A few years after I entered my practice as a newly certified internist, about two decades ago now, I started to burn out. I felt I was becoming a documentation drone and a guideline-following automaton. I was embarrassed for some of the care I gave–attempting to fit patients’ round needs into the square peg of the medical model. Patients who came to talk about depression were marched through a complete review of systems because that is what I understood it meant to be a good doctor. In a brief visit, I would try to:
- accomplish all the screening and advising that was recommended by every agency and organization;
- do a credible job evaluating multiple complaints;
- be compassionate and smart in the care of those who were ill;
- dodge legal bullets by what I said and what I documented;
- repeat the same detailed, normal physical exam into my recorder patient after patient because the note was how I thought my care was graded; and,
- comply with the then new and confusing coding rules.
My nurses were mostly on the phone, reporting lab results to patients and refilling prescriptions; they didn’t have time to do much real nursing work. I would rush through the day’s schedule and then make a run to the elementary school by 3pm where my children would be waiting at the curb. “Why am I doing this?” I thought.
Finally, I decided that if I was going to stay in medicine I would have to do things differently. I asked myself: What do I enjoy about being a doctor? And what do patients want? The answers were remarkably similar—good medical decision-making and relationship-building. This didn’t look much like what I was doing. So my husband Tom, also an internist, and I gradually began to redesign our practices. We systematized anything we could, so that the right things happened by default, and we eliminated waste wherever possible. Using the newly freed-up nursing time, we delegated standardized, predictable work to the nurses so we could direct our energies to work that needed our medical training. And we made room again to talk with patients. We had a system and it worked.
Fast forward fifteen years. Our children graduated and moved into their adult lives. As I lifted my head up from my own part of the garden and looked around, I realized other primary care physicians were suffering. I started to shadow physicians in different practices and began to channel their angst. At the same time, my own angst was returning. Each year after the implementation of our EHR in 2003 new work had been added to the physician’s plate. Things that took five seconds in the paper world took two minutes in the electronic world. Once again I did not like how I was spending my time with my patients. I did not like the doctor I often was.
After visiting more than 50 physician practices and speaking with countless others after presentations on practice redesign, medical home and finding joy in work, I grieve for our specialty. I understand more than I did as a young doctor about what it means to be someone’s physician. I see how important primary care is to the sustainability of our nation’s health care system. But I don’t know if primary care will survive. At the very time when primary care is most needed, and when it could be the best of times for the best of specialties, with primary care physicians trained to meet a broad range of the problems patients face, I fear it will be ground out by the unopposed forces that sap the joy out of practice, namely:
- security obsessions
- compliance fears
- penny-wise and pound-foolish staffing
- inaccurate assumptions that safety is promoted if the doctor does every task: signs every chart (why, really, do we sign any chart?), every prescription for hearing aid batteries, home health referral, meals on wheels, and enters orders for every mammogram and ear wash.
As physicians, we know we are not spending our time on the right things. We know we are not living up to our professional obligations when we tend to the computer more than to our patients, barely looking them in the eye; when our energy is focused on the mandatory tasks of clearing the paper and electronic inboxes, leaving less time for thoughtful research and consideration of unusual symptoms. Patients’ lives are at stake and we fiddle with attestations, under threat of audit not of our clinical skill but of our checking boxes. .
With the support of the ABIM Foundation, our team of investigators went out in search of joy in practice, visiting 23 high performing primary care practices. We found signs for hope along with signs for caution. Even the best of practices were losing oxygen to regulatory constraints and administrative caution. But we also found administrators who were courageous and willing to put the needs of the patient first, understanding that also means making work life manageable for the clinicians. We found teams that worked together, not just in theory, but with true trust and reliance. We found technology that has been harnessed for the patient and serves the team, rather than the more common scenario where the clinical work has become subservient to the computer work. The physicians, nurses, medical assistants and leaders we met give me hope.
Is it too late for primary care? I don’t think so. But we have to move quickly. The health of the US economy depends on the health of the US health care system, which in turn depends on the strength of its primary care foundation. More than half of all primary care physicians show signs of burn out. I believe we can find and promote joy in primary care. It will take a concerted effort of educators, administrators, policy makers, technology vendors and physicians ourselves to do so.
Christine A. Sinsky is an internal medicine physician and a director, American Board of Internal Medicine.