Curbside Consult with Dr. Jayne 5/23/22

I’ve been mentoring young physicians for many years. I was recently asked by one of them to speak to a group of physicians who are struggling with burnout and inability to effectively balance work and home life. Some of them are even thinking about leaving medicine altogether. They were looking for tips from someone a bit more “seasoned” (which is just a nice way to say that at least for those still in training, I’m nearly old enough to be their mother). As we got into the conversation and they were talking about the stresses they were facing in their daily work, I realized several things.

First, these young physicians have always used EHRs. They had no frame of reference for the era of paper charts and how outpatient practices used to operate. They had never been confronted by an unreadable chart, much less a chart that was missing entirely, and as such have never had to perform an established patient visit “blind” as many of us have. There is tremendous anxiety at the idea of not having all the information at their fingertips.

Conversely, they have never had the satisfaction of being able to know what is going on with a patient by scanning a brief note that might say, “Strep, Amoxicillin x 10 days” as the assessment and plan. They’ve been surrounded by so-called note bloat for their entire careers and are used to wading through pools of useless information to try to find important nuggets to use as they care for patients.

Additionally, they’ve never had to go through an EHR implementation, so they have not had the experience of carefully evaluating their workflows to determine if they make sense, or if they need to do some streamlining. They’ve not had much experience pushing back on administrators and tend to be much more likely to take things at face value than my colleagues who trained 20 years ago and who have been through various stages of clinical transformation. Because they’ve always had an operational EHR, they haven’t had the opportunity to ask a lot of questions about why the workflow is the way that it is, or if anything can be made better.

For example, one of them was complaining about the sheer volume of inbox messages that she receives from their practice’s patient portal and how none of them require her expertise. She regularly receives appointment requests, billing questions, and other non-medical messages that she then has to forward to others to address. I asked her why her practice has all the patient portal messages routing directly to the physicians rather than to staffers who can filter the messages. She was unaware that you can even do that with an EHR (and having been a user of her particular system I know it can be done) so didn’t think to ask.

I challenged her to think critically about the other processes in her office. Do all the telephone messages come directly to her, or are they worked by the scheduling team, a medical assistant, and others first, with only those that no one else can address coming to the physician? There’s no reason that messages originating from the patient portal should be handled any differently. I could almost see the light bulb going on over her head as she thought about pushing back on the task of being her own receptionist.

Second, I found that there was a large amount of learned helplessness among these physicians. Some of them are doing four or more hours of documentation at home after leaving the office, but they’re not willing to discuss it with their practices for fear of appearing weak or looking like they can’t keep up or aren’t as productive as their partners. I think some of this comes because of their being in training or their recent proximity to training and not wanting to do anything that would raise a red flag about not being a team player or that they’re not good candidates for highly competitive fellowships or job opportunities.

For the most part, they didn’t seem to be aware of resources that are available to them, such as EHR optimization assistance, classes on personalization or creating templates and macros, or being able to book time with a trainer. It made me wonder if this situation is part of their having grown up in an entirely tech-enabled universe where they assume systems are intuitive even when they’re not, and where people are rewarded for problem-solving on their own without any help. I know that during the early stages of the pandemic, a lot of organizations cut out some of these services, but to not even be aware of a super user in your practice that could help you out is concerning. To be afraid to ask for administrative support is even a bigger red flag as practice arrangements go.

Third, I noticed that many of these younger physicians have no business savvy. There are few subspecialties that require practice management education during training (thank goodness mine is one that does) and I was shocked by the general lack of knowledge around navigating workplace situations. Of the group, only one had an attorney review their employment contract, and most of them weren’t even aware with how much notice they would have to give if they decided to leave or if their medical liability insurance “tail” would be covered upon departure. Failing to understand or negotiate these things up front leaves them locked into these positions longer than they might want. And the lack of business savvy wasn’t only in their own employment – due to the challenges in arranging childcare as a physician, nearly all of them have household employees such as nannies or housekeepers and not a single one had a signed employment agreement or contract for services.

With that lack of understanding, it’s unlikely that any of these physicians would be able to have their own practices or succeed in a physician partnership as compared to being an employee. If they’re not able to demand a drug screen and adherence to policies and procedures for the people caring for their children, would they be able to demand those things of their medical assistants or medical office staff? It feels like they would always be at risk for being taken advantage of or committing some kind of regulatory offense simply out of ignorance.

I was glad to be able to spend a couple of hours taking them under my wing and explaining the concept of being an empowered physician. I stressed the need to spend a little time trying to fully understand the healthcare landscape well enough to be able to make good choices. I was glad to be able to share some information about how to push for better EHR usability and improved clinical workflows. I’m not sure how much a difference our time together will make for their progressive burnout, but it felt good to at least try to make things better.

What does your organization offer to better educate early-career physicians on the non-clinical aspects of working in healthcare? Or does the teaching stop after HIPAA or Fraud, Waste, and Abuse modules? Leave a comment or email me.

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