Mergers, rationalization and much more. - healthcare systems have reached a point of productivity where hardly anything further is possible. However, one resource available to the healthcare system seems to be free of charge and almost unlimited: the professionalism of physicians and nurses.
Dr. Danielle Ofri, Ph.D., is a Clinical Professor of Medicine at the University School of Medicine and internist at the Bellevue Hospital, both based in New York City, USA. She is particularly concerned with humanity in medical practice and the physician-patient relationship and is a successful author. In a recent article in The New York Times, she talked about how professional ethics and the humanity of employees hold the whole system together1. If physicians and nurses were only to do their duty and tasks by the book and simply leave at the end of the paid hours, the impact on patients would be devastating. Physicians and nurses know this and the majority continue to try to do what is right for the patient, often with great personal commitment. The healthcare system knows this too - and exploits it.
The demands placed on healthcare professionals have increased dramatically in recent decades, but without any proportional increase in time or resources to adjust for these demands. First, our patients are becoming more and sicker; the number and severity of chronic illnesses are constantly increasing. Data from the "athenahealth study" of 40 million visits to primary care physicians showed that the average work done per patient contact alone increased by 6% between 2010 and 2015, the number of diagnoses registered per appointment increased by 10%, and the proportion of highly complex cases by 12%2. More diagnoses need to be taken into account, more complications treated and more medication adjusted during the same working or visiting time.
Documentation is one of the biggest causes of the increasing workload. Although the electronic patient file has many advantages, the amount of data input is almost brain-destroying and time-consuming. Primary care physicians now spend almost two documentation hours per hour of direct patient contact3. For the same number of patients, most physicians now have to invest additional hours every day.
There is an amazing elasticity in healthcare - you can add more and more work and somewhere it is eventually "absorbed" or squeezed in. Dr. Ofri makes a nice comparison: if you suddenly put 30% more parts into a production line in an industry, the process would come to a standstill. Or imagine a craftsman or lawyer working 30% more without charging anything. But in healthcare, it is normal that the additional patients are also cared for. We all know how to do that: we don't have lunch or stay longer because the staff is in short supply.
A family or colleague emergency makes it necessary to spontaneously work an extra shift. A physician may be attending one of their kids’ events and receives a call from a relative of an old patient that urgently needs to check on an unexpected issue. Such situations are not covered by the insurance company but we have no choice other than to discuss the issue. We may have 15 minutes for an outpatient appointment, although the patient's medical history requires 45 minutes of a proper discussion. In places where it is possible to log into the system from home, many colleagues sacrifice their evenings and weekends because they simply cannot go into their free time with a clear conscience until they have documented all the critical details of their complex patients, checked outstanding laboratory values and examination results, eliminated inconsistencies in prescriptions, and answered all calls and emails. This still does not include many administrative needs that theoretically have to be done "between" patient appointments.
It is precisely this ethic that is exploited on a daily basis to keep healthcare companies afloat.
For most physicians or nurses, it would be unthinkable to go home without having done their job, since you neither want to endanger your patients nor be unprofessional and careless. So every additional task after another is thrown at a medical staff that can hardly say "no". Patients continue to receive their appointments, medication, and outpatients so that from an administrative point of view everything seems to run smoothly. But the human costs for this management cannot be dismissed.
A recent WHO publication looks at the severe consequences of burnout due to chronic stress at the workplace4. Burnout rates among physicians have reached a new high. For example, more than half of all physicians in the US were affected by burnout in 2014 and such figures continue to rise relentlessly, much faster than among the general population5. Physicians and nurses are significantly more likely to commit suicide than members of any other professional group. And higher rates of burnout are accompanied by an increase in treatment errors and endangered patient safety6.
Dr. Ofri concludes urging decision-makers and leaders to reconsider the consequences of their actions. Counting on physicians and nurses to absorb every new pressure in the healthcare system is not just a bad strategy, but bad medicine. It is wrongful to place rising demands on these professionals, assuming that this is intrinsic on the responsibilities and ethical guidelines that were “clear” when they chose their careers.
Interestingly enough, between 1975 and 2010, the number of employees working in administration in the healthcare system rose by 3,200%. Today, there are about 10 employees per physician who work in administration rather than on patients7,8. Dr. Ofri says that if we converted only half of these salaries into additional physicians and nurses, we might have enough staff to cope with the work. After all, healthcare is about caring for people, and not for documents.
Sources:
1. Ofri, D. Opinion | The Business of Health Care Depends on Exploiting physicians and Nurses. The New York Times (2019). Available at: https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals-physicians-nurses-burnout.html. (Accessed: 4th August 2019)
2. Why primary care physicians are working harder than ever. athenaInsight (2016). Available at: https://www.athenahealth.com/insight/primary-care-physicians-working-harder-ever. (Accessed: 4th August 2019)
3. Arndt, B. G. et al. Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations. Ann Fam Med 15, 419–426 (2017).
4. WHO | Burn-out an ‘occupational phenomenon’: International Classification of Diseases. WHO Available at: http://www.who.int/mental_health/evidence/burn-out/en/. (Accessed: 4th August 2019)
5. Shanafelt, T. D. et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin. Proc. 90, 1600–1613 (2015).
6. Hall, L. H., Johnson, J., Watt, I., Tsipa, A. & O’Connor, D. B. Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review. PLOS ONE 11, e0159015 (2016).
7. Kocher, R. The Downside of Health Care Job Growth. Harvard Business Review (2013).
8. The rise (and rise) of the healthcare administrator. athenaInsight (2017). Available at: https://www.athenahealth.com/insight/expert-forum-rise-and-rise-healthcare-administrator. (Accessed: 4th August 2019)