Twenty-five years ago, when I entered medical school clinical notes were written in paper charts that were filed numerically on shelves. We didn't have EMR and burnout wasn't on the radar.
In the last few years, this has changed. Burnout rates among physicians have increased dramatically as professional fulfillment has decreased. We have the burden of EMR weighing us down with excessive non-clinical work. We are more isolated and have less time for interactions with each other — our computer is our lunchmate now.
The negative impact of burnout affects a physician both professionally and personally. Physicians who are burned out deliver substandard care, they make more medical mistakes, they have lower patient satisfaction scores, they become disengaged and often leave a practice or medicine altogether. Physicians who are struggling with burnout develop challenges in their relationships, often disrupting partnerships and child-parent interactions. They have a higher rate of substance misuse and abuse, depression and anxiety, and tragically have an increased risk of taking their own lives.
We can do better.
There is a significant amount of new research that identifies not only the causes of burnout, but also identifies steps a physician can take to increase resiliency and steps an organization can take to promote and support joy in practice
Organizations around the country, including Austin Regional Clinic, have started to address burnout and professional fulfillment in a concerted way. How did we address the emotional and mental wellbeing of our colleagues, the toll that evolving technology is having on clinicians, the growing "paperwork" of our in-basket? We started by revamping our nurse triage training to improve workflows and decrease burden and waste. We wanted to take some load off physicians, improve job satisfaction for our nurses, and improve the timeliness of patient care.
Finding the Roadblocks
We know that nurse morale and physician morale are inter-dependent and we engaged both groups in our process improvement. By interviewing our nurses and clinicians, we learned that:
- Nurses want the patient to be satisfied but they often didn't have all the tools they needed to do so.
- Doctors have confidence in their nurses to address certain patient issues, but our protocols got in the way. ("The nurses should be able to take care of that.")
- Nurses were unaware of what they were allowed to do. ("We can do that?")
- While HER (electronic health records) and training were extensive in the beginning, there wasn't follow-up to reinforce information.
With this information we created a tactical strategy to redesign nurse triage, giving nurses more responsibility to make decisions that their physician colleagues knew they were capable and trained to do.
We streamlined our referral process. We recognized that all too often a patient will speak to a nurse who will take a message that will be sent to a physician for disposition - for example a referral to orthopedist for a hand fracture diagnosed in the ER. The message will be sent to a physician who writes orders and/or responds with a disposition, when she or he sees it, which may be hours or even 1-2 days later. The message then will be sent to a clinical staff member who calls back the patient. If the patient does not answer, a voicemail will be left and the patient may call back and speak to a triage nurse again, creating frustration for the patient and time waste for everyone.
The protocol was re-written to empower nurses to refer to some predetermined cases directly (ophthalmology, orthopedics for fractures, update of existing referral). Time and burden was decreased for everyone — nurses, physicians, staff and, most importantly, patients.
We also changed triage nurse result reporting. Patients frequently call for lab results that have not yet been reviewed by a physician. The previous triage protocol was to send a message to the physician for every call. A nurse was not allowed to relay the results for anything, even a negative strep test. We realized that we could modify this workflow but still support patient safety.
The positive impact we saw from these changes was immediate. Given the success of the pilot, we are planning to roll out these changes to all 26 clinics.
Long, Steady Road
There is a process to change a process — listening, training, executing — and modifying an established culture requires time and reinforcement for success. But we can already see that these changes have resulted in immeasurable value.
Other physician resiliency projects we have started include providing opportunities that support community amongst physicians. This has been proven to promote job satisfaction and engagement. This means Resiliency and Burnout Discussion Groups, afterwork ping pong parties, storytelling and new physician meet-ups.
While the ongoing or future projects don't require heavy financial expense, they do require patience and time commitment. But in an era where we're seeing an increase in emotional exhaustion among doctors and when we know that an energized physician workforce is essential to public health, it is time well spent.
Dr. Claire Hebner is a pediatrician at Austin Regional Clinic.