A guest column by the American College of Physicians, exclusive to KevinMD.com.
The administrative burden associated with caring for patients in today’s health care system has emerged as a primary driver of the loss of joy in the practice of medicine and the epidemic of burnout among physicians.
No medical specialty is immune from the upward creep of administrative tasks associated with patient care, although it seems particularly problematic in the primary care disciplines where the burden is particularly high, with most believing it is a major contributor to the avoidance of new physicians entering generalist careers. And I’ve also seen efforts to manage these administrative tasks lead to suboptimal behaviors by physicians, such as attempting to “off-load” them to other clinicians that, while understandable, often reflect a lack of collegiality and professionalism.
Administrative work has always been a part of taking care of patients. So what has happened in recent years to allow this aspect of clinical medicine to become such a powerful force that it is causing significant moral injury to physicians, negatively affecting our professional behaviors, and even influencing the composition of the physician workforce?
The most obvious manifestation of this excessive burden is simply the sheer volume of administrative expectations now placed on clinicians in the course of routine patient care. I frequently hear comments from colleagues in practice that they find them absolutely overwhelming, with a common description that they feel as though they are “underwater” or “drowning” in their attempts to do what is now required of them to care for their patients.
This can be seen more objectively in studies that have shown that for every hour spent on patient interaction, a physician has an added one-to-two hours of finishing progress notes, ordering labs, reviewing study results, prescribing medications, and completing additional documentation, among other activities. These administrative requirements outside of the actual encounter have the effect of displacing other critically important work of physicians, such as thinking about and reflecting on our clinical decisions and allowing adequate time for ongoing self-education. And a more devastating consequence of this volume of administrative work is that it compels clinicians to sacrifice their personal and family time after hours doing things such as chart review and documentation, with this phenomena ironically being termed “pajama time.”
But perhaps a more important aspect of this increased administrative burden lies in the nature of the work we are being asked to do. Physicians have no problem going the extra mile on behalf of their patients as long as they know they will benefit from these activities, even if some of these tasks do not necessarily require the specific training and skills of a physician. However, we now spend an incredible amount of time doing things not actually related to improving patient care although they seemingly are.
It is increasingly difficult to see the benefit to patients in needing physician approval for a wide range of routine medical products and services for which the intended purpose is seemingly only to manage utilization, recording an increased volume of patient metrics that are not clearly associated with improved clinical outcomes, and spending huge amounts of time on insurance-related activities such as pre-authorizations that feel more like “rationing by hassle” than a meaningful review of medical necessity. And there are many more examples.
Add to this the major issues associated with the electronic health record which requires input of information such that on many occasions documentation itself seems to be the primary goal instead of the medical record serving as a forum for our thoughts and assessment of the care of the patient and a vehicle for conveying meaningful medical information to others.
But I believe the real damage to us from the volume and nature of the administrative work currently associated with patient care lies in the emotional responses it can trigger. It can create a deeply visceral conflict between the inherent desire and drive to do the right thing for patients and the personal sacrifice that doing so now involves.
Failure to complete patient-related administrative tasks may lead to feelings of guilt and inadequacy in our self-perception as caregivers. Yet, knowing that many of these activities do not actually improve patient care creates a parallel sense of frustration at the needless obstacles to optimal patient care that these administrative requirements impose. And then there is the outright anger that results from the sense that at many times the health care system is taking advantage of the goodwill of physicians for purposes other than the well-being of patients, knowing that their dedication to those under their care will compel them to shoulder this burden.
Add these emotional responses to the fact that administrative tasks are increasingly permeating into and changing the nature of the patient encounter and the patient-physician relationship and their intrusion into our personal space, it’s no wonder that the result is physician burnout that is now approaching crisis proportions.
So what can we do?
It is clear that physicians need to reassert themselves and regain control of the conversation around the administrative burden that is profoundly affecting the care of patients and the well-being of those doing the hard work of clinical care. However, this is not something easily or feasibly done by individual doctors – it requires the collective will and actions of physicians to make meaningful changes to the administrative aspects of our health care system.
I do believe there is some reason for optimism. Ongoing efforts by medical professional societies to address administrative burden, such as ACP’s Patients Before Paperwork initiative, are raising awareness of this issue, which is being increasingly recognized by key health care agencies such as the Centers for Medicare and Medicaid Services (CMS). And we are starting to see some slow progress in decreasing the volume and changing the nature of the administrative tasks required for patient care.
But much more remains to be done. Physicians must to continue working together, speaking out at the local, regional, and national level in seeking to lessen the administrative burden associated with patient care. And most importantly, we need to support each other personally in our efforts to provide the best care possible to our patients despite these unnecessary administrative burdens as we collectively seek to remove them.
We need to do this because the status quo is not sustainable — not for medical professionals and not for our patients.
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