Toxic Work Environment

At the 2018 MSMA Annual Meeting, I had the great privilege of participating in a session on physician burnout, for the Missouri Psychiatric Association. The main speaker was Dr. C. Robert Cloninger, professor of psychiatry and director of the Center for Well-Being at Washington University. His presentation was much more complex and sophisticated than mine, resting on his extensive work on the psychobiological theory of personality.¹ But we agreed on the central point of the problem. Since Dr. Cloninger made the point much better than I did, let me paraphrase his argument. Physicians are people who have made it through rigorous selection and training processes, and are resilient and adaptable, as well as compulsive and highly conscientious. If this group of people are frustrated with their working environment, a reasonable conclusion is that the working environment itself is flawed. We are, as a group, being subjected to a toxic work environment.

A recent commentary on the website of WBUR, Boston’s public radio station, focused the debate more clearly on Electronic Health Records.² Three eminent Boston physicians engage in harsh criticism of the use of the EHR, saying it forces physicians to relate as much to the computer as to the patient, and robs patient encounters of the time needed for the physician to listen to the patient. They point out that the current EHR systems force large amounts of unneeded work on physicians, offload most of the work involved in hospital billing onto physicians (and nurses), and come between physicians and patients. EHRs, in short, have failed in their promise to make health care simpler and more cost-effective. They have, in fact, made it more complicated, more expensive, and more frustrating to both doctors and patients.

And the economics of the whole system is just nuts. Consider. Physicians and nurses are the most highly paid people in hospitals.³ So, we require them to spend up to half their working time shoveling data into computers. Besides drastically lowering their actual productivity, this forces them to eliminate parts of their former activities. Like, for example, sitting down and actually talking with patients. As a result, we need nurses and physicians in much greater numbers, and they are working far less efficiently, with less patient contact. Data entry can certainly be productive work, but not for physicians and nurses.

So … why are EHRs so difficult to use? Given that we all need to document our findings and our procedures, why have we made it so difficult? Probably the best answer comes from the observation that those using the systems are not those purchasing them. Hospital administrators are properly concerned with such things as billing, operations, and inventory. But while hospitals often solicit opinions from doctors and nurses, they don’t really take their needs into account. The EHR companies are focused on managing data, and the interaction with the “users” is of relatively small importance.⁴ Many physicians and computer scientists have worked out better ways of interacting with EHRs, but they don’t run the computer companies, nor do they have much influence within health care organizations.

The Boston physicians noted that they are organizing town meetings, and other such activities, to try to improve the EHR. Whether this sort of “grass roots” pressure will be effective is anybody’s guess. Personally, I’m not hopeful. There is a great deal of inertia to overcome. EHR systems are very expensive, and there is a very large installed base. It is difficult to make even small changes in existing systems. Government regulations have the effect of freezing existing systems. Significant changes may require Congressional action and/or regulatory reform. Any objective observer would realize that the whole regulatory framework for EHRs is ineffective, and should be scrapped. The AMA, after a great deal of work and much lobbying, succeeded only in softening the terms of MACRA, which is now called MIPS. (Don’t bother to remember those. They’ll be different next year.) So, improving EHRs is going to take a lot of work, much political capital, and a long time.

But our toxic work environment isn’t limited to EHRs, frustrating as they may be. Let us consider piece work. Now, piece work is the practice of paying the worker for each item produced. It was the common method of paying industrial workers at the end of the 19^th century. But in industry after industry, it was abandoned during the first half of the 20^th century, because of union pressure, technological change, and the increasing need of companies to obtain a stable work force. For a case history, see the reference below.⁵ Of course, it still exists for physician practices. More than that, modern management fads such as “pay for productivity” and “incentive payments” have tried to move piece work from private practice into organizations for knowledge workers such as physicians.

Piece work is not especially conducive to either good medical care or a healthy working environment. Shanafelt, et al. reported on the American College of Surgeons study of 7,900 general surgeons.⁶ They found that compensation based only on productivity was significantly associated with burnout symptoms (odds ratio, 1.37:1). Piece work is superficially attractive to managers, insurers, and government. For one thing, it makes it easier to cut pay. There has been a steady erosion in physician reimbursement for standard services over the last 30 years. Since there are more services now, with new ones popping up every year, cutting our pay has not resulted in lower costs. A hospitalization which required one or two physicians in 1960 might require ten consultations today. Personally, I believe the team approach provides better care. But it has the entirely coincidental side effect of increasing overall physician reimbursement.

As most of us realize, painfully, our work environment has other toxicities. With the ever-increasing role of regulation in medicine, we are all subjected to multiple bureaucratic harassments. Some of these are unnecessary, perhaps even most of them. Do we need quality measures? Sure. But why aren’t they any better? Does an internist control his or her patients so closely that the average hemoglobin A1c level have any meaning? What about the average blood pressure? These aren’t quality measures, except in the negative sense that they indicate physicians who are willing to care for difficult patients.

Some are self-inflicted. For example, we awarded power to specialty boards, who then approved re-certification examinations, and maintenance of certification. We are not doing nearly enough to take back that power. Why should a cardiac sub-specialist, for example, have to take three exams every ten years, and engage in multiple MOC activities? And yet, these particular ills are inflicted on the profession by itself.

A great deal more can be said about the working environment for physicians today. Unfortunately, most of it is negative. Perhaps some of it is not avoidable. But the EMR isn’t going to get better without a lot of agitation by physicians. Re-certification and MOC aren’t going to improve, unless we reform the specialty boards. That won’t be pleasant. The boards have entrenched power, and money, and strongly resist any changes. Government regulation will continue to be intrusive and will get worse if we don’t start pushing back. If we do not find ways to make out work environment more functional and less frustrating, and if we cannot push our health care organizations into promoting change, we will be in a toxic work environment for a long time to come.

Biography

Charles W. Van Way, III, MD, FACS, FCCP, FCCM, MSMA member since 1989, Missouri/AMA Delegate, and Missouri Medicine Contributing Editor, is Emeritus Professor of Surgery, University of Missouri - Kansas city.

Contact: cvanway@kc.rr.com

Reprinted with permission, Kansas City Medicine.