In too many settings, health care delivery has evolved into a series of disconnected transactions, based on the mistaken notion that anybody will do, according to Christine Sinsky, MD, the AMA’s vice president of professional satisfaction.
The notion is that any physician can round on the patient in the hospital, or any clinician can be on the other side of the telemedicine screen. It’s about check boxes and bullet points, and it’s all in the EHR.
But health care, Dr. Sinsky said during her keynote address at the 2023 American Conference on Physician Health, is relational, and accordingly it must be oriented around relationships.
“Connections with our teams, with our colleagues, and with our patients … can be considered the secret sauce, the hidden architecture within the health care system,” Dr. Sinsky said during the conference, held in Palm Desert, California, and co-sponsored by Stanford Medicine, the AMA and Mayo Clinic.
“If we bring the value of connections out into the open, and we intentionally strengthen this key backbone of our health care system … we will be more likely to achieve the quadruple aim outcomes of better care for individuals, better health for the population at a cost we can afford while preserving professional well-being,” Dr. Sinsky said. “These connections—they're a source of individual resilience. And even more importantly, connections are a source of system resilience. So, the more our system is strong through all these connections, the better able the system is to support and serve the people within.”
“Relationships are our superpower. Relationships are how we will increase efficiency and increase our capacity, decrease the total amount of work to be done and increase continuity,” she said, noting “that continuity between physicians and their teams and their patients … is associated with better outcomes, higher quality care, lower cost, fewer ER visits, fewer hospitalizations and even lower rates of mortality.”
Additionally, “when the same people are working together in the emergency room,” operating room or ambulatory clinic, then “costs are lower, quality is better, and burnout is less,” Dr. Sinsky said.
Reducing physician burnout is a critical component of the AMA Recovery Plan for America’s Physicians.
Far too many American physicians experience burnout. That's why the AMA develops resources that prioritize well-being and highlight workflow changes so physicians can focus on what matters—patient care.
Here are some system-level approaches for prioritizing relationships to reduce physician burnout and improve well-being and quality care.
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“There's some interesting data from the University of Wisconsin looking at the density of electronic communication and the density of face-to-face communication among the team,” Dr. Sinsky said. “And in those teams that had greater face-to-face communication, they had better clinical outcomes, fewer hospitalizations, fewer urgent care visits, fewer ER visits, and the cost per patient, per year, was reduced by $600 per year.”
“Conversely, as the density of EHR communications increase, the clinical outcomes decreased, the more you're sending those asynchronous messages round and round in the clinic, the more sludge that develops and the less able the team is to work at their best,” she said.
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“How the space is constructed can organically either facilitate or hinder teamwork and relationships within the team,” Dr. Sinsky said. For example, if a medical assistant or the nurses are on one end of the hall and the physician is in another, “they may not see each other throughout the day. That doesn’t support relationships. But if there’s co-location … then they can get a lot of communication done in small moments throughout the day.”
“That prevents the need for so much asynchronous communication that requires back and forth and back and forth,” she said.
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“A lot of the dissatisfaction in health care can be traced back to the way we don’t have a really scientific or intentional approach to our scheduling, and we don’t have a relationship-prioritizing approach to the schedule,” Dr. Sinsky said. “Scheduling on the wave is a very efficient way to schedule and it’s based on queuing theory.”
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“Most physicians in most specialties, and in most settings, can save three to five hours a day by more intentionally reengineering workflows and by more strategically delegating work to upskilled team members,” Dr. Sinsky said. For example, “doing pre-visit planning, having more meaningful rooming activities for your staff, taking a systematic approach to prescriptions; each of those saves 30 to 60 minutes per strategy.”
Additionally, “having team documentation can save one to two hours or more per day,” she said, noting the “AMA STEPS Forward® Saving Time Playbook” has a section on how to stop the unnecessary work as well as “how to incorporate the practice fundamentals to get rid of some of the unnecessary workload and how to make the case to leadership for making some of these changes.”
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“I spent 16 years working with paper records, the last few of those dreaming about how much better life would be when we got an electronic health record. And then I spent the next 16 years thinking about how it didn’t actually turn out quite as good as I thought,” Dr. Sinsky said. “Some things were better, but many things were not. And part of why some things were worse was this great work transfer. That work that used to be done by the receptionist, the pharmacist, the medical records clerk, the transcriptionist in many settings … got pushed to the physician.”
“It led to two hours on EHR and desk work for every one hour of patient time, some moral distress because we’re spending our days doing the wrong work for our patients and we’re not doing all that we really want to be able to do,” she said, noting that the “AMA STEPS Forward EHR Inbox Reduction Checklist for Health Care Organizations” (PDF) is a quick place to start and find some things to implement in the next month in an organization.
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There are a lot “of ways that we can build the system, build the structures to support collegiality. One way is a morning huddle,” Dr. Sinsky said. For example, at Brigham and Women’s Hospital, the team that is working together pauses in the morning to ask how things are going and if there are special needs for the staff or for the patients who are coming in.
Additionally, having team meetings every two weeks is “another strategy for not only improving the workflow, removing the friction, removing the sludge, removing all those 30 seconds here, two minutes there that you could save in the daily workflow. It is also a way of having fun together and a way of building trust and reliance,” she said.
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“There is so much sludge in the system that we’ve got a lot of opportunities to start to remove that sludge and remove some of that weight that physicians and their teams are carrying around,” Dr. Sinsky said. One place to start is with the AMA’s de-implementation checklist (PDF) that outlines processes or requirements that add little or no value to patients and their care teams, but place unintended burden on physicians.
The AMA’s “Debunking Regulatory Myths” series can also help “reduce some sludge to get rid of a policy or practice that may have made sense at one point, but no longer makes sense. It has outlived its usefulness or never lived up to it,” she said.
“We can unleash the power of connections to create the efficiency that provides more room for relationships, greater satisfaction, and better quadruple aim outcomes,” Dr. Sinsky said.
