization will be rare
Leadership must stop simply loading on more work responsibilities and cracking the whip. Organizations must be committed to caring about the doctors and staff and constantly focused on creating a healthier and more efficient workplace.
With this new priority of physician wellness, these same organizations will be able to activate the power of a physician staff that is balanced and healthy, with their physical, emotional and spiritual needs met. This is the natural foundation for consistent quality care and patient satisfaction.
Just imagine a work environment ...
... where you enjoy your work team and the practice environment, the systems work to let you care for patients smoothly and effectively and you know that your leadership "has your back" and really cares about the quality of your experience as a member of the group. What would that be like? What quality of care would doctors and staff in that organization offer to their patients naturally and automatically.
Our healthcare workplaces don't have feel like a coal mine. We don't have to sit around and wait for the canary to drop.
PLEASE LEAVE A COMMENT
Dike Drummond, M.D., is a family physician, executive coach and creator of the Burnout Prevention Matrix report with over 117 ways doctors and healthcare organizations can work together to prevent physician burnout. He provides stress management, burnout prevention and leadership development services to physicians through his website, The Happy MD.
Follow Dike Drummond, M.D. on Twitter: www.twitter.com/dikedrummond
I'm sure there is some stress-inducing dysfunction in the system, but it sure looks like it's balanced out (for him) with a work load that doesn't seem like it would burn anyone out - and at a pretty healthy salary to boot.
Is my friend's lifestyle-oriented practice simply an exception in the health care profession? Are most doctors working a lot more hours, in much more of a meat grinder, than he is?
Dike
Dike Drummond MD
http://www.thehappymd.com
I'm a management consultant specializing in organizational architecture. Creating a healthy, stimulating workplace that doesn't compromise the mental/physical health of employees is central to what I do. That these factors apply to doctors, too, shouldn't be a revelation.
But much of this reads like doctors complaining about things that the rest of us have ALWAYS dealt with. Maybe doctors had come to think of themselves as a "privileged class", immune from the stresses and economic factors that buffet other professions. Maybe doctors felt that after surviving the meat grinder of residency, they were due 30 years of easy living?
Perhaps we're at a point now where a "correction" has occurred. The average internist, per the other article written by a doctor complaining that docs are "exploited", takes home $100K even after taxes and loan repayment - twice the GROSS pay of the average FAMILY.
Not to say the system couldn't be fixed/improved. Many industries have developed fundamental dysfunctions. But maybe we're reaching a point where doctors need to make a choice the rest of us have always had to make: lifestyle vs. maximum compensation.
Doctors have the same workplace & job satisfaction concerns as the rest of us? If this is a new concept, then I can only conclude that doctors have been riding atop a bubble for a LONG time, one that was due to burst.
A large number of US doc are in their late fifties or older. They trained in an era with more respect and autonomy, and business far less intrusive. These Docs have already struggled with many changes, many find Medicine less emotionally rewarding now. Many want to slow down or retire. Medicare has neglected to shape the physician workforce, though they hold the pursestrings. There seems to be no plan to replace these Docs except with advanced practice nurses and PA's.
Selfless devotion to duty is still the rule. Doctor strikes are almost nonexistent, far more than other health professionals can say. Lots of docs older than 65 still work, albeit less.
Drummond's right, the training programs for many specialists are brutal, even moreso 30 years ago. Perfection is the expectation, mistakes are shamed. It took years for me to realize my training at a notorious inner-city trauma center caused PTSD, by then I'd also spent years in ICU's, horror shows too. Burnout is a problem, so is getting Docs to address it.
With the number of frivolous malpractice suits rising steadily over the years in a country where few take responsibility for their unwise choices, an overabundance of lawyers with nothing better to do than ambulance chase, a government continuously ignoring torte reform, and now Obamacare with all its negative changes for the deliverers of healthcare, I wouldn't go in to healthcare if you paid for my education. As I said, I was lucky to have served my patient population when I did ... when even handwriting patient notes, prescriptions and orders was faster than today's electronic records.
Indeed, doctors are going to be the new canary in the coalmine. How many will die before the higher powers responsible for the health care albatross of Obamacare do something about it. Will their fix be something 'intelligent' like lowering the qualifications required for admission/graduation from medical school to increase the caregiver field even at the expense of more life-threatening mistakes? Woe be the patient today.
Dike
Dike Drummond MD
http://www.thehappymd.com
But, your input is valuable. Thanks.
When I graduated with a B.S. degree I applied to several medical schools. In spite of my education, mensa-IQ, and relatives in the profession I could not get accepted. So I went to another field and later earned 2 Masters degrees in other areas. But I, like most others in most fields, got stuck in the world of seniority and limited opportunity to move about.
So I got burn-out too. But at the same time I had fewer choices than anyone with an M.D. degree has.
Perhaps you are thinking of the AAMC.
http://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/accreditation-collaboration.page =
"provides health care accreditation and related services that support performance improvement in health care organizations. The Joint Commission currently evaluates and accredits nearly 17,000 health care organizations and programs in the United States."
But my point was not to nit-pick the various agencies and organizations invovlved. I wanted to point out that there are not enough medical schools, and there have not been enough medical schools for decades in this country. I have to wonder how much of this is motivated by politics and/or money.
These are the docs who have taken action to get themselves out of the mine. This is a viable option for primary care docs - not so much for everyone else.
Dike
Dike Drummond MD
http://www.thehappymd.com
Maybe his practice is an exception and not the rule, but he's about the only one of my friends who I NEVER hear say, "Man, work is kicking my ass!"
I'm having a very difficult time hearing a profession whose average take-home pay - even after medical school loans - is in the six figures as being so stressed and burned out. Welcome to the rest our world, the world where margins are tightening and professionals have to work more for less than ever before, and burnout is common. I'm not sure where doctors got the idea they're entitled to be above it.
I have no doubt there is dysfunction in the system that needs to be improved, and health care is a very complex issue with interactions on multiple levels. There are no silver bullets. But this is the second article I've read lately - another from a doctor trying to make the case that doctors are essentially no better paid than schoolteachers and are being "exploited" (his word, not mine) - and it just doesn't jibe with what I see in the lives of any of the doctors I know personally.
The myriad (and counting) number of regulations associated with Obamacare will also complicate patient care.