The Doctor Can’t See You Now (with Dr. Christine Sinsky)
Americans are having a hard time getting in to see a doctor, and burnout among heathcare workers is a leading reason why. The stressors of the Covid-19 pandemic exacerbated a burnout crisis among physicians and nurses. But even before the pandemic, burnout was already a rampant problem for physicians and other health workers. Dr. Bob Wachter sits in for Andy and talks with AMA vice president and burnout expert Christine Sinsky about the root causes of burnout and what it will mean for all of us.
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Christine Sinsky, Andy Slavitt, Bob Wachter
Bob Wachter 00:18
Welcome to IN THE BUBBLE. I’m Dr. Bob Wachter. Professor and Chair of the Department of Medicine at the University of California, San Francisco and I’m sitting in for Andy Slavitt. The pandemic has been extraordinarily stressful for clinicians. Recent surveys show sky high levels of burnout among physicians, which seems understandable after three arduous years. I recently heard from a CEO of a very large health system, who told me that he had more physicians die in his system of suicide than of Covid during the pandemic. But the seeds of burnout were planted long before the pandemic and physicians are not the only health professions who are suffering from burnout, the nursing profession is also quite troubled. And the consequences is a tremendous nursing shortage and actually a fairly significant physician shortage in certain regions. One that is compromising patient care. So today, we’re going to talk about burnout among clinicians, why it happens, why patients should care about it, and what can be done about it. I’m thrilled that we have a leading expert on the topic, Dr. Christine Sinsky. Chris, in addition to being an old friend was a practicing primary care physician in Iowa. For three decades along with her husband, Tom, she became a leading expert in burnout and in 2014. So now, eight years ago, I became the vice president for professional satisfaction at the American Medical Association. So Chris, thanks so much for joining us.
Christine Sinsky 01:39
That is my pleasure. Glad to be here.
Bob Wachter 01:42
So let’s start with a little bit of a discussion about your practice, you practice for a pretty long time and midsize community in the Midwest. What were the joys of the practice, and what were the sources of stress?
Christine Sinsky 01:57
I think when people think about what stresses physicians and other health professionals might experience, they think about the stress of dealing with sick people, with people who are at the worst times of their life. And yet, I think for most of us, that’s actually where we find meaning and purpose. And the things that were stressful were the things that got in the way of that. For the first 16 years of my practice, we didn’t have an electronic health record. And for much of the latter of that period of time, I would dream about how wonderful it would be to have an electronic health record so that we knew exactly what medications the patient was on, we had access to all of their inpatient and outpatient data at the same time. And then lo and behold, we had an electronic health record. And life got better in some ways. And it got worse in a lot of unexpected ways. And so I would say that the technology, and the sort of clunkiness of the technology and the misfit of technology to the purpose was probably the biggest source of stress, that it added so much time, and cognitive workload and administrative burden to the daily work that it made it harder to feel connected to the patient, made it harder to live up to my aspirations as a physician, and how I cared for my patients.
Bob Wachter 03:19
For regular people who are not physicians, the idea that digital tool comes into your world, and it means you don’t have to read doctors, chicken scratch, and all the information is in one place. And you can see the same information. If you’re in a hospital or in an office, you would think that would be an unmitigated good. It just feels like you know, as you said, you were dreaming about it. How much of the problem relates to the reasons why you have to document there’s, you know, it’s one thing if you’re documenting, you’re typing things. And obviously, in the old days, you were scribbling things. So you there was always some interaction between a doctor and some tool to record information, right? But how much of it is the fact that now you’re recording things, in part to satisfy a whole bunch of other needs that may not have very much to do with the clinical care of the patient in front of you, whether it’s billing or some way that you or your practice are being measured?
Christine Sinsky 04:20
I think you’re absolutely right. And I think in some sense, the electronic health record gets blamed for things that are beyond its responsibility, if we can speak of in that way, that is many, many stakeholders saw the opportunity to use this new technology for their particular goals. So researchers to have more data that the doctors would input so that they could do additional research that billing and coding and regulatory bodies use the electronic health record as the vehicle by which they would have more information and more input into the nature of medical care. And each one of those things individually is make sense around a conference table. But in some created just an unmanageable work environment for physicians.
Bob Wachter 05:17
Yeah, I call it the just one more thing, syndrome. You know, when you’re sitting in a room and an insurance company or a federal agency, and you say, well, if we just asked the doctor to document you know, whether the patient wear seatbelts or smokes, or and it all makes sense, perfectly reasonable. And then at the point of care, it’s maddening, you are spending so much of your time checking those boxes that you can’t make eye contact with the patient.
