Perspectives in Safety—Joy in Practice
This month's interview features Christine A. Sinsky, MD, the Vice President for Professional Satisfaction at the American Medical Association and a primary care physician in Dubuque, IA. We spoke with her about physician professional satisfaction, including its relationship to patient outcomes and safety.
In Conversation With…Christine A. Sinsky, MD
Editor's note: Christine A. Sinsky, MD, is the Vice President for Professional Satisfaction at the American Medical Association, as well as a primary care physician in a community practice in Dubuque, IA. She has made pioneering contributions to understanding physician professional satisfaction, its relationship to important patient outcomes (including patient safety), and ways it can be enhanced.
Dr. Robert M. Wachter: What got you interested in thinking about joy in practice and physicians' professional satisfaction?
Dr. Christine A. Sinsky: I personally experienced a gradual decrease in professional satisfaction with my daily work. As I looked around, I saw that others were experiencing the same thing. I think that was part of it. As many external forces came to bear, often more heavily on primary care, some of the usual sources of physician satisfaction were being diminished while clerical activities were being enhanced.
RW: When this first began to strike you in your practice, what do you think the main culprits were?
CS: Over time the list has changed, and the responsible culprits have changed in order. It's been challenging for physicians because we're serving many masters. We have to serve our patients, but also I always felt like there was a lawyer and maybe an auditor in the room. The electronic health record (EHR) really changed the balance; it felt like the auditing piece, the measurement piece, and the documentation piece grew greatly. The rewarding piece—interaction with the patient, the feeling that you were doing your best for the patient—seemed to get smaller. It was harder to preserve the interaction with the patient and the other things that drive satisfaction.
RW: How much of that surprised you? When computers entered your world, is it something you thought would happen or were you optimistic and thought that computers would make everything better?
CS: I was surprised. I'd spent a fair amount of time pre-EHR thinking: Wouldn't it be great if a med list could be transferred from institution to institution and I could just check off the meds rather than handwriting all the medications? Wouldn't it be great if we could get clinic and hospital information to flow across boundaries? And many of those things have actually been great. I just didn't expect that my profession and my professional work would change so greatly and include so many more clerical tasks than in the past.
RW: It may not be obvious to everyone why that would happen since the imperatives to do the clerical work, whether it's for billing, auditing, or quality measurement, might have been there in the paper world and then in the computer world. You might think that the computer would make that stuff easier. Why did it get so much harder?
CS: I would have thought it would have made it easier too. However, most of the documentation—particularly when you're trying to document in a way that generates discrete data—takes a lot longer electronically for both input and retrieval. When you're handwriting the daily progress note, you use a lot of symbols and shorthand. When you're creating that note in structured text, you're typing a lot more. It may take 2 minutes to do what used to take 30 seconds. Multiply that across many, many tasks and you end up with several hours a day of extra work. Then it's harder to retrieve information. We haven't focused on that change in the health care environment as much as perhaps we should and will in the future. If you have a six-page note and three lines of that clinical communication are critical, it's really hard to find it. So you're taking a lot of time to find that information. We've been thinking a lot about how long it takes to put data in and how long it takes to document the notes. But we haven't thought as much about how long it takes to find the important information in the sea of distracting documentation that has developed.
RW: Physicians often gripe about their work. Are there data that say this is real—that physicians actually are less happy and more burned out than they were in the past?
CS: There's pretty compelling data that more than 50% of physicians are burned out. The rates of burnout among physicians are higher than they are among similarly trained professionals. Perhaps most alarming are the rates of physician suicide. Each year, 300 to 400 doctors commit suicide. I believe for male physicians the rate of suicide is 3 times greater than the average population, and for women it's 4 or 5 times greater.
RW: Physicians have generally done well in society. They're paid well; the profession has prestige. The unemployment rate is extraordinarily low. Why should patients care about this?
CS: Patients intuitively know why they should care about physician burnout. All you need to do is consider whether you want to get care from a grumpy, burned out, frustrated physician who no longer likes coming to work. I think we all recognize that sounds like an unsafe situation. And there's data to support that. Physicians who are burned out make more mistakes. Patients of physicians who are burned out adhere less reliably to their medications and to other treatment recommendations. Which makes sense. If physicians are really happy about their work, enjoying their work, and well supported in their work, they will listen to you. I think their diagnoses will be better. And you as a patient are more likely to be on board for the treatment that you both create together.
RW: You've spent a fair amount of time observing people in practice, talking to a lot of physicians. Have you seen anything that makes you hopeful in terms of addressing these problems?
