Physician Health

In EHR age, physicians long to restore medicine’s personal touch

Francis W. Peabody, MD, a physician in the early 20th century, once wrote, “The treatment of a disease must be completely impersonal; the treatment of a patient must be completely personal.” Though physicians vary by specialty and practice type, nearly all practicing doctors have felt the dramatic rise of burdensome administrative work in the last decade. A recent study investigated the fundamental sources of physician satisfaction and dissatisfaction and how that administrative work fits into a physician’s ability to provide the best care for patients.

The qualitative study provides context to a recent time-motion study conducted by experts at the AMA, Dartmouth-Hitchcock Medical Center, Sharp End Advisory and the Australian Institute of Health Innovation at Macquarie University in Sydney. That study, published in Annals of Internal Medicine this summer, found that physicians spend nearly two hours on electronic health record (EHR) and other clinical desk work for every hour of direct face-to-face time with patients.

In a series of interviews, participating physicians first explained what they find satisfying in the practice of medicine, including scientific and humanistic rewards, and the intellectual challenge that treating patients provides.

Scientific satisfaction arises from the intellectually rigorous practice of medicine, the study found. “Seeing patients that are badly traumatized and seeing them through … surgery, physical therapy, walking without a limp,” is very rewarding, one physician said.

“The actual practice of medicine, the investigation, the management, getting to use your skills … is still the best part of medicine,” another physician said.

The humanism of medicine rose to the top of the list of sources of satisfaction for physicians. “I don’t think there’s anything cooler or better in life than helping somebody in a vulnerable position and having a positive outcome on their lives,” one physician reported.

“I take care of her sister; I take care of her mom,” another physician said. “[Seeing] patients today that I plan to see 20 to 30 years from now. I think that’s the main gratification.”

The bottom line is that physicians find the greatest satisfaction in spending time with patients, helping them when they are in need and seeing the impact their efforts have on patients’ lives.

Sources of dissatisfaction

Though physicians find tremendous satisfaction in their work, the sources of dissatisfaction that surfaced in the interviews focused on the roadblocks that cause physicians to lose valuable time with patients.

“The biggest dissatisfaction is all the things that get in the way of taking care of patients and using your skills,” one physician reported. “All kinds of externally mandated requirements that … don’t translate into better patient care. Part of that involves [EHRs]. Part of it involves Medicare rules and guidelines. Part of it involves insurance company-mandated prior authorizations.”

Among the many sources of dissatisfaction, three key factors rose to the top, according to the AMA-funded study.

Poor EHR usability. Too much time is being stolen from patient care by all the boxes in the EHR that physicians must click and many warnings—often irrelevant—that pop up. “All the clicks, all the different pages … I feel like I’ve become a data input person, rather than an actual clinician,” one physician said. “That’s dissatisfying. [Entering] injections for instance is like 20 clicks [in the EHR].”

Patient portals and the limits of electronic communication. The patient portals and patient-physician emails encouraged under the Meaningful Use program also present a time burden, the study points out. These tools can create tension between patients and their physicians due to the limitations of electronic communication. Many times there is a disconnect between patient expectations on timeliness and the ability of the physician to diagnose and treat through those methods.

“The patient portal is being misused by patients who describe their symptoms and expect a response from the doctor on what to do or what medication to take,” a physician said. “[I advise] the patient that they need an appointment to be evaluated properly.”

Regulatory and payment compliance. Physicians reported to the interviewers conducting the study that the EHR has turned what began as way to document medical information for physicians and nurses into a tool to justify billing to Medicare and other payers.

Public and private payers were the second largest source of dissatisfaction. “Prior authorizations kill us,” one physician said. And trying to find a medication for a patient that is actually covered by insurance companies can become a burden as well. “Insurance companies will tell us ‘we don’t cover that medication,’ but then never give us alternatives,” a physician reported.

Consequences and solutions

These factors that lead to physician dissatisfaction have a negative effect on patient care. Physicians reported that this kind of extra EHR and clerical desk work requires so many external approvals that it disrespects their expertise.

Physicians feel that the scientific expertise and compassion instilled in them during training remain important throughout their lifetime, but these dissatisfying factors impede their ability to use that training, according to the study.

And so we return to the words of Dr. Peabody, first published in 1927 in the Journal of American Medical Association.

“Our study suggests that nearly a century later physicians are most satisfied when following Peabody’s guide, including both scientific means to treat disease and thoughtful caring relationships with patients,” the study said. “Conversely, physicians are dissatisfied when these core values, the soul of medicine, are compromised.”

The challenges highlighted by the study provide more evidence that standard, systemwide processes and consistent, modern methods of communications among physicians and their staff, health plans, patients and pharmacy professionals are needed.

“Physician professional satisfaction is dependent on many factors, but ultimately rooted in the individual physician’s ability to provide high-quality patient care,” the authors wrote. “The acknowledgement and study of the administrative and operational tasks that burden a practice staff are important steps in improving and reforming health care.

“High-quality patient care and professional satisfaction require a system that works for the health care team, not against it.”