In this episode of AMA Thriving in Private Practice, AMA’s vice president of professional satisfaction Christine Sinsky, MD, joins the conversation to discuss how burnout shows up in private practices, how the AMA is addressing burnout and tools to improve physician well-being.
- Christine Sinsky, MD, vice president, professional satisfaction, American Medical Association
- Carol Vargo, director, physician practice sustainability, American Medical Association
Vargo: Hello and welcome to AMA Thriving in Private Practice, a 10-episode series exploring the unique needs of physicians in private practice settings. In our show, we’ll talk about efficiency solutions and how to transition into the world of private practice. We also will focus on other tips and tools to help free up time so you can focus on your patients. I’m your host, Carol Vargo, director of physician practice sustainability at the American Medical Association.
Joining me on the show today is Dr. Christine Sinsky, vice president of professional satisfaction at the AMA and one of the nation's foremost experts on addressing physician burnout. Welcome, Dr. Sinsky. How are you today?
Dr. Sinsky: Well, thanks so much, Carol. It's a pleasure to be here with you today.
Vargo: Great. Let's give our listeners some background. Can you share with us how your previous experience in private practice led you to your role in researching and developing solutions to burnout?
Dr. Sinsky: Sure, Carol. I'm happy to. I spent 32 years in private practice in Dubuque, Iowa, where I went into practice right out of my residency. I was fortunate to land in a physician-owned, multi-specialty practice that has about 100 physicians, that has had that amount over the last several years.
Because we are physician-owned, we own the business. In our case, we also owned a health plan that covered about a third of our patient population. Therefore, as physicians, we each wore three hats, the practice owner, the payer and the physician. Although I wasn't wise enough to recognize it when I joined the practice, I was really fortunate to be in this setting. We had a lot of individual agency over how the practice was structured and over our compensation because we were responsible for our own overhead. Over time, I and the other physicians that worked in my particular pod were able to gradually re-engineer the way we did our work in a way that both contributed to better patient care and also to a better experience for the staff and for ourselves. That model of care helped to reduce our own burnout. As I began to experience what was happening in other practices, I found that that was unique. That led to increasing involvement in efforts to improve practice efficiency and workflow, and professional satisfaction and reducing burnout.
Vargo: That experience of over 30 years in being able to re-engineer, as you noted, and then do all this research really has led you to become, as I said, one of the nation's experts on burnout. Let's talk a bit about burnout now. How does burnout manifest for our private practice physicians?
Dr. Sinsky: Great question. The symptoms of burnout I have found are quite similar whether a physician is practicing in an urban setting or rural setting, whether they're in private practice or in an academic setting or an employed setting. The symptoms are traditionally identified as being emotionally exhausted, just feeling spent at the end of the day, having a sense of depersonalization, really caring less about our individual patients and then feeling ineffective, a feeling like what I did today didn't really matter. I think the symptoms of burnout can be very similar for physicians no matter where we practice.
Vargo: Those are great points about the impact of burnout overall for all physicians but does practice setting have anything to do with variations in burnout or attempts to reduce burnout?
Dr. Sinsky: Right. I think when we think about the drivers of burnout, we think about them in three buckets, organizational culture, practice efficiency and organizational support for individual self-care. Those drivers will have different flavors in a private practice setting versus in an employed setting. For example, in small practices, each physician has a greater influence over the culture of the practice. That's an advantage that private practices have, that they can help to create the culture among their fellow physicians and among their staff that aligns with their own values, whether that be the value of growing the practice or serving a particular patient population or being financially stable, you can have greater influence on culture.
In terms of practice efficiency, again, physicians in private practice have more agency over how the workflow goes and how the information flow goes and so have the opportunity to set up really strong models of team-based care. Private practice physicians may also feel the extra financial burden and feel like they're taking a greater financial risk in terms of building up those advanced models of team-based care and having stronger team.
I know in my own practice, the fact that I was directly cost accounted for all of my overhead, it gave me the freedom to make the choice that I wanted to hire an extra nurse to be part of our practice. I was really glad that I did because as the increased productivity that resulted more than made up for the additional cost of that nurse. Even if it had been neutral, or even a little cost negative, the improvement in the quality of my life and the improvement in the quality of care I felt we gave to our patients would have been worth it. Small practices have the additional financial stress of being responsible for the bottom line but also have the additional agency or control to be able to make those decisions for themselves.
Vargo: Yes, those are great points. I know that in the research we have done with individual physician practices, having that flexibility and agency and quite frankly being able to evaluate the trade-offs which you had flagged and highlighted, I think did give them a general sense of satisfaction about the job and the practice setting that they've selected. I think those are great points for our listeners
Dr. Sinsky: I agree, Carol. That third bucket that I mentioned of drivers of burnout or professional satisfaction, it's inverse. The third bucket is institutional support for individual self-care. Here's another area where physicians in private practice do have more flexibility. An example was when my husband, also an internist, and I had two toddlers, when we started our practice, we were able to set our schedules to meet our needs as parents and as the children grew, we were able to modify our schedules. Once they were in elementary school, we modified our schedule so one was there when they left for school and the other was there when they returned home. That kind of authority over the details of your daily life is so important to work-life integration and to professional satisfaction. It is something that physicians in private practice can take advantage of.
Vargo: I couldn't agree more. We hear this quite often from residents and young physicians going into practice that are really intrigued by the private practice model because of that flexibility that is offered to them. That's really a great point. What is the impact of a physician’s working environment? Are there any similarities with physicians in other practice settings with regards to burnout?
Dr. Sinsky: Carol, that's a really interesting question. When I first started becoming involved in practice transformation and burnout at the national level, one of the things I had the opportunity to do was to visit now over 75 practices across the country and shadow physicians as they did their work. This was a variety of settings, both private and academic and employed and FQHCs, small and large, rural, urban. One of the things that struck me was how similar the challenges were, that the administrative structures were often very different but when you got down at the practice level, most physicians were facing very similar challenges, how to manage the volume of work, and that's really become an issue with the inbox, which right now is just exploding for many, many physicians. How to find and retain support staff and how to train that support staff. How to stay current with the exponential growth of medical knowledge.
Then, I think physicians, particularly in smaller private practices, have the additional responsibilities of actually running the business, of dealing with the insurance companies and the regulations and all of those kinds of responsibilities. I think by and large, the challenges are similar, yet while physicians in private practice do have advantages in terms of flexibility and autonomy and agency, they also have the additional responsibilities. One thing that I was surprised to find was that physicians who were not in private practice and particularly physicians who didn't own their practice can easily feel disempowered, can feel somewhat at the mercy of a large system, whereas physicians who own their own practice naturally took on a more owner's mindset, which is that, “Oh, here's a problem, let me see if I can solve that.”
Vargo: The points you make resonate with the work that we're doing at the AMA and actually why we have really enhanced our focus on supporting physicians in the private practice setting. As you know, Chris, from all the tremendous work you're doing on burnout reduction with health care systems, the AMA, all of the work that we do supports physicians in all practice settings. Because of some of those really specific, unique challenges that you just highlighted, we have undertaken this initiative and have developed very specific tools and resources for the private practice physician. Thank you for highlighting those. Back to actual burnout. Are there particular areas that private practices need assistance with to improve their own well-being and that of their staff to reduce physician burnout?
Dr. Sinsky: Carol, I think that there are some unique needs for private practice because as physicians going through medical school and residency, we are not trained in process improvement, in change management or even in team-building approaches. Having some additional support in terms of process improvement can be quite helpful. We have several Steps Forward toolkits that are free and