Cleaveland: Storm clouds grow over clinical medicine

From the Chattanooga Times Free Press
By Dr. Clif Cleaveland, 

Increasing numbers of physicians report symptoms of burnout — a combination of unrelenting, physical and mental fatigue that results from caring for sick and injured people. Symptoms may occur during medical school, residency training or practice. If ignored, burnout can lead to early retirement or dropping out of medical practice for other employment or, in extreme cases, to suicide.

Burnout leads to a sense of dread in facing another day at work. Extra effort may be needed simply to get through the day. Clinical responsibilities intrude into home life. Burnout is more prevalent in practices that manage a large volume of patients with complex needs.

The causes include an increase in administrative responsibilities, problems with the electronic medical record, the explosive growth of medical knowledge and fear of litigation.

Administrative responsibilities for many physicians are out of control. Juggling forms, reviewing lab results, coordinating care among multiple providers, approving prescription refills and renewals of outpatient therapies take time and lead to frequent interruptions throughout a workday. Requests for information come from multiple sources. A practitioner may feel under siege. He must play perpetual catch-up.

The electronic medical record (EMR) was promoted as a solution to many administrative problems. The entirety of a patient's data, including lab and X-ray studies, would be a click away. Another click would send records to consulting physicians or to insurance companies. Prompts would alert a physician to a patient's allergies or to potential, adverse reactions among medications. EMRs succeeded in the Veterans Administration health system and within some large, multispecialty health systems.

For many practices, however, the EMR proved an expensive, time-consuming headache. A variety of EMR systems were promoted. Some seemed to serve the needs of data analysts rather than care-givers. Systems were uniformly expensive and required lengthy training sessions. Not all systems functioned as promoted. Some failed. Others lacked adequate, technical backup. Some practices have endured several different systems. Many physicians find that they must spend two or more hours at the end of each day to enter required data.

The professor who spoke at my medical school graduation warned that half of what we thought we knew would be replaced within the next 10 years. That prediction is out-of-date. Medical discoveries in all branches of medicine come in an accelerating and uninterrupted stream. Journals and conferences proliferate. Staying abreast of change is comparable to trying to climb a steep sand dune. You will struggle to prevent sliding backward.

Certification for a specialty, which requires years of apprenticeship followed by rigorous examinations, used to be permanent. Voluntary exams could be taken to assess one's knowledge within a field of specialty. Several years ago, specialty designation became time-limited. Repeat examination at 10-year intervals is the new standard. Preparation for these exams is time-consuming, expensive and often exasperating.

Litigation is a persistent threat to a clinician. Although the actual number of lawsuits is small, the threat of litigation is ever present. A single lawsuit, regardless of merit or outcome, may take years to resolve or to be dismissed. Stress and uncertainty fester during this interval.

What are solutions for burnout?

First, the problem must be acknowledged and addressed early in training. A program director or practice manager must assure that excessive, administrative work is not piled onto individual doctors. Regular hours, including time for dealing with administrative responsibilities must be developed and followed. Counseling must be readily available for medical students and residents.

Practice assistants can reduce the administrative load for clinicians. A medical scribe can accompany the physician and enter clinical data during the examination. A clinical assistant can discuss with a patient appropriate use and precautions for medications, provide dietary instructions and arrange follow-up and referral.

Direct-pay, or "concierge medicine," attracts increasing numbers of internists and family physicians. In this type of practice, a physician typically restricts his workload to a few hundred patients. In exchange for a monthly payment that may range from several hundred to a thousand dollars per patient per month, he will guarantee unhurried visits and immediate availability for any acute, medical problems. He will provide the full range of office services such as preventive care, periodic health assessments and address any acute problems that arise. Lab and other diagnostic services usually require additional payment. A concierge doctor usually does not participate in Medicare or other health insurance plans. He will refer his patient to a specialist or to a hospital as needed. He deals with minimal paperwork and administrative duties. This style of practice works only in relatively affluent communities.

Burnout can end a medical career, a very expensive loss to patients and society. Awareness of the problem is necessary before solutions can be crafted.

Clif Cleaveland, M.D., is a retired internist and former president of the American College of Physicians. Email him at ccleaveland@timesfreepress.com.

Source: https://www.timesfreepress.com/news/life/e...