Deep Dive: Getting to what matters to physicians

1. Deep Dive: Getting to what matters to physicians Thomas Spain, MD, MPH October 4, 2017

2. Objectives: Following this deep dive, MidSouth PTN coaches will be able to: List at least 2 attributes of “professions” that are central to the physician’s identity Recognize long-term trends that influence currently practicing physicians Discuss at least 3 factors that positively and negatively impact physician professional satisfaction Recommend tactics for improving physician “buy-in” to transformation efforts

3. Disclaimer

4. What does it mean to say “Medicine is a Profession”? • Pre-1960’s: High social trust in authority • Altruism was assumed • 1960’s-70’s: Significant sociological challenges to authority, arguing that • Monopoly and authority used to further profession’s interests • Poor self-regulation • Serving profession more than society • 1980’s: Conversations began about medicine’s “social contract” with society. • A characteristic of modern professions • Advances in medicine and society created need for “renegotiation” CruessSR, Cruess RL, Professionalism and Medicine’s Social Contract with Society. AMA Journal of Ethics. 2004; 6(4).

5. Some Elements of the Social Contract CruessSR, Cruess RL, Professionalism and Medicine’s Social Contract with Society. AMA Journal of Ethics. 2004; 6(4). Society’s Expectations • Services of the healer • Guaranteed Competence • Altruistic Service • Morality and Integrity • Promotion of the Public Good • Transparency • Accountability Medicine’s Expectations • Autonomy • Trust • Monopoly • Status and Rewards • Self-regulation • Functioning healthcare system

6. Physician Trends • Age • Typically start practicing in early-mid 30’s • Average retirement age ~65, but commonly work into 70’s • Perspective on healthcare shifts: Early, mid, late http://www.aafp.org/news/practice-professional-issues/20160713retirementstudy.html

7. https://www.forbes.com/sites/dandiamond/2015/06/02/why-doctors-really-quit/#2ef400e37621https://www.forbes.com/sites/dandiamond/2015/06/02/why-doctors-really-quit/#2ef400e37621

8. Physician Trends • Age • Typically start practicing in early-mid 30’s • Average retirement age ~65, but commonly work into 70’s • Perspective on healthcare shifts: Early, mid, late • Income • Significant rise leading into 1980’s, Specialist > Primary Care • 1995  2003, dropped 7% overall, ~10% primary care • Somewhat flat in recent years • Employment • Practice ownership declining, now < half (47.1%) • Specialty http://www.aafp.org/news/practice-professional-issues/20160713retirementstudy.html http://www.hschange.org/CONTENT/851/ http://www.modernhealthcare.com/article/20170531/NEWS/170539971#

9. Professional Satisfaction • RAND/AMA Study (2013) • 30 diverse physician practices across US • Quality of Care • Electronic Health Records • Autonomy and Work Control • Practice Leadership • Collegiality, Fairness, and Respect • Work Quantity and Pace • Work Content, Allied Health Professionals, and Support Staff • Payment, Income, and Practice Finances • Regulatory and Professional Liability Concerns • Health Reform https://www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_RR439.pdf

10. Professional Satisfaction: Quality of Care “Providing High-Quality Care Is Inherently Satisfying” – RAND/AMA Study “If the patient came in, … they’re not feeling good. If [I] can say anything to them to make them feel better, I feel like I did my job.” – A Primary Care Physician “[I joined this practice] because it is putting the doctor-patient relationship back at the forefront of what’s important in medicine. I mean, there’s a lot more to taking care of patients than just knowing which pill to give them. I mean, the whole healing art, it isn’t just biochemistry. This organization allows you time to get to know your patients and also to dig deep, take care of all the details, which are important, and do a good job of it without having to work 16, 18 hours a day doing it.” – A Primary Care Physician https://www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_RR439.pdf

11. Professional Satisfaction: Quality of Care • In general, physicians will value/embrace changes that they believe will improve the quality of care they deliver to their patients. • In general, the following create dissatisfaction • Leadership not receptive to ideas for improvement • Obstacles/barriers impeding the physician-patient relationship or preventing care that feels high-quality (insurers, protocols) • This is part of why transparent, regular reporting can be so powerful (if you can get past the initial turbulence) https://www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_RR439.pdf

12. Professional Satisfaction: EHRs EHRs improve data access and communication – RAND/AMA Study “When the system’s working well, I can get to information quickly and old notes quickly.… I do like that, and I like the immediacy of having the note right there and not waiting three or four days [asking], “When is my dictation coming?” I can route it and I can senditto somebody quickly. .” – A Primary Care Physician “[All of the [EHRs] that I’ve seen have actually been very time-consuming for physicians. Physicians have to order everything themselves, which is time-consuming, and do all the data entry themselves, which is time consuming. [EHRs] at this point in the development are not time savers for physicians. They’re big time sinks. Everyone agrees, everyone I talk to in every practice..” – A Primary Care Physician https://www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_RR439.pdf

13. Professional Satisfaction: EHRs • In general, physicians accept that there are certain advantages to digital records over paper. • In general, the following create dissatisfaction • Cumbersome/time consuming experience • Electronic workflows that don’t match physical workflows • Interference with face-to-face human interaction • Templates degrade quality of documentation • Forcing physicians to do lower skilled work • Making measurable improvements here takes time and commitment. AMA Steps Forward has some good places to start. https://www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_RR439.pdf

