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Curbside Consult with Dr. Jayne 11/25/19

November 25, 2019 Dr. Jayne 3 Comments

Clinician burnout continues to be a hot topic, so this American Academy of Family Physicians article caught my eye. It looks at the possibility that being able to better address the social needs of patients might reduce the possibility of burnout. I’m not surprised by this – physicians and other clinicians are trained to do their best to address all their patients’ issues, whether they are purely biological, psychosocial, or somewhere in between.

In many residency programs, we have all kinds of ancillary providers that help us do these things. My training program had PhD pharmacists, social workers, diabetic educators, dieticians, and psychologists to which we could refer our patients for a variety of services. Need a patient to receive education on anticoagulant drugs, their long-term monitoring, and the need for dietary changes? Check. Want to enroll a patient in smoking cessation clinic? Check. Newly diabetic patient who needs supplies and training? You got it. Patient who needs help navigating Medicaid enrollment or applying for supplemental nutrition assistance? Done.

When I headed out into practice, however, I was on my own to try to deliver many of these services. Even referring to subspecialists often became a battle that was made worse depending on the patient’s insurance coverage, ultimately resulting in the patient not receiving needed services.

At one point in time early in my career, only one of the city’s practices was taking new neurology patients who had Medicaid, which made the wait to see a consultant nearly a year long. This led to primary care physicians trying to do what they could to manage complex neurological issues that they weren’t trained to handle. You don’t have to ponder to hard to see where that could cause stress and burnout.

Not much has changed in the last couple of decades, although at times it’s a little easier to get patients in to see subspecialists, or maybe I’ve just built up enough friendships to be able to call in more favors. There are other more complex issues that we can’t solve through a phone call to a friend or classmate. Maybe it’s housing issues, transportation issues, or food insecurity. These are the types of issues that the study mentioned was looking at, along with whether inability to address patients’ social needs was a contributing factor to primary care clinician burnout. The authors went on to note that increasing services in the practice to address social needs tended to reduce burnout and improve clinician morale.

The study noted that participating physicians were concerned about how addressing social needs would impact their workflow. I’m curious about how those physicians went about adding services or training staff to address social needs and how that impacted not only the workflow, but the practice bottom line. Theoretically, some of the new care models, such as Comprehensive Primary Care Plus or Primary Care First, should provide additional funds to cover these additional services. However, it’s still not going to be enough.

A friend’s EHR has the ability to link out to transportation resources for patients, such as Uber. However, the practice has to pay for the transportation, leading to an ongoing internal conflict about which patients should receive those services. Independent physicians can make these decisions locally, but employed physicians are often subject to the whims of their owners, and productivity and case mix determines which physicians (and therefore patients) receive additional support and which don’t.

On the technology side of healthcare, we face similar difficult decisions. We have limited budgets and requests for more projects than we could possibly fund or staff. At one of my large health system clients, decisions often impact broad swaths of patients. Are we going to focus on systems to improve labor and delivery workflows this year, or fund the initiatives that the heart failure program has requested? How many patients would benefit from either approach? What about the community diabetes screening initiative, or the dental care mobile van? Should we look just at patient count, or go further to see how interventions would impact people over time?

At one point, money earmarked for optimization of frontline nursing workflows was diverted to cover consulting services needed to complete a required regulatory upgrade. This led to a relative revolt by some of the staff involved in advocating for projects that didn’t get the nod.

The emotions felt by some of the IT staff were no different than what was probably felt by the physicians in the study. In particular, those whose projects weren’t taken forward felt disenfranchised and often had a profound sense of loss. Some of those whose projects succeeded had something akin to survivor’s guilt as they watched other worthy initiatives wither. It also engendered a sense of fear and concern, with people wondering whether their project would be the next one to be defunded or otherwise not fully implemented. Sure, projects get canceled in every industry, but I think my colleagues in healthcare IT feel it more acutely because they know their work has the direct ability to impact patients’ lives.

The emotions become even more acute when you are working for organizations that are sitting on billions of dollars of resources, but may not be spending as much on patient care as they should. The marble lobby of the tertiary referral hospital is particularly luxurious (and the fountain is pretty darned impressive), but neither of those see patients. They don’t make up for the negative emotions felt by the clinical staff that empties the exam room trash cans every other day because the housekeeping budget was cut and services are only provided on even days. The luxury boxes at the ballpark and the over-the-top billboards are also a visible reminder of the money the health system is willing to spend on non-patient-care activities.

As the old adage goes, you have to spend money to make money, but somehow that spending is becoming less palatable when healthcare is on the line and patients are literally dying due to lack of basic interventions.

It’s easy to see why people in healthcare are burned out, no matter where you work or what your role is. Our inability to meet our patients’ needs is only a proximal cause, with many root causes beneath. I’m cautiously optimistic about new models of care that might help alleviate suffering or reduce gaps in care, but it may take years to determine how successful they really are. In the meantime, we need to support each other and continue to try to come up with innovative ideas to solve some of the most difficult problems humanity faces.

What would make you feel less burned out? Leave a comment or email me.

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Currently there are "3 comments" on this Article:

  1. Very well stated. AT my facility we have a weekly Length of Stay meeting to review our longer staying inpatients. It’s the same old problems that keep popping up:
    1) no available outpatient dialysis bed (oftentimes for problematic behavior)
    2) family of the patient isn’t ready to accept comfort care only
    3) patient needs some treatment that isn’t available at a shelter
    4) Patient needs long term medication and the facility the patient is to be sent to for LTAC won’t be reimbursed for the medication, so they are no longer accepting the patient.
    Not certain how to address these chronic issues locally, but it does make a case for better access to primary care to prevent these tertiary issues. We also need to address the homeless population which has really grown exponentially in my area (SF Bay Area), which impacts so many facets of life.

  2. I understand the frustration and helplessness that Dr Jane felt in knowing that a Medicaid patient required the services of a specialist, but realizing that there could well be a wait of a year or more to get the patient that needed appointment because of the paucity of specialists will to schedule a Medicaid patient due to the low payment schedule for their services. Not to mention the fact that, in my experience, state-run Medicaid claims examiners routinely deny needed services, requiring the beneficiary or his or her physician to begin a costly series of appeals.
    My most recent experience was with a Tennessee Medicaid beneficiary who was covered under a managed care program that included both medical and dental services. The beneficiary had several broken and rotting teeth in his mouth, teeth that had become a source of infection, that required a skilled oral surgeon, as these could not be simply extracted, but would have to be cut out of his jaw, not something that a family dentist could or would attempt to do. His medicaid plan gave him the names of five dentists, some one hundred miles away, who would accept Medicaid assignment for the needed surgery. He contacted them all. Two were no longer in practice, two others had dropped out of the Medicaid program, and one said that he had never been in the Medicaid program for the state. He notified his Medicaid program manager, they reviewed the issue, and sent him, along with a very nice, apologetic letter, the names of the same five dentists. He then called around on his own and located a local dental surgeon, not contracted with Medicaid, who said he would perform the surgery for the in-network fee of the plan manager. The Medicaid manager declined the dentist’s offer, stating that he was not contracted with them and they would not pay him for the service.
    We are appealing, but I get the feeling that this will just go around and around in circles. I can hardly wait until we all get to enjoy Medicare For All – when this fiasco will be the rule, and not the exception. Yes, and I do realize that most Medicare (as opposed to Medicaid) programs provide little to no dental coverage at all.







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