To revitalize neurology we need to address physician burnout

Neil A. Busis, MD

Correspondence to Dr. Busis: [email protected] Neurology® 2014;83:2202–2203

Illness causes suffering in unexpected ways. Patients suffer not only from their disease but also from diagnostic tests and treatment.1 Physicians are susceptible to adverse health consequences of their chosen profession. In this issue of Neurology®, Sigsbee and Bernat2 report that neurologists frequently experience burnout, a syndrome characterized by loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment. Burnout is associated with work– life imbalance, work–home conflicts, substance abuse, depression, and suicide. Burned out physicians may abandon clinical medicine or choose early retirement. Burnout is more common in physicians than other workers. Neurology is the only medical specialty that has both one of the highest rates of burnout and the poorest work–life balance.3 Sigsbee and Bernat highlight an important problem that has been barely mentioned in the neurologic literature. Physician burnout has been extensively studied in internal medicine and surgery. Which findings can be extrapolated to neurology? Do burnout rates, characteristics, and determinants differ in different career stages, including training? Do new resident work hour restrictions change trainee burnout rates or career expectations? Do outpatient- and hospitalbased neurologists have different burnout rates and determinants? Will new care models alter burnout rates? The American Academy of Neurology Workforce Task Force predicts a future shortage of neurologists.4 Physician burnout could contribute to the shortage, but could also result from a shortage. If burned out neurologists continue to practice, patient care may suffer due to poor medical judgment and more errors. If neurologists drop out of the workforce, access to care will decrease. If medical students consider neurology undesirable, few will enter the field. The guiding principle of today’s health care policy is the triple aim: increasing quality of care, decreasing costs, and improving the patient experience. Paradoxically, it ignores what should be a core strategy: ensuring the well-being and engagement of physicians and

other health care providers.5 This omission commoditizes health care. The triple aim can only be achieved if physicians are mentally and physically capable of providing the best care for their patients. Currently, most interventions to help burned out physicians focus on the individual and are reactive— methods to handle stress and better adjust to the current system. That is not enough. We must be proactive to prevent burnout and related problems from developing in the first place. We need to revise the structure, processes, and desired outcomes of our health care system to value the health of physicians and other health care providers as well as patients.5,6 RAND recently published a comprehensive study of physician satisfaction that provides a framework for health care system improvement.7 Two main drivers of frustration are barriers to practicing quality medicine and poor electronic health record (EHR) functionality. Other major factors that contribute to physician satisfaction include the following: •

Access to resources for change management • Organizational priorities during consolidation of physician practices • Predictability and perceived fairness of physician reimbursement policies • The burden of rules and regulations that interfere with patient care Given these data and Sigsbee and Bernat’s discussion, how best to proceed? Improvements in health care reimbursement and delivery models and health information technology are priorities. Health care reimbursement policies do not accurately reward physician work. The relative value system, used since 1992, defines physician work as the product of work intensity multiplied by time. These variables are determined by magnitude estimation and retrospective surveys. More precise methods to quantify work intensity and time are available and, if further validated and implemented by payers, may lead to fairer reimbursement for cognitive services.8 The requirements for correct coding, reporting mandated quality measures, and proper patient care

See page 2302 From the Department of Neurology, University of Pittsburgh School of Medicine, PA. Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the author, if any, are provided at the end of the editorial. 2202

© 2014 American Academy of Neurology

are misaligned. Many elements needed to document the level of an evaluation and management service or meet quality reporting requirements are not necessary for good patient care. The decreased signal-tonoise ratio in medical records designed to comply with coding and quality requirements impedes care. Conversely, clinically indicated neurologic examination elements may not count towards increasing the level of service. Fee-for-service models reward volume, which incentivizes overscheduling, decreased time with patients, and excessive use of resources for marginal or no gain in quality, rather than value, defined as quality of care divided by cost. The Choosing Wisely campaign and other initiatives are leading the transition from volume-based to value-based reimbursement.9 The global period reimburses physicians for a defined number of office visits after certain procedures, whether or not they are done. Other types of bundled payments that endorse teamwork, care coordination, and quality improvement, including the medical home, accountable care organizations, and episodes of care, might provide better value to all stakeholders. Health care quality measures should be clinically meaningful and closely aligned to important outcomes.10 Quality measures relevant to specialties should be endorsed by payers and built into EHRs. EHRs need to be redesigned. Optimizing EHR usability at the point of care is the key to achieving the full benefits of this promising technology.11 EHRs from different vendors should have standardized ways of doing common procedures. Information needs to be readily exchangeable between different EHRs. The continuous quality improvement cycle should be applied to reengineering health care systems to value physician well-being. Outcomes can be readily measured using assessment tools for burnout, quality of life, work–life balance, career plans, health behaviors, fatigue, depression, and suicidal ideation. To revitalize our specialty we need to advocate for another triple aim: revising the structure, processes, and outcomes of health care systems to recognize, value, and optimize physician wellness and career satisfaction.12 If our efforts are successful, we will be

better able to accomplish our professional mission: to increase the quality of neurologic care, decrease health care costs, and improve patient satisfaction. STUDY FUNDING No targeted funding reported.

DISCLOSURE N. Busis has received honoraria for speaking at American Academy of Neurology courses. Go to Neurology.org for full disclosures.

REFERENCES 1. Detsky AS, Krumholz HM. Reducing the trauma of hospitalization. JAMA 2014;311:2169–2170. 2. Sigsbee B, Bernat JL. Physician burnout: a neurologic crisis. Neurology 2014;83:2302–2306. 3. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012; 172:1377–1385. 4. Freeman WD, Vatz KA, Griggs RC, Pedley T. The Workforce Task Force report: clinical implications for neurology. Neurology 2013;81:479–486. 5. Spinelli WM. The phantom limb of the triple aim. Mayo Clin Proc 2013;88:1356–1357. 6. Brennan MD, Monson V. Professionalism: good for patients and health care organizations. Mayo Clin Proc 2014; 89:644–652. 7. Friedberg MW, Chen PG, Van Busum KR, et al. Factors Affecting Physician Professional Satisfaction and Their Implications For Patient Care, Health Systems, and Health Policy. Santa Monica, CA: RAND Corporation; 2013. Available at: http://www.rand.org/pubs/research_reports/ RR439.html. Accessed August 10, 2014. 8. Horner RD, Szaflarski JP, Ying J, et al. Physician work intensity among medical specialties: emerging evidence on its magnitude and composition. Med Care 2011;49:1007–1011. 9. Langer-Gould AM, Anderson WE, Armstrong MJ, et al. The American Academy of Neurology’s top five Choosing Wisely recommendations. Neurology 2013;81:1004–1011. 10. Panzer RJ, Gitomer RS, Greene WH, Webster PR, Landry KR, Riccobono CA. Increasing demands for quality measurement. JAMA 2013;310:1971–1980. 11. Middleton B, Bloomrosen M, Dente MA, et al; American Medical Informatics Association. Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. J Am Med Inform Assoc 2013;20:e2–e8. 12. Sergay SM. Doctoring 2009: embracing the challenge. Neurology 2009;73:1234–1239.

Neurology 83

December 9, 2014


To revitalize neurology we need to address physician burnout Neil A. Busis Neurology 2014;83;2202-2203 Published Online before print November 5, 2014 DOI 10.1212/WNL.0000000000001087 This information is current as of November 5, 2014 Updated Information & Services

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Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2014 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.

To revitalize neurology we need to address physician burnout.

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