EPtalk by Dr. Jayne 2/23/23

In the “not a major surprise, but it’s nice to see some data” category, a recent study published in the Journal Healthcare finds that scribes are linked to a 27% reduction in primary care burnout rates. The authors looked at using remote scribes to assist primary care physicians in an effort to boost physician wellness.

The research was performed at University of Wisconsin Health and included approximately 200 physicians in the specialties of family medicine, general internal medicine, general pediatrics, and adolescent medicine. Individual scribes were paired one-to-one with physicians. The intervention group included 37 physicians and the control group numbered 160. The scribes used an audio-only cellphone connection to listen to visits and create documentation in real time. Orders were entered and held in a pending status for physicians to execute. The final notes also underwent review, editing, and signature by the physicians.

Prior to the intervention, more than 70% of physicians reported burnout. Post-intervention, that number was down to 51%. Although that change is dramatic, it is accentuated by the fact that for those physicians who didn’t work with a scribe, their burnout rates rose from 50% to 60%. Additionally, those working with scribes were more likely to describe their workplace as “joyful” and “supportive.” Measures of EHR-related stress were lower than those clinicians who didn’t have scribes. Working with a scribe slashed up to 66 minutes of EHR time out of an eight-hour physician day, with half of that being outside the scheduled workday.

Interestingly, looking at the study design, those receiving scribes were self-selected and had to agree to not only participate in program evaluation efforts, but to see one additional patient per half-day clinic session in order to offset the costs of the scribe. Both of those factors may have had an influence on satisfaction.

The authors noted that four of the intervention group dropped out of the project within the first year, and it would be interesting to look at the reasons given. They also noted that the project began just prior to the COVID-19 pandemic, “which dramatically disrupted clinical operations and could have affected the post-intervention wellness and EHR measurements.” Still, they conclude that “the fact that a scribe program can be revenue-neutral with modest increases in productivity makes them an attractive intervention to help organizations improve the wellness of their physician workforce.”

I think that if primary care colleagues fully did the math, many of them would be willing to see one or two more patients per day in order to shave time off their after-hours documentation.

Working with scribes was critical to my survival in the early days of the pandemic, when my urgent care’s volumes spiked. It would have been impossible to see 80+ patients per day without a scribe. A good chunk of those visits were for COVID testing or COVID concerns without any symptoms, and my scribes were able to capture not on the patients’ stories, but all of my counseling and medical advice, before I left the room.

Unfortunately, many of our practice’s best scribes gained admittance to medical school in the summer of 2020, decimating the program. It wasn’t able to recover prior to the subsequent COVID peaks, and the lack of scribes was directly associated with a number of physicians leaving the organization in the first half of 2021. There is definitely some work effort involved in onboarding a scribe program, but if your organization is experiencing clinician burnout, it’s worth considering.

Senator Tammy Baldwin of Wisconsin is going after health system Ascension. In a letter to the health system’s CEO, she calls out the fact that “Ascension is required to provide charitable benefits to the community and operate solely to serve a public, rather than a private interest. Despite these requirements, Ascension has significant for-profit investment activities that dwarf what the system providers in annual charity care.” She goes on to state that “by operating like a private equity fund, Ascension is squeezing staff, closing facilities, and extracting cash from its member hospitals for dubious ‘management fees’ all to advance its investment activities and provide compensation to its executives.”

Baldwin also calls out the fact that at the recent J.P. Morgan Healthcare Conference, Ascension’s CEO talked up its $18 billion in cash and investments, noting “This number raises questions about why Ascension, a mission-driven health system with non-profit status, is not prioritizing reinvestment into serving vulnerable communities and its own operations – which should include increasing pay and improving working conditions for its burned out and overextended health care workforce.”

She cites data that Ascensions investment funds lost the system more than $200 million more than the organization provided toward charity care during the most recent financial quarter. She closes with a demand for data covering fiscal years 2015 through 2022 that describes investments, returns, charity spend, debt collection practices. She also asks for information on management fees charged to hospitals, how monies from the Provider Relief Fund were used to address hospital staffing, details on over $250 million in charitable care during the last three months, and a list of compensation packages for executives and board members.

I’ve worked for several health systems that sat on billions of dollars while the proverbial city burned. I’ve seen essential frontline workers struggle to maintain full-time status while managers are incentivized to turn them into part-time workers so they don’t have to pay benefits. I’ve seen these systems put the squeeze on primary care physicians while they build fancy non-clinical additions on their buildings. And we’ve all seen some of these organizations aggressively pursue patients for their portion of payments, while barely paying heed to their supposed charitable missions.

On my most recent patient-side visit to one of these systems, I experienced understaffing, scheduling issues, and dirty facilities. With cash in the double-digit billions, it feels like they shouldn’t have baseball-sized dust bunnies in the waiting room. They also shouldn’t be shifting patients away from established physician relationships to brand new mid-level providers because the physician panels are full and they “can’t afford to hire” additional physicians.

It will be interesting to see how this plays out with Ascension, and I’m sure other nonprofits will be following closely.

What do you think about so-called non-profit health systems who have billions in the bank? Leave a comment or email me.

Email Dr. Jayne.