14. Professional Satisfaction: Collegiality, Fairness, Respect “I’m a little baffled by … this whole egalitarian thing going on, where everyone is kind of at the same level, from front desk, to medical assistants, to nurses, to nurse practitioners, to docs. All the docs and nurse practitioners are called “providers” because it’s the common denominator. … I don’t feel like it’s really that respectful a place for a physician to work, because the physician, in my mind, is taking on tremendous risk. … [It’s] the same risk that any primary care doctor takes on. Risk of failure to diagnose. Risk of failure to timely diagnose. Risk of prescribing a medication with an adverse effect. … There is this lack of the basic respect that … it’s the physician’s license, and the physician’s reputation, and the physician’s risk.” – A Primary Care Physician “The news is [telling patients] to demand more and more. For one thing, I’ve had some patients come in and say they want to interview me before [having their first appointment]. … I just haven’t been able to handle that. I just say, “If that’s the way you feel, you need to go talk to another doctor.” … But that’s what they tell them on Good Morning America, so I’m sure that’s going to be a big thing in the future. People are going to interview you to see if [they] want you for [their] doctor.” – A Primary Care Physician https://www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_RR439.pdf

15. Professional Satisfaction: Collegiality, Fairness, Respect In general, physicians value interaction and collegiality with other health professionals, particularly physicians. Team-based care is a double-edged sword, with perceived benefits and perceived threats to the physician and profession. https://www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_RR439.pdf

16. Professional Satisfaction: Work Quantity/Pace “I guess it’s the wave of the future is to be able to see more patients in a shorter amount of time. … I just don’t think a 15-minute visit is remotely feasible. I think it’s ridiculous that they expect … me to update their health maintenance, reconcile their medications, and see them for their problem. … And then, usually, when you update something, it suddenly gets them to talk about that other thing. They’re like, “Oh, you’re really in for a sinus infection. We just updated your [medications], and you told me you’re not taking your antidepressants.” Now, we’re talking about depression..” – A Primary Care Physician [At another local primary care practice,] I think their salaries are probably a little higher, but the bean counters tell them how many people they’ve got to see. I know in one group, if you don’t make your quota every day, they dock your pay. So, if you’re really caught where you got a tough patient who has an issue you can’t quite decide, or needs counseling and is crying and their child is five, whatever, you know, if they know they’re going to dock your pay if you spend a little more time being humanly kind, that’s different than, “If I don’t see another patient, maybe some patient will have to wait.” [Here,] we’re under … our own control. We decide what we want to do. I think that appeals a lot to me and other people. ” – A Primary Care Physician https://www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_RR439.pdf

17. Professional Satisfaction: Work Quantity/Pace “There’s a number of things I’d like, but one of them goes back to the quality of life. I think our last patient’s at 5:20. No one here leaves before 6:30, and no one’s work is done before 6:30. I think that [it would be good] to somehow shave the number of patients that we’re required to see a day so that it’s more of a 9:00 to 5:00 in the office job. Now, not one of us went into medicine expecting 9:00 to 5:00, yet as we’ve grown, lots of us have young families. You want more time with that. I’d like to be able to see less patients to provide more comprehensive care, because I do feel rushed. I do feel like, trying to make ends meet, trying to take care of my panel, I do shortchange people on time, and I’d like to not have to do that. – A Primary Care Physician “[So, the whole … thing is built on the Toyota model, you know, the lean collaborative. You’ve heard about these things, and it makes sense, but you never [quite believe it]—I mean it is very tedious to label everything. … [But after] you put the whole thing together, it’s very difficult [not] to think, “Well, why didn’t I do it before?” … I’m feeling a lot better. You know, I’m taking more care of my health now. … [Before lean], when you’re in this black hole, you feel like you’re sucked in. You feel like you’re trapped. You feel like there’s nowhere to go. … It’s like you’re on a treadmill, and if you stop, you fall. Now [after leanredesign], you have room to wiggle a little bit.” – A Primary Care Physician https://www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_RR439.pdf

18. Professional Satisfaction: Work Quantity/Pace • In general, physicians want “work-life balance” like everyone else. • Norms about work, priorities, tension • Remember the satisfaction of high quality care and patient relationships • Too many and too few are both undesirable • Early wins here can be practice changing https://www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_RR439.pdf

19. Professional Satisfaction: Additional Domains • Work Content, Allied Health Professionals, and Support Staff • Work that matches level of training/competence • Payment, Income, and Practice Finances • Stability, “fairness” • Regulatory and Professional Liability Concerns • Cumulative effects, frustration • Health Reform • Uncertainty, “flavor of the month” https://www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_RR439.pdf

20. Tactics

21. Tactics • Listen. “What matters to you?” • Physician leadership (“Guiding Coalition”) • Who are the influencers? • Who are the decision makers? • Who are the informal leaders? • Who are the followers? • Choose an MD identified problem to tackle first. • Make professional satisfaction a goal • Keep the physician (provider) – patient (person) relationship front and center • Academic detailing

22. Discussion and Questions