Christine Sinsky 05:43
Right, it only takes minutes. But all those minutes add up. Yeah. And so you know, that Tasks that used to be performed by a receptionist and medical records clerk, a transcriptionist, a pharmacist that got transferred to the physician through the electronic health record, and I think that contributed to the time pressure and the cognitive load that has been impacting physicians and other health professionals.
Bob Wachter 06:13
Do you have any data on how much time physicians spend on their electronic tools?
Christine Sinsky 06:19
Yes, so there’s several studies we did one, a number of years ago, it was a time motion direct observation study. And we found that for every one hour of direct FaceTime with patients, physicians, were spending two hours on EHR and desk work. I will tell you from my own experience, I would say that the change in how work was done and the vehicle on which it was done with the electronic health record added several more hours to my day. And I believe that that’s a pretty universal finding. I also found that I was able to see fewer patients. And I could take better care of them in some ways. And in other ways, I couldn’t take as good of care. But I think overall, the overall burden of work has gone up. Even though yes, we had documentation work in the pre-EHR world as well.
Bob Wachter 07:14
And we just say in ways not as good care. What were those ways was this causing you mentioned that it’s taking time and maybe taking and maybe distracting you a little bit, but were there ways where it was, frankly dangerous or led to its own set of problems? Yes.
Christine Sinsky 07:31
I’m thinking about one of my internist colleagues in my practice, who made the observation, you know, the electronic health record isn’t working for me, I’m working for it. And I think that wasn’t an uncommon feeling. But I would go to something fundamental, and that is teamwork. And the two nurses that I worked with, day after day, these two RNs, and I formed a team. And we really had a good workflow, they were able to have independent relationships with the patient, they were able to take actions and independent judgment up through their skill level. And when we changed from one electronic health record to the other, so we had one for eight years. And then we switched to another one, I was really surprised at how that disabled our ability to work as a team, because the design of that electronic health record had a certain role for nurses in mind. And so they only had permission through the technology to interact with certain screens. But that was not consistent with the teamwork and the workflow that we had developed. And so someone sitting in Kansas City had decided what the interaction between nurses and physicians would be, and build the electronic health record to match that mental model, but that wasn’t our mental model. That wasn’t our actual model.
Bob Wachter 09:04
Alright, so let’s move up to the addition of COVID to all of this. So you talking about a profession that has changed a lot of new stressors around documentation, around billing, around autonomy, challenges to the physician patient relationship and the physician relationship with his or her team. And now all of a sudden you have a pandemic; how did that change things?
Christine Sinsky 09:28
Yeah. So I think that changed things, again, in both good and bad ways. So for the good, I believe that there was a strong sense of purpose and a strong sense of being valued. I remember hearing from the one of the medical directors at a large system in Boston, and she said that her physicians went from really disliking their electronic health record to valuing it almost overnight. At the beginning of COVID, in the respiratory care clinic that she led. And why was that? It’s because they realize that in this crisis situation, they had to change to crisis standards. So the physicians could now give verbal orders and ask for a chest X-ray to be done without having to go in and spend the two minutes to put in the order. And the nurses or other staff were empowered to do medication reconciliation, which had reverted to just a physician task previously. So in some ways, I think COVID led us to realize that are, you human resources were too precious to waste. And in particular, our highest train people were too precious to waste. On the other hand, as everyone knows, it was really chaotic and emotionally draining, to have the frequency of death among your patients that the physicians and nurses encountered, particularly in that first year of COVID.
Bob Wachter 11:28
One of the things that also emerged during COVID is in many places, a lot of misinformation a lot of patients getting information that was did not reflect the evidence, yes, and challenging their physicians, or their health systems to give them hydroxychloroquine give them ivermectin arguments about vaccinations? How much of that contributed to burnout?
Christine Sinsky 11:53
That’s a great question. And Bob, you’re asking something that I’m currently in the process of writing up a research paper that we’ve done about that. And I’ll step back and just say we’ve been measuring burnout among physicians since 2011. And we do that every three years. And we do it with researchers at Stanford and Yale. And so we were due to do a survey at the end in 2020, about 9 months into the pandemic. And we wondered what we’d find, and we found that burnout rates were the lowest they’ve been in the entire time we’ve been tracking, they continue to 6 year trend have declined to 38%. And then we did a mid-cycle survey a year later. So toward the end of the second year of the pandemic, and burnout rates spiked to the highest that they’d ever been at 63%.
Bob Wachter 12:46
So 63. So 2 out of 3 physicians have symptoms of significant burnout?
