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In this episode, Susan Walker, a pediatrician, shares her experiences and insights into the demands placed on doctors, and how these demands can sometimes interfere with their ability to provide the best care for their patients. Susan discusses the importance of prioritizing patient care, and why it’s crucial for doctors to have the time and support they need to focus on the work that matters most. This is a must-listen for anyone interested in the medical profession, and the challenges facing doctors today.

Susan Walker is a pediatrician.

She shares her story and discusses her KevinMD article, “I saved a baby’s life.”

The Podcast by KevinMD is brought to you by the Nuance Dragon Ambient eXperience.

With so many demands on their time, physicians today report record levels of burnout. Burnout is caused by many factors, one of which is clinical documentation. Studies indicate physicians spend two hours documenting care for every hour spent with patients.

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show we have Susan Walker. She’s a pediatrician. Her KevinMD article is titled “I saved a baby’s life.” Susan, welcome to the show.

Susan Walker: Thank you for having me, Kevin.

Kevin Pho: So we’ll get into the article in a little bit, but first off, briefly share your story and journey to where you are today.

Susan Walker: So I am an academic general pediatrician out on Long Island, in Stony Brook, New York, and I’m actually from Long Island. I grew up here, went elsewhere in the United States for training, came back for my residency, and then stayed on as faculty at Stony Brook. My current job involves outpatient primary care as well as teaching medical students, both clinical and preclinical, and residents. I have an academic focus and interest in physician well-being, and I’m the co-chair of our department’s pediatric well-being committee.

Kevin Pho: All right, so I talk to a lot of pediatricians who are in a private practice setting, and you’re an academic pediatrician. So contrast that setting with, say, a private practice setting for those who aren’t familiar.

Susan Walker: So in academic pediatrics, we are taken care of by our parent organization in terms of having a practice space set up. They purchase all of our vaccines and provide us with clinical staff to help us take care of our patients. So in that regard, it’s a very nice setup. We are free to do a little bit more of the patient care, rather than private practice, where, I’m sorry, Kevin, in private primary care, the doctors are really more responsible for the business of medicine as well, in addition to taking care of the patients.

Kevin Pho: So you mentioned you’re also on the physician well-being committee over at Stony Brook. So tell me what you do in that role.

Susan Walker: The committee has been in place for a couple of years, and it was mostly focused on personal well-being activities, things like cooking classes, yoga classes, and well-being events such as that. But recently we’ve changed our focus, because we found, and studies have shown, that physicians are resilient people, and just improving our resilience is not going to get us out of the burnout mess that we find ourselves in.

Rather, there are some other things that are really impactful on physician well-being, one of them being the day-to-day practice issues that we face, such as a lot of time in an electronic medical record, taking the time for prior authorizations, a lot of inbox messages, the things that really take us away from the things that we love to do, which is take care of patients. And so our committee is trying to focus more on those types of things, as well as the personal well-being events, to make that better.

Kevin Pho: So can you give an example or share a story of how this well-being committee has moved the needle when it comes to physician burnout at your facility?

Susan Walker: Because we really want to find out what impacts well-being in our particular institution, the first thing we did was to create a survey to survey all of the pediatric faculty at Stony Brook and find out what things impacted their well-being. That survey, we put it together very thoughtfully. It took some time, and we’ve just put it out and are starting to get responses. So I have not really done all of the data analysis yet, but I’m really looking forward to seeing what my individual physicians think impacts their well-being the most. And then the next step, the challenge, will be what we can do to move the needle, as you said, to make those things better.

Kevin Pho: Who comprises this committee? Are they primarily all physicians? Is there any representation from administration on this committee?

Susan Walker: We have physicians, we also have resident physicians, and we’re in the process of having nursing and clerical representation join us as well. So it really is the entire department.

Kevin Pho: All right, so in your KevinMD story, you talk about some of these obstacles that sometimes impede us from optimal patient care. It’s titled “I saved a baby’s life.” So tell us about this story and how this article came together.

Susan Walker: Sure. So it was a Saturday afternoon in my office, a busy day, as it usually is, and this baby came in, and it was very clear to my office staff right away that this baby was very sick. They came to get me quickly, and we really needed to move very quickly to help this baby. I have fantastic office staff. They did a great job of getting EMS activated. They got the oxygen in the room, the bag mask, and we started resuscitating this baby. It’s something that I hadn’t done since my residency, and I certainly had never done it outside the walls of a hospital, so it was a scary experience. But fortunately, the baby did very well, spent some time in the ICU, and then recovered.

