Physician Wellness, Osteopathic Principles, and Strategies for Change

Katherine Lincoln, DO, FACOFP, FAAFP Katherine.Lincoln@guthrie.org

No relevant financial affiliations

As the oath goes on, “I will endeavor to work in accord with my colleagues in a spirit of progressive cooperation.” It is through the long-term effects of burnout, this desire to learn and grow with colleagues is often lost. Physicians begin to lose passion for the role each play in the healthcare system. It can become a slippery slope to not feel like work matters. It can begin to feel like a factory job, just adding a widget to a greater machine without greater purpose, self-satisfaction and contemplation. As physicians see their jobs released to non-physician providers, they can lose sight of the patient care that was the motivation for their education in the first place. As service lines begin to compete for the healthcare dollar, the desired progressive cooperation can be lost.

Physician burnout has been written about extensively by Dike Drummond, MD. Dr. Drummond is a Mayo Clinic trained family physician who is a teacher and trainer on stress management, burnout prevention, physician engagement, and tools for effective physician leadership. In one of Drummond’s articles, he writes “The difference between stress and physician burnout is this ability to recover in your time off. Physician burnout begins when you are NOT able to recharge your batteries between call nights or days in the office. You begin a downward spiral that has three distinct symptoms.

1. Physical and Emotional Exhaustion
2. Depersonalization
3. Reduced Sense of Personal Accomplishment3

It must be noted that burnout is not fatigue. Burnout is not physician laziness. Burnout is not young doctors being “soft.” Burnout lasts for months or even years. Burnout can make a physician feel like a failure and can manifests itself in the physician creating a cynical attitude and feelings of hopeless. According to multiple sources4,5 it is an emotional exhaustion that is not replenished after a vacation or other restful activities. Callousness and exhaustion brought on by burnout cannot be cured with a mandatory class in patient satisfaction surveys or institutionally required courses and activities.

The average modern physician is overwhelmed with administrative tasks, unprecedented educational debt, increasing patient demands, and the struggle with work/life balance. After years of training, Osteopathic physicians have many choices: they may choose to practice in a private practice setting or as employees to a large groups or companies. Each choice comes with a downside. Private practice focus may have to be on maximizing revenue and minimizing cost just to survive. Private physicians may be responsible for taxing and overly burdensome administrative roles within the practice. On the other hand, employed physicians may feel that their work doesn’t matter, that they have little control over their time and patient interaction or they have become “just a worker,” having lost their passion for patient care.

According to the article, “Physician Burnout: It Just Keeps Getting Worse,”6 the top four key areas of physician burnout were identified as (in order from worst to least): too many bureaucratic tasks, spending too many hours at work, income not high enough, and the increasing computerization of practice.

Those in private practice may work longer hours compared to peers to attain higher income goals. The benefits of this are higher incomes and more autonomy. However, by pushing oneself to maximize benefit, a balance between work and non-work can be lost. The act of leaving work to exercise or to spend time with family is sacrificed in order to earn more. When physicians are pushed to maximize work time, sleep time is lost to charting and other non-paid administrative tasks. As Osteopathic physicians, it is clear that nature's laws dictate that humans have a sleep-wake cycle. When physicians ignore the laws of nature, just like in every human, the results can be devastating; physicians can lose their sense of purpose in medicine and in their personal lives.

In employed settings, physicians may have waived their rights to autonomy in exchange for fewer administrative burdens. Physicians may be able to come to the office or other practice setting, see the patients to whom they are assigned, finish their charts, then simply go home. Though it removes these time consuming tasks of scheduling, marketing, oversight, and day-to- day practice operations from the family physician it also places these administrative duties on someone outside the control of the employed physician. By exchanging control for a regular paycheck and benefits, autonomy is lost. The physician relinquishes control to terminate patients for bad behavior or fire staff for misconduct.

A tenet of Osteopathy states “the Body is a unit, and the person represents a combination of body, mind, and spirit.” Taking this tenet and applying it to physician burnout, it can be seen how the inherent flaws of the current physician practice models can lead to burnout. If a physician in the workplace is forced to complete meaningless tasks, such as trivial but “required” documentation into an EMR, the unit of a mind, body, and spirit breaks down. The mind of an Osteopathic physician seeks to restore health through natural processes, such as sleep, leisure time and laughter. The mind of an Osteopathic physician sees the patient as an integrated collection of parts, each with dependent structures and functions. The mind of an Osteopathic physician seeks to find meaning for the ill as the illness plays a role in the patient’s own family and society. As the body is forced to click EMR tabs and sign forms, the mind and spirit become disconnected from the root of health. While the body is typing charts for hours, the mind can wander and the spirits wither.