CS: I did. We called that study "In Search of Joy in Practice," because I wasn't certain whether we would find things that supported professional satisfaction and joy in practice. But we did. It's my working hypothesis that where the office practice runs smoothly, when the workflow works, when the team is functioning as a well-oiled machine, where it's not the doctor by themselves running up and down the hall looking for information or for their support staff, but there's a process for everything—that's where physicians are happier. That's been my observation and my hypothesis. Mark Linzer recently published a study around burnout. The strongest predictor of improved rates of burnout was improved workflow. Clinics that had improved their workflow were six times more likely to have improvement in burnout scores.
RW: Physicians are increasingly working for large organizations. As it pertains to the issue of joy and burnout, do you see that as a hopeful trend or another challenge?
CS: It can go either way depending upon the wisdom of those involved. If physicians become aligned with a larger system that recognizes the need for some level of control over one's environment, then that can be positive. Because having some control over your local environment—autonomy in terms of developing your workflows, developing your schedule, how you practice within your team—that's a predictor of physician satisfaction. If a large system understands that and balances the concept of standard work with an equally powerful concept of local control and local responsibility, then I think coalescing into large systems can be positive. An advantage of large systems is that there can be more resources to bring to bear on practice transformation.
For example, Bellin Health Center in Green Bay, Wisconsin embarked on a reengineering process for their work and they told us they used the Joy in Practice study as their bible. I went back to visit them several months later. The physician that I shadowed could not contain his joy. He was thrilled with the work he was doing because he knew he was doing physician-level work during his day. He also realized he could now do so much more for patients because not only was he more efficient, but because, when he had a complex patient, he had a pharmacist, a care coordinating nurse, a social worker, and a health coach that he could bring in to help with that care. He gave an example of a 44-year-old patient with emphysema who had been hospitalized several times in the previous 4 months. The physician brought all those team members to bear on that patient's care, and after 4 or 5 more months the patient hasn't been back in the hospital. It is fun because we can do so much for our patients now. I am actually optimistic because when physicians don't have to waste so much of their time on documentation that others can do, on an inefficient approach to lab results reporting and prescription management, and when there are more people around to help with the care, it's really good.
RW: What's your experience in trying to effectively make the case that the investment it will take to create that kind of infrastructure will pay off at some level?
CS: One of my missions in my new position at the AMA is to make it an organizational best practice to regularly measure and respond to professional satisfaction. To put that on the organizational dashboard as a priority; to move the focus from the Triple Aim to the Quadruple Aim, with the fourth aim being professional satisfaction. Because professional satisfaction drives all the other outcomes that the organization wants. It drives quality of care. It drives patient satisfaction. I believe it will drive lower overall cost. There is some data to support that. When you go from two exam rooms to three exam rooms per doctor, your quality scores increase by 6%. I suspect if we had the science to look at other things, we would see that when you have really efficient workflow, you would have lower costs and higher quality.
RW: How much do you think physicians were complicit in this happening to them? To some extent, some of those decisions around workflow, particularly in physician-owned practices, it was the group deciding the balance of how they were going to organize their day. Some changes were imposed on physicians, but it strikes me that physicians participated in some decisions that led to the current predicament.
CS: I absolutely agree with you. To generalize (and somewhat to stereotype), as physicians we are used to relying on ourselves. We feel hyper responsible, and we feel that if we're responsible then we have to take ownership and accomplish all the tasks ourselves. The idea of sharing responsibility with other members of our health care team is somewhat foreign. I put a fair amount of responsibility on our profession for having held on to tasks that aren't necessarily physician-level tasks. Sometimes when you're so busy, you have your nose to the grindstone, and you're just trying to plow through the day, it's hard to step back and realize, if I do the labs before the patient's visit I actually save a lot of time and have a better interaction with the patient. How can I make that happen? That takes effort, and I don't think that's happened as much as it could.
RW: Part of the change in the locus of control here is not just the physicians giving up tasks to nurses or others, but patients and family members taking on more things sometimes enabled by new technology. What do you see the impact of that on physician joy and ultimately the safety and quality of care?
CS: It depends on how it's done. For most physicians what drives satisfaction is being able to provide quality of care, and that's what the RAND study showed. If we can harness smartphone apps, support groups online, and support groups in person to help patients take better control of their own chronic conditions, that should be a win across all domains: for the patient, the payer, and the physician. But the devil is in the details. Because all those things, poorly executed, could end up simply generating more paperwork and more forms to be signed by the physician, and decreasing the amount of relationship building and sense of caring that the physicians can provide in a day. So it could be a negative thing. But overall I'm optimistic that the more we engage patients as our partners in care, the better we will also feel about their care and our work.
RW: One disconnect is you often hear from physicians is that "I wouldn't encourage my kid to go into this field, and it's not the field that I went into 30 or 40 years ago." Yet last time I looked, med school applications were up. What do you think about that?
CS: It's really striking; 70% to 80% of primary care physicians would not encourage their friends or family to go into medicine or primary care. And that's disturbing. The fact that there are still people who want to become physicians doesn't mean that we don't have a problem. That to me doesn't make logical sense. First of all, those medical students haven't gone through the process so they haven't experienced some of the situations. But once they do get in and they experience some of the issues around the clerical work, particularly the burdens of primary care, they don't choose primary care. So they specifically are choosing specialties with a narrower focus and specialties with lower clerical burdens.
RW: Do you see these problems largely centered in primary care? Are there generic problems in being a physician today with primary care maybe experiencing a greater concentration?
CS: What I've learned from giving talks across the country to the next group of specialists is that although these problems may be felt most acutely in primary care, they are generalized. Some specialties have been able to protect themselves a little bit more from having these clerical tasks encroach on their professional roles than others. But this is a universal experience of physicians nowadays, with primary care doctors being the canaries in the coal mine.
RW: When you think about the concept of joy in practice or its definition, what are you thinking?
CS: When I'm thinking about joy in practice, I'm thinking about getting up in the morning and being enthused about going to work. I'm thinking about being able to make really good medical decisions with my patients and to have a few minutes with each patient to enjoy their company, to get to know them. I think of really solid medical care and strong personal relationships and a feeling of being effective.
RW: You've taken a new job at the AMA to work on this. Why, and what's your sense of the AMA's engagement on this issue?
CS: What I have learned and the way I think of it is this is not your grandfather's AMA. This is your granddaughter's AMA. I was actually blown away when I learned what the AMA was doing and that when the new CEO came a few years ago, the AMA wiped away all the previous strategic initiatives—there were 140 of them—and boiled it down to 3. Improving professional satisfaction in practice sustainability is one of those three. That's the area I'm predominantly working in—to improve joy in practice for physicians.
RW: What do you think the AMA's unique role is in this area? People understand this as an important issue not just for physicians but for patients and for the health care system. What can the AMA do that's different than anybody else?
CS: Well I think the AMA is in a place of being a connector—we're connected to all the physician specialties in the country—then as a voice can connect to regulation, technology, and education because there are so many moving parts here. One of the challenges has always been that it's going to take efforts at all different levels within the health care system to start to effect change. Other organizations are also working toward the same aim. The American College of Physicians has chosen improving joy in practice as one of its goals for this year. It feels like this issue has risen to the surface or, to use another metaphor, has reached the tipping point. Many organizations are recognizing the importance of professional satisfaction to other values. So I am glad that the AMA is working on it and I'm glad that other organizations are as well.
RW: Do you have a sense of the right organizational approach to this? At UCSF, we now have a physician lead on patient experience, who works with a staff focused on this issue. Now many organizations have someone like this—often called a Chief Patient Experience Officer. As we move into recognizing physician professional satisfaction as being important in its own right and probably related to patient experience, the same arm of our organization—previously focused on patient experience—has now taken clinician experience on. At some level I see a lot of synergy. But I also worry about them getting burned out trying to do both patient and provider experience. Do you think patient experience and physician satisfaction are different sides of the same coin, or do you think the approach to the clinician side should be very different than the way you're thinking about the patient's experience?
CS: I do think that they are related and that focusing on professional satisfaction is going to be one of the strongest drivers of patient satisfaction. But I would separate them organizationally just to not get things muddied and to make sure that the professional satisfaction got its full attention. I believe that a physician wellness committee of some sort at each organization would be one of the levers to press to improve patient satisfaction.
RW: Interesting. Until you said professional wellness I hadn't thought much about it. Maybe incorrectly, I tend to frame that as the one physician who is unwell or depressed or suicidal, as opposed to the generic issue of the professional satisfaction of all of the physicians.
CS: Yes, and I've been thinking about that because, again this is just my observation, probably 80% of physician wellness is related to systematic issues. And 20% might be related to individual issues. When people have thought of wellness committees in the past, it's probably focused more on individual resiliency or the individual who's at risk or has some other issues like substance abuse or something. That it's their depression. But I really see the whole issue of professional wellness being much larger than the individual and predominately related to systems issues.
RW: You and your husband are both primary care doctors. When your kids asked you whether they should go into medicine, what did you tell them?
CS: As it turns out, neither child asked, and I have wondered about that. I think we brought home more of the challenges than of the rewards. We probably didn't talk about how great it was when this or that happened. But we talked more about how frustrating it was when negative things happened. But should they ask, I think the answer would be hard to give. If we continue down this path of squeezing out autonomy, mastery, and purpose and making this job a series of rigid metrics and "nastygrams," that's not going to be a satisfying career. However, the optimistic side of me says there is nothing better than being a physician. It is inherently such meaningful work—few professions are naturally so meaningful. A patient comes to you in need and they entrust their care to you. Right there you have 90% of the meaning you can ask for out of life. If we find our way through this tumultuous time to a point where that can be the experience and focus for our professionals, I think it will be great.
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