But in the afternoon and evening following that event, I thought to myself, “I feel a whole lot less burned out today than I usually do.” And I started to think about why that was, and it occurred to me that for that period of time in the office, I was not worried about my inbox. I was not worried if an insurance company was going to deny a medication I wanted for my patient. I was just taking care of this baby, and it was really rewarding.

I think that’s an experience that other clinicians might agree with. It might resonate with them that when we are in the room taking care of the patients and everything else falls away, that’s when we’re the happiest, and that’s when we’re really fulfilled in our job. And those are the things, I think, that are protective against burnout.

Kevin Pho: So take us into your workflow. Take us into the exam room on a normal day. You mentioned that sometimes not all your time is spent taking care of patients and talking to patients’ families. Just illustrate: What are some of those impediments that you encounter on a daily basis?

Susan Walker: As we do in medicine, we have computers in each exam room. The first thing that we do, let’s say I’m taking care of a well child, is we pull up the well-child template note, and then I’ve got to fill in the little fields that are specific to the patient. There’s clicking that has to be done, certainly. Let’s say I’m seeing a well child, and when I go in the room, I decide this child is doing great, we’re ready for the vaccines, and the parents agree. I have to enter a diagnosis, then click on a PowerPlan and click on the vaccines that I want. Although there are some workarounds to make this easier, it’s a lot of clicks, and it takes time, and this is time that I’m facing the computer in the room rather than facing the patient.

After the visit, there’s more of the documentation. Let’s say I’ve decided that this child needs a particular medication. Perhaps it’s a visit for ADHD, and I would like to start the child on a stimulant, and I picked the stimulant that I think fits this situation best. An hour later, I get a message from the pharmacy that says this child’s insurance does not have this medication as a preferred medication. And so then I have to either decide, “OK, we’ll try something else,” or I have to start fighting with the insurance company to have the medication covered. All of these things, you know, take away from the time that we spend with our patients.

Kevin Pho: So let’s take that example. When you have to fight against the insurance company to cover a particular medication, do you do that personally? Do you have support staff? How long, in general, does that take?

Susan Walker: Certainly, we have support staff that will do the initial legwork, but most of the messages come back to us, in terms of the insurance company saying, “We’ll cover this. Do you find that acceptable?” And then, if so, I have to cancel the other medication and order this medication. Or it will say you need to do prior authorization, and you need clinical documentation that they failed this and that medication, and then we work together to do that.

So it’s hard to put together exactly how much time all of this takes, but it’s sort of the nickel-and-diming and the death-by-a-thousand-cuts type of thing, where you’re just trying to take care of patients, and you keep having these messages come into your inbox that detract you from what you’re focusing on. In order to get this patient the medicine that they need, you’re back and forth multiple times with messages, rather than doing what you really would prefer to do, which is be with the patient.

Kevin Pho: So hypothetically, say, in a half-hour to one-hour block of your time in the clinic, if you were to guess, what percentage of that one-hour time would you say is spent face to face with patients, and what percentage would be, say, in front of a computer doing clinical work that isn’t necessarily face to face with patients?

Susan Walker: I would say a quarter of that time is face to face with patients. So 15 minutes of a typical 60-minute block would be face to face, and 45 of those 60 minutes would be spent doing prior authorizations, clicking on the computer, and documenting.

Kevin Pho: Would that be many times?

Susan Walker: Many times, I would say that’s the case.

Kevin Pho: And would you say that a lot of the physicians in your practice or at Stony Brook are encountering a similar situation?

Susan Walker: Definitely. I talk to a lot of physicians about this same issue, and it’s not uncommon in practices across the country.

Kevin Pho: So when you have these physician meetings, sometimes with administration, and you bring these issues up to the powers that be, in general, what kind of response do you get?

Susan Walker: So I am in a very fortunate position here at Stony Brook. Our leadership is very committed to making changes to improve physician well-being. The chairman of our department has convened the well-being committee for exactly this purpose. And so we’re in our infancy in making these changes, but I am convinced that once we collect all of this data and find out exactly what the real problems are and what the real impediments are, we’re going to be able to move the needle here at our institution. And I hope then to serve as a bit of a model to help others elsewhere.

