Map of life expectancy at birth from Global Education Project.

Thursday, January 25, 2018

Physician, heal thyself

Two essays in today's NEJM about physician burnout, which they are allowing you unsubscribing rabble to read. Wright and Katz put a lot of blame on electronic health records, which is a common sentiment. EHRs were supposed to make life easier for physicians, but apparently the demands of documentation take a lot of time and come between the physician and humane contact with patients. The argument is often presented unclearly -- after all, physicians had to create paper records in the past, and if anything EHRs ought to make documentation easier. But the problem seems to be that the functionality of EHRs has caused health systems to demand more of physicians in the way of clerical work. I think EHRs may be something of a scapegoat -- in general the days when physicians were independent entrepreneurs is largely over. Now they are salaried employees of big corporations that are incentivized to squeeze more productivity out of them, even as Medicare and particularly Medicaid are screwing down levels of reimbursement.

Dzau and colleagues discuss some of the consequences of burnout, which include harm to patient care and even suicide. Physicians are at high risk for suicide. We think of the profession as highly lucrative, highly prestigious, and glamorous. The first two are certainly true, but the third generally is not. It's an extremely demanding job and for people who take it seriously and care about their patients, it can be very emotionally burdensome.

I think that solutions have to start with redefining the job. We can't afford to pay more for health services in the U.S., so we aren't likely to decrease the clinical load any time soon, but we can take  a lot of it off of physicians and put it onto nurse practitioners and physician assistants. This crisis is mostly located in primary care and there are lots of ways to reorganize primary care to make it more effective, and more patient centered, while actually reducing the M.D. workload. We can also have more scribes doing documentation in appropriate circumstances, although this needs to be carefully managed. Continuing to improve the design of EHRs can't hurt. We also need to re-align financial incentives to get more medical school graduates pursuing primary care careers. I'm happy to hear other thoughts about this. But it's an under-recognized crisis that threatens to be a serious problem for public health.

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