In Osteopathic medical students, their minds are engaged in high endeavors with visions of charity and mercy when they become attending physicians. Collaboration is held up as a desired part of their chosen field. The student spirit is filled when senior doctors make students feel like a part of the team, each person sharing the collective responsibility of care. As training ends and attending to life begins, a physician can feel like a silo of medical care. Osteopathic family physicians see patients daily with multiple complex comorbidities and handle their patient’s care with grace and dedication. As the months and years of “real life” wear on, the spark of spirit filling love of medicine can wane. The mind can start to dull and wander. It can become easy to wonder if the prescriptions and the phone calls and missed lunches and late nights of patient care matter at all. A great divide can occur between an active mind filled with medicine and the physical body being pushed, insulted, micromanaged, and fatigued from late night documenting. The spirit, previously engaged and filled with intellectual curiosity, now goes dormant. Life goes on. Time goes by. Patients are born and patients die. Physician families age and grow, contract and expand. Without intervention, physician burnout can cause the rifts between the physician’s mind, body, and spirit to expand.

In order to reintegrate, Osteopathic physicians need to identify the problem. For this, the Maslock Physician Burnout Inventory can be very useful. It is free and can be found at mindgarden.com/117- maslach-burnout-inventory.7 This validated inventory can be taken periodically by physicians as a touch point for personal wellness. Once physician burnout is identified, the Osteopathic physician should be allowed to decipher which people, conditions, episodes, and locations of patient care are most meaningful to him/ her. It has been demonstrated that when people find meaning in their work at least 20% of the time, they are willing and able to suffer with less engaging work the rest of their work life.8 As leaders of the Osteopathic family physicians, the ACOFP should encourage physicians to screen themselves with standardized tools such as Maslock Inventory and others. Once a physician acknowledges personal burnout, it can help move the needle back toward physician wellness and away from the many malignant manifestations of burnout.

The Mayo Clinic has constructed work levels in which to analyze strategies for change.9 When a physician accepts burnout data in the self and in the work group, it can be helpful to have a framework for the institution of change. This framework can view options for change at the individual level, work unit factor, organizational level, and the national level.9

At an individual level, Osteopathic physicians can analyze their specialty and practice location. Each can assess their personal efficiency and organizational skills. Each person can identify meaning in work and use self-awareness to shape career interests.9 Individual physicians can assess their personality traits and relationship building skills. Each can integrate work and life outside work by using personal priorities and values.9

As strategies for physician engagement are created, work unit factors must be considered. Work units are the local teams which physician’s work and exist in every day during work. It may include nursing support, clerical staff, other professionals, and administrative assistants. These are the team units which have their own culture in the daily experience of work. Areas of analysis should include team structure and productivity goals.9 To assess efficiency and resources, daily huddles are found to be helpful. These huddles can address “pebbles in my shoe,”10 small frustrations which may have simple solutions once they are clearly identified. For example, if a front desk staff member identifies it is very frustrating when the phone is ringing when she is trying to assist a patient in from of her, routing some calls to an alternate person during a high-volume time, some angst may be alleviated. Guthrie Medical Group in Sayre, Pennsylvania encourages each work unit to hold these huddles with pebble in my shoe on the agenda at least weekly. It allows the physicians and staff to have a space for change, using concrete elements to change work flow.

From an institutional perspective, group leaders should seek to help physicians reengage in the Osteopathic oath’s “progressive cooperation.” Institutions can create initiatives to engage physicians to reintegrate body, mind, and spirit. One way is to encourage reintegration is through fellowship with physicians centering around a common cause, such as interest in special areas of patient health, legislative medical issues or women in medicine special interest groups. When physicians engage in meaningful, cooperative dialog with near peers, they feel like their opinions matter. They feel like they want to move forward, move ahead, and move on, instead of staying stagnant. When leadership of influential medical groups encourages finding meaning in one’s work, it helps struggling individuals feel less alone.