Kevin Pho: So if you were in charge of the workflows that physicians face, in your ideal world, what would you like to see happen?

Susan Walker: I’d love to have the documentation offloaded. Scribes have been found to be very useful in other institutions, and I think that would be a great step forward in being able to spend time face to face with our patients. I’d like to be able to click less and get more done with the clicking that we do, so EMR efficiency would be one thing that I would be really interested in seeing. And then there’s the issue of autonomy. It’s nice to be able to maintain a little bit of autonomy over your schedule, and if you feel that a patient needs a little bit more time, that you’re able to give them that time.

Kevin Pho: So I find that a lot of the solutions that help with these workflow issues that contribute to burnout, and you mentioned things like scribes and having more autonomy in your schedule, which in a lot of cases means seeing fewer patients, are sometimes in tension with, of course, the business aspect of medicine, right? A lot of the things that help with burnout prevent the institution from generating revenue. So inevitably, when you come up with these suggestions, you’re going to get pushback from the administration. What are some ways you feel that you could navigate some of that pushback and tension that you’re probably going to get?

Susan Walker: Well, there’s data in the literature that documents how much money burnout costs an institution in terms of physicians leaving their position completely and how much it costs to onboard a new physician. And then also examples of those numbers, you’re putting me on the spot. Like, yeah, I don’t remember exactly the numbers, but it’s not an insignificant amount of money.

And then a lot of physicians react to feeling burned out by lowering the number of hours that they work in a week, so dropping what we call their FTE, their full-time equivalent, and that is also a loss of revenue to the institution. And then there’s calling in sick, both staff and physicians. And so there is a business case to be made for creating another metric in terms of good patient care, and that is the well-being of the patient care providers.

Kevin Pho: Now, for those other pediatricians, and physicians for that matter, listening to you who are experiencing exactly what you’ve been describing, maybe only 25 percent of their time at a clinic being face to face and the rest being administrative work and EMR work, what can they do to help their own situation? You’re in charge of a well-being committee, but for those other physicians, what can they do in their own institutions?

Susan Walker: Well, there are ways to become a little bit more efficient with the electronic medical record, and we’re working on this at Stony Brook as well: pre-completed notes, and having autotexts, which are little lines of text, things that you would typically put in an EMR, that you can then use over and over again. Make sure you’re being as efficient as you possibly can be.

And then I think it’s really making sure that you speak up and say, “Look, this is a problem, and I think it needs to be fixed.” Because I think if we just put our heads down and work hard, that’s going to get our work done, but it’s not necessarily going to change things for ourselves or for our colleagues.

Kevin Pho: We’re talking to Susan Walker. She’s a pediatrician. Her KevinMD article is titled “I saved a baby’s life.” Now, for those medical students who are considering, say, pediatrics as a career, and they’re listening to you, I think the scenario that you’re describing sometimes may not be the most palatable, especially with all these impediments, all this administrative stuff. So tell me some of the rewards that you get from pediatrics today, despite everything that we talked about today.

Susan Walker: No, there are so many. One of my favorite things about primary care is your ongoing relationship with the patient. So when I see a newborn in my office, I can look forward to 20-plus years of learning and growing with this child and his or her family. I can’t imagine a more rewarding experience than guiding the growth and development of a human being.

When I’m in the room with the child, let’s say it’s a two-year-old who’s wearing Paw Patrol sneakers, or let’s say it’s a teenager who is feeling anxious and depressed and is looking to me for answers, that’s when I’m most engaged, and I feel like I’m making a difference in that child’s life. And in primary care, you get that opportunity over and over again. Even with the challenges, and even with burnout what it is, I can’t imagine for me a more rewarding way to spend my time.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Susan Walker: So the first is that it’s not a lack of resiliency that leads to burnout. We physicians are very resilient people, and I think it’s important for those of us who are feeling a little bit burned out not to blame ourselves. It’s not that we can’t do this job. It’s not that we’re not capable. There are systems that need to be changed, and I think we can all work together to change those systems.

And the second is that studies have shown that physicians who spend 20 percent of their time doing what they feel passionate about are protected against burnout, and I think that’s not all that much, 20 percent. So I encourage all clinicians to find what their passion is and then work to make sure that they’re spending at least 20 percent of their time on that passion. That’s the way to stay a resilient physician.

Kevin Pho: Thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Susan Walker: Thanks for having me, Kevin.