Although the years-long trend of hospitals purchasing practices has had some positive effects, negative consequences include a potential weakening of the physician-patient relationship, a prominent policy watcher says.

Nov. 30—Physicians are increasingly overwhelmed by their professional demands, according to researchers. But, as policy experts note, some organizations have found ways to mitigate the problem. 

Mark Linzer, MD, director of the Division of General Internal Medicine at Hennepin County Medical Center in Minnesota, has studied physician burnout for 20 years and noticed it spiking over the past three to four years. At this point, burnout symptoms are present in more than half of physicians.  

“It’s become what is known as the epidemic of clinician burnout,” Linzer said. 

A major factor in the increasing workplace stress is the implementation of electronic health records (EHRs), which Linzer says are “incredibly challenging,” but many other factors affect burnout. 

Beyond the toll on physicians as individuals, burnout also has been linked to adverse clinical consequences for patients and increasing costs for healthcare organizations.  

But a growing body of research also has identified interventions that appear to reduce the incidence of burnout. 

Linzer cited mitigating factors that include greater professional satisfaction, reduced workplace “chaos,” greater value alignment between clinicians and organizational leaders, greater collegiality between clinicians, and improved communication between provider groups. Practical steps can include the use of scribes to enter data into EHRs and team-based care to reduce the clinical workload. 

“So there are ways to predict a satisfying environment and there are ways to intervene to make one more satisfying,” Linzer said. 

After taking steps to reduce burnout, organizations within a year can reduce its incidence by a factor of three, increase the likelihood that physicians will stay with the organization by eight-fold, and avoid any adverse impact on quality, according to a randomized controlled study of 168 clinicians that Linzer co-authored. 

“The structure of a work environment for physicians matters,” Linzer said. 

A Complex Issue 

Darrell Kirch, MD, president and CEO of the Association of American Medical Colleges (AAMC), said physician burnout is a “very complex problem” that stems from numerous factors. He took note of the focus on EHRs as a root cause when he attended a 2016 meeting of industry leaders at the National Academy of Medicine. However, as leaders discussed the issue, they quickly realized that the burden of using digital records is only one of many factors that impact physician satisfaction. 

“This problem, we need to acknowledge, has existed for a long time,” Kirch said.  

Impact of Consolidation 

Although the years-long trend of hospitals purchasing practices has had some positive effects—such as increasing access for low-income people whom private practices cannot afford to treat—negative consequences include a potential weakening of the physician-patient relationship, which is a key factor in physician satisfaction, said Robert Berenson, MD, a fellow at the Urban Institute.  

Although many policymakers emphasize the need for all types of clinicians to practice at the top of their license, physicians will struggle to develop patient relationships if their caseload is reserved for the most complex patients, Berenson said. 

But consolidation doesn’t have to mean that patients feel an adverse impact on relationships with their physicians, Kirch said. 

“What the patient benefits from is feeling that they have multiple people supporting them, meeting their needs, and covering all of the bases; that they are not just dependent on this one individual relationship with the doctor,” Kirch said in an interview. 

The superior patient support under team-based care is exemplified in cancer care, where patients are cared for by an oncologist, nutritionist, radiation oncologist, and infusion nurse. 

“It actually creates more patient-centered care, rather than detracting from that relationship,” Kirch said. 

Another downside of consolidation, Berenson said, is a reduced focus on clinical care. He noted that some of the best quality results have been attained by small practices, including lower rates of avoidable hospitalizations.  

Costs and spending also may increase with consolidation, he said. 

“Volume-based payment and vertical integration is a combustible mix,” Berenson said. “It generates lots of high prices and it generates lots of unnecessary volume.”  

An increase in physician practice consolidation, therefore, requires a faster transition to two-sided risk models, Berenson said. 

Younger physicians are overwhelmingly choosing employment over independent practice, according to Kirch, for reasons that include the opportunity for a better work-life balance and reduced stress about business issues.  

Berenson said employers of physicians need to respond with environments that combine the best aspects of independent practices—a focus on clinical care and close patient relationships—with a more supportive working environment for clinicians. 

Such environments have been encouraged at some of the largest health systems, like Mayo Clinic and Kaiser Permanente, where employed physicians routinely report above-average job satisfaction, Kirch said. 

An example of how these high-performing organizations separate themselves is that “in the C-suite, there is as much discussion about the quality of care and the patient experience as there is about the supply chain,” Kirch said. 

Researchers also are exploring ways to measure workplaces to determine how healthy they are for clinicians, Linzer said. 

“Those things can be measured, and organizations could be held accountable,” Linzer said. 

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Thursday, November 30, 2017