Christine Sinsky 12:51
That’s exactly right.
Bob Wachter 12:53
And how does that compare to other, do we know anything about other professions.
Christine Sinsky 12:56
So every year we also, when we do the survey, on every three year cycle, we also assess burnout in the general population. And it’s always been higher than physicians for the jet, excuse me in physicians. For the general population, the burnout rate is closer to 20%-22%. So two thirds of physicians experiencing burnout is high. And it’s not because physicians are less resilient to the than the general population. In fact, other data shows that physicians have a significantly higher resilience than the general population. We also know that fewer physicians will choose to be a physician, again, it went from 72% in 2020 to 57%, who would choose the profession again. So you brought up though the politicization of medical care, and that was something that we asked physicians about in our survey at the end of 2021. And that is something we’re in the process of analyzing but I can share with you that stress around conversations about vaccination around unapproved therapies, around misinformation, impacted the vast majority of physicians, and was a driver is a driver of burnout among physicians. So I think you’re spot on it is a serious problem.
Bob Wachter 14:28
So in your role at the AMA, your job is to understand this and help it and help the organization and try to address it. What are the main approaches that you’re taking?
Christine Sinsky 14:40
Right, right. So we are working in several areas, research so that we have knowledge about the state of burnout and about its drivers and consequences. And then we have a lot of resources to help individual physicians and to help healthcare organizations change their organizational culture, improve practice efficiency to make the work life more manageable. Bob, you’ve talked about a manageable cockpit and you visited Boeing and in realize that their engineers really explicitly work to make sure the cockpit for pilots was not overwhelming, but was safe and manageable. And we don’t have that in medicine, but something that we need. And as part of that, we are working at the AMA to debunk regulatory myths, so people aren’t laboring under misunderstanding of what regulation is. And we are working on very practical things this morning, I’ve been working on collecting best practices around inbox management. So that the inbox which has become, I think, one of the biggest burdens for physicians in the last several years, so that we can reduce the volume of inbox work and reduce the emotional drain that the inbox takes on physicians.
Bob Wachter 16:07
So we’ve talked a lot about the documentation burden that the physicians are having to spend a lot of time typing things into the record and then looking stuff up in the record. And what the new twist on the theme is that patients now have a portal, they have an electronic version of the electronic record themselves, and have the ability now to send a message to their doctor that may be to schedule an appointment or get a medication or ask a question, and they are quite logically using it. And that sort of lands on the physicians in the physician’s world through an electronic inbox as part of their electronic health record. Because I don’t remember hearing the inbox be a major, be discussed as a major contributor five years ago. So that seems like a new theme.
Christine Sinsky 16:51
It really is. And we last year set that up as one of our major priorities. One of our two priorities in the work that I lead is to address the inbox because it has become such a challenge. Even pre pandemic, there’s data that family physicians were spending an hour and a half every day, clearing their inbox, post pandemic, we know that there’s been an increase to 157%, higher patient medical advice requests, messages from patients post pandemic, and that rose in a very sharp incline right at the onset of the pandemic and the spring of 2020. But it has stayed elevated since that time. And there are many messages that come in patient medical advice request those communications from the patient represent a minority of the total in basket volume on the order of 15% of the inbox volume. And it’s important, I don’t think anyone is suggesting that patients shouldn’t have that kind of access to care from their clinical team. But we haven’t set aside the time for physicians to do that work. And we’ve also allowed the inbox to be full of a lot of other things that don’t need either to come to the clinical team at all, or that don’t need to come to the physician as part of that clinical team.
Bob Wachter 18:17
Yeah, when I send an inbox message to a lawyer or an accountant, they charge me for every six minutes. Most medical systems I don’t think have there’s no economic model for how all this work gets allocated and potentially compensated. Is that part of the answer?
Christine Sinsky 18:35
So there are several institutions, you’re on included that are piloting, considering care that was delivered through the patient portal as reimbursable care. And I think that that is probably part of the solution. I think the bigger solution, though, is to just be intentional about what goes into the inbox so that we don’t end up with all of the clutter. People get notified if they’ve ordered a test but the test is result isn’t yet available. And that is an inbox message that many people are having to clear out copies of notes that aren’t necessary to share with other physicians are being shared with other physicians and add to the clutter of the day. So I think there’s just a lot that can be called out of the inbox, while allowing patients to have this new and valued source of connection with their physician and care team.
Bob Wachter 19:34
If I’m a patient, I may be hearing this and feeling like okay, you know, that’s too bad, but physicians are well compensated and prestigious and there are very few unemployed doctors and you know, this is not the profession that I have the most sympathy for. So why should a patient care about this?
Christine Sinsky 19:53
Yeah, yeah, your point is exactly. Spot on. Physicians. We are fortunate in many ways well compensated, and we have really meaningful work. I think the reason the general public should care about burnout among health professionals, among nurses and physicians, is it impacts not only the quality of care that they have, but their basic access to care. In the community in which I live, the larger community where a university is, there isn’t a single primary care physician currently who is taking new patients. And yet, I believe we waste about half of our primary care physicians work day on administrative burdens and on lower level clinical tasks that they’re doing, because we haven’t built a strong clinical team around them. So this has consequences directly to the patient. Because if your doctor is spending, for all the doctors are spending so much time typing, then there aren’t enough physicians to allow access to care. So at the bigger the higher level, I see that as an issue. On the individual level, it certainly makes sense to us has face validity that if our physician is burned out and frustrated and may be feeling a lot of negative emotions all day long, it’s going to be harder for them to care for us, and we won’t have the good experience that we want. And so I think it’s not patient’s responsibility to fix the problem. But to be aware of the issue, I think is important. If you do feel like your physician is not able to give you the care that you would like. And part of it is from maybe feeling pretty cynical or emotionally drained, you may want to seek another physician, but you may have trouble finding them because physicians are in short supply.
Bob Wachter 21:58
My mother’s doctor in Florida is a concierge doctor, she pays a few 1000 bucks a year to get what feels like a little bit higher level of service and attention and probably a little bit more time for each appointment. And I think that’s probably a response in part to all of this, that for certain physicians in order to have the time to do what they want to do. The only way to make that work is to collect some more money up front. What do you think about that phenomenon?
Christine Sinsky 22:56
Yeah, so I think it’s mixed. Because it it’s a sub optimal solution. That is it optimizes for an individual patient and physician, but it’s not generalizable for the entire population of the country, because of all of our physicians cut back the number of patients they were caring for by 50% or 60%, then 50% or 60% of the population won’t have access to care. I think what our challenges is to say, how can we build the systems? How can we build the stronger teams, so every patient gets the experience that a concierge patient currently gets. And I know that’s possible. And I know that’s possible, in part because that’s what we were able to deliver in, in my own practice, where we had control over a lot more of the details where we were the payer, as well as the provider, where we had two nurses per physician in tight, stable teams.
Bob Wachter 23:53
Another thing patients may see is they walk in to see their physician and there’s this stranger in the room and they get introduced as the scribe. Tell us what that’s about. And whether that’s a contributor to fixing some of the problems here.
Christine Sinsky 24:04
Well, and we had a version of that my own practice where we had collaborative visits and the nurse and I would see the patient together. And then the nurse would do some of the data entry and some of the data retrieval and they would put in the orders in real time while we were in the room. And we wondered what that would be like for patients, would they feel more reluctant to share everything that they might have been expecting? I really felt like it’s sacred space between the doctor and the patient and with this, disrupt that and to my surprise, and to an extent I was I realized it actually make care better. So that’s one model of that. Helping with the documentation piece, another model is to have a scribe either in person or via the phone listening in a virtual scribe and I have experienced both of those at the university that I now from which I now receive my care, I found them absolutely either not a problem at all in the form of the iPhone or just an enhancement, because there’s one more person who is listening to the story. And is there as part of the care?
Bob Wachter 25:23
Yes, I think you know, my wife, Katie writes for The New York Times, and she brought scribes to national attention. And it was because I came home one day, and I said, honey, do you know, every other profession digitizes brings computers in and immediately starts laying people off? Only in medicine could we figure out a way of bringing a computer and then we have to add an extra person to room to feed the computer? Yes, it was sort of an odd phenomenon. But we found the same thing here in San Francisco that the scribes had been a major satisfier for the physicians and the patients have liked it just fine. It’s just it’s kind of a workaround. You know, it doesn’t really get at the fundamental problem of all the documentation.
Christine Sinsky 26:02
Well, and I think that’s absolutely true. When you’re talking just scribing. When you’re talking about a collaborative visit with the nurse and the physician together, I thought that big benefit would be the documentation relief that I would experience. And that was welcome. But the biggest benefit was that we were doing this work together, and the patients got better care. The care gaps were closed, the nurses were present in the room, so that when the patient might have had a question between visits, they were able to manage those on their own. And it was just better care all around for the for the patient. Great. We did just published a study showing that burnout was 85% less for those who used a virtual scribe than those who did not use a scribe, so those that did not have any documentation assistance. And so one more piece of evidence in a building, body of evidence that having relief from some of the administrative tasks, makes a big difference for physicians.
Bob Wachter 27:11
Let’s talk for a second about nurses. You mentioned that, that they’re part of the mix. What do we know about burnout in nurses? And what is that doing to that profession?
Christine Sinsky 27:22
Right. So pre pandemic, burnout among nurses was actually consistent with the general population, it was not higher than the general population. But what nurses suffered was much higher levels of dissatisfaction with work life balance, with work life integration. And I think that makes sense with the night shifts that nurses need to take. But the pandemic has changed that and burnout rates among nurses have also gone up. We know that what’s protective for nurses, and what’s protective for physicians against such a spike in burnout is feeling valued by their organizations. I think we have reason to worry about the workforce. We did a study that showed that 1 in 5 physicians, and 2 and 5 nurses intend to leave their current position within the next two years, if even a third of those individuals who express that intent carry it out, we are headed for a workforce shortage that’s even beyond what we’re currently experiencing.
Bob Wachter 28:33
Are we seeing this reflected in applications to medical school and applications to nursing school?
Christine Sinsky 28:39
So I don’t think we are I think applications to medical school are staying steady or even higher than they may have been a decade ago. I don’t really know about nursing school. But I wouldn’t be surprised if those two are holding steady or even increasing because the purpose and the meaning of work is clear to young people. But I think it’s once nurses and physicians get into their roles, and they find that the daily work is not fully aligned with what they had aspired to and entering the profession. I think that’s where we see this intent to reduce to part time or the intent to leave coming out,
Bob Wachter 29:21
as you think about this over the next five or 10 years, or are you hopeful do you see change on the horizon? Clearly, the last several years as brought this issue to national attention, people are talking about burnout in the health professions. But there’s probably a tendency to attribute a lot of it to Covid and therefore, Covid. Changes to something more manageable. I can imagine people believing that this problem will work itself out and yet we talked about a whole lot of underlying causes that have nothing to do with Covid. Right,
Christine Sinsky 29:51
right. So I am optimistic. I am optimistic because there’s so much opportunity to make improvements. That we just have some as potential there’s so much sludge in the system now that removing even half of that sludge would feel like a huge relief to our nurses and physicians and, and I believe we can do it, we just need to collectively put our minds to it. And there are many bright spots across the country where organizations are taking action at very specific levels to reduce the inbox work to improve the possibilities of teamwork, to prioritize the relationships between physicians and patients, between nurses and patients. And then there are activities at the national level that should give us hope. The Surgeon General just had an advisory around clinician well-being and has very specific recommendations for multiple stakeholders within the healthcare universe, if you will. The National Academy of Medicine has been addressing clinician well-being for the last six years, and released a report a couple of years ago that’s full of specific data and recommendations. And then this year, just a few months ago, released a national plan that calls on multiple actors to help drive policy and system change for well-being. So I think this is not something that’s underneath the rug. It’s something in the open now.
Bob Wachter 31:29
Maybe last question, if you had kids who are of profession choosing age, and they said, Mom, I’m thinking about being a doctor, what would you tell them? Yeah,
Christine Sinsky 31:39
I would say it is such a wonderful profession. It is so full of meaning. Every day you know that what you do matters. And I’m working to help make that a manageable profession. I and others, not just me, of course, many of us are by going with your eyes open because it is not perfect. And there is a lot that is a source of administrative burden and frustration. But I still think unbalanced. It’s just a terrific profession.
Bob Wachter 32:17
Thank you, Chris. Sounds great.
Christine Sinsky 32:18
Yeah, thanks, Bob.
Bob Wachter 32:35
Coming up on Wednesday, you’ll hear our new reality audio show being golden. And then on Friday, Andy talks with Oscar winner Matthew McConaughey. Until then, stay safe and thanks for listening.
Thanks for listening to IN THE BUBBLE. We’re a production of Lemonada Media. Kathryn Barnes, Jackie Harris and Kyle Shiely produced our show, and they’re great. Our mix is by Noah Smith and James Barber, and they’re great, too. Steve Nelson is the vice president of the weekly content, and he’s okay, too. And of course, the ultimate bosses, Jessica Cordova Kramer and Stephanie Wittels Wachs, they executive produced the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, with additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia where you’ll also get the transcript of the show. And you can find me at @ASlavitt on Twitter. If you like what you heard today, why don’t you tell your friends to listen as well, and get them to write a review. Thanks so much, talk to you next time.