Nationally, changes can be made to reduce physician burnout.11 A healthcare model which encourages quality care over EMR box clicking would be a reasonable start. The United States has had a third-party payer system for healthcare since Medicare and Medicaid was enacted. As years have passed, the Centers for Medicaid and Medicare (CMS) have continued to support legislation requiring increasing mandates on physicians. This burden has mounted to a new high as MIPS (Merit-based Incentive Payment System) and MACRA (Medicare Access and CHIP Reauthorization Act of 2015) reporting will most likely cause small, private, rural medical practices to surrender to local Accountable Care Organizations (ACOs)12 or other financial models that destroy physician autonomy. Presently there is a CMS awareness of the excessive burden that has been generated by the new MIPS payment system and legislation to curb the burdens are being encouraged by the present Administration of the United States.13 If a national payer consensus does occur and reduces the administrative burden on physician practices, physicians could spend more time engaged in patient care.

As previously noted, the major causes of physician burnout are too many bureaucratic tasks, spending too many hours at work, income not high enough, and the increasing computerization of practice. Each of these is closely tied to national healthcare policy. If future national legislation effectively reduces required bureaucratic tasks, physicians could spend less time at work. As these tasks were streamlined, the over-“computerization” of medicine and the depersonalization that occurs with that activity would decline. Osteopathic physicians should “employ only those recognized methods of treatment consistent with good judgment and with my skill and ability.” Depersonalization of direct patient care brought about by the bureaucratic requirements just mentioned is surely not consistent with the Osteopathic Family Physician’s best judgment, skill or ability.

As the future of physician wellbeing is sought out, reflection should be taken from Osteopathic history. By examining the Osteopathic oath and Osteopathic tenants, guideposts can be created for sculpting the future. By embracing treatment of good judgment and a spirit of progressive cooperation, the future can focus on healthy, content, well balanced Osteopathic family physicians who will be able to bring best care to their patients during long and fulfilling careers.

REFERENCES

1. AAFP Physician Burnout (Position Paper). Retrieved May 21, 2018 from https://www.aafp.org/about/policies/all/physician-burnout.html.

2. Anderson, P. “Physicians Experience Highest Suicide Rate of Any Profession” posted on May 07, 2018, retrieved on May 14, 2018 from https://www.medscape.com/viewarticle/896257.

3. Drummond, MD, Dike. “Physician Burnout: Why it’s not a Fair Fight” retrieved on May 14, 2018 from https://www.thehappymd.com/blog/ bid/295048/Physician-Burnout-Why-its-not-a-Fair-Fight.

4. “Physician Burnout”. Agency for Healthcare Research and Quality. Retrieved May 21, 2018 from https://www.ahrq.gov/professionals/ clinicians-providers/ahrq-works/burnout/index.html.

5. “Leadership Survey: Why Physician Burnout Is Endemic, and How Health Care Must Respond”. New England Journal of Medicine Catalyst. Published December 8, 2016. Retrieved May 21, 2018 from https://catalyst.nejm. org/physician-burnout-endemic-healthcare-respond/.

6. Peckham, Carol. “Physician Burnout: It Just Keeps Getting Worse” Medscape Family Medicine January 26, 2015 retrieved on My 14, 2018 from https://www.medscape.com/viewarticle/838437.

7. Maslach Burnout Inventory. Retrieved on May 14, 2018 from https:// www.mindgarden.com/117-maslach-burnout-inventory.

8. Friedman, U. “7 Ways to Find Meaning at Work,” posted July 4, 2016, The Atlantic. Retrieved May 14, 2018 from https://www.

9. theatlantic.com/business/archive/2016/07/meaning-work-happiness- brooks/489920/. https://www.cms.gov/Research-Statistics-Data-and- Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/ ReducingProviderBurden.html

10. Shanafelt, Tait and Noseworthy, J. “Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout”. Mayo Clin Proc. Jan 2017:92(1):129-146.

11. (10) TD Jakes. “What are the Pebbles in your Shoe?”. Retrieved on May 13, 2019 from https://www.tdjakes.com/posts/what-are-the-pebbles-in-your- shoe

12. “Reducing Provider Burden”. Center for Medicare and Medicaid Services. Updated May 1, 2018. Retrieved May 21, 2018 from https://www.cms.gov/ Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare- FFS-Compliance-Programs/ReducingProviderBurden.html

13. Belliveau, Jacqueline. “Is MACRA a Trojan Horse for Small Practices, Value-Based Care?” RevCycle Intelligence. Retrieved May 21, 2018 from https://revcycleintelligence.com/news/is-macra-a-trojan-horse-for-small- practices-value-based-care.

14. “Administrative Simplification Overview”. Center for Medicare and Medicaid Services. Retrieved May 21, 2018 from https://www.cms.gov/ Regulations-and-Guidance/Administrative-Simplification/HIPAA-ACA/ index.html.