March 12, 2019

Keeping Physicians Engaged

By Pat Curry

When a longtime patient of Bruce Nitsche, MD, made a donation to the Virginia Mason Foundation, the patient asked if Dr. Nitsche could be involved in how to use the funds. A study from the Mayo Clinic found that sharing a meal helped with physician engagement; the foundation used some of the donated funds to try it.

"I called up the head of nutrition services and said, 'Do you think you could get the chefs to cater a lunch in the doctor's dining room once a month?'" Dr. Nitsche said.

They started with Cinco de Mayo, complete with Mexican music, mocktails, and handmade tortillas; it was a tremendous success.

"It was just fun," Dr. Nitsche said. "I remember sitting at a table with a longtime urologist and one of the newer internal medicine doctors. They had shared a lot of the same patients, but they had never met, and they introduced themselves to each other."

The lunches are just one way Virginia Mason, MultiCare Health System, Allegro Pediatrics, and other systems are addressing issues presented in Stanford Medicine's 2018 Physician and Advanced Practitioner Wellness Survey, commissioned by WSMA and the Washington State Hospital Association. Notably, the survey found that 42 percent of the surveyed physicians were moderately or highly likely to leave their organization within two years.

"It costs $500,000 to $1 million to replace a doctor who leaves, quits, or cuts down on their practice," Dr. Nitsche said. "It's a huge financial burden on the organization."

And it's not going to go away, said Scott Hansen, MD, who heads up Virginia Mason's psychiatry consultation service and professional staff engagement.

"What younger physicians will accept as working conditions is different than what physicians would accept several decades ago," Dr. Hansen said. "They aren't willing to spend 120 hours a week in a hospital."

Dr. Hansen noted that research very clearly shows what physicians believe to be important in their practice experience. Physicians want an electronic health record system that supports both good care and reduces time spent on activity that doesn't feel meaningful. They seek a sense of community and want to understand that they have the support of their supervisors.

"Developing frontline leaders is critical; it has so much to do with the experience of physicians over time," Dr. Hansen said.

Giving physicians more flexibility

Physician-owned Allegro Pediatrics, which has about 100 physicians working in eight locations, began studying physician burnout about three years ago. A physician survey focused on scheduling, how long physicians had with their patients, what their day looked like, and what was getting in their way of doing their jobs.

"The providers were saying they needed more support," said Tiffany Spanier, MD, who works in Allegro's Bellevue location. "It was very clear this was something we needed to address."

The results led to discussions about choice, flexibility, and autonomy, Dr. Spanier said. Physicians can pursue a partner track, a locums position, or a time-limited contract. Senior physicians have the choice of decreasing their call nights and weekend shifts, which lets them feel less burdened.

New physicians receive an extensive orientation and a mentor, and all physicians know that if they need to be out of the office for a family emergency, "the coverage is there immediately," she said. "That support is a huge sense of relief."

The practice also offers three-month paid sabbaticals to let physicians recharge and refresh. "A lot of them use that time to do research; others travel," she said. "We have a lot of part-time providers working in endeavors outside our practice: travel medicine, research; I'm teaching mindfulness. We're finding ways to give them the opportunity to pursue their passions."

Allegro continues to survey its physicians and encourages them to talk to clinic leadership. Dr. Spanier said she's going into clinics and starting conversations with physicians to "give them the framework to speak up even more.

"A lot of times, providers think the responsibility for burnout is going to land on their shoulders, and we don't want that," she said. "We don't want this on their shoulders. We want to continue to address it systemwide; we want them to know they're not alone."

Finding better workflow

It's not uncommon to hear physicians say they're being offered personal solutions, such as resilience training, to tackle systemic problems. MultiCare Health System is addressing that point with its Provider Wellness Team. The two-pronged approach offers free, confidential counseling and practice optimization consulting to address the pain points in a physician's practice.

"Eighty percent of burnout is the result of the workplace environment," said MultiCare practice optimization consultant Ellie Rajcevich. "Being able to provide that support has been a cornerstone of our program."

Most often, physicians contact the team because they're frustrated with some aspect of how their practice is running. For example, an internal medicine physician called because she had reduced her FTE from full time to .8 "to keep her head above water," Rajcevich said. "Even then, she was using days off to work. If the problem is all this work, reducing the FTE doesn't address the root of the problem."

To find solutions, the team starts by shadowing the physician.

"We look at the processes and what that physician's time and the team's time looks like," Rajcevich said. "The teams we work with don't have the chance to step away from all the things they have to do every day. Having someone come in and say, 'This is what your work could look like' is an interesting experience for them."

Sometimes, dictation software or a medical scribe proves helpful. Other times, the consulting team identifies a task that is unnecessary or could be completed by someone other than the physician, such as responding to MyChart patient messages.

Quite often, part of the solution involves dealing with the Epic electronic records software. That's such a big part of a physician's workload that the consulting team is adding dedicated Epic trainers "so they can access what they need accurately and quickly."

Small steps toward a solution

All these efforts help, but they just scratch the surface of addressing what makes so many physicians consider leaving their jobs, Dr. Nitsche said.

"What needs to be done is make the job require less resilience to survive it," he said. "The whole health care system is troubled. It's like living in a dysfunctional family; you need to fix that. But you can also make people feel better along the way."

This article was featured in the March/April 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may purchase a subscription.

Pat Curry is WSMA Reports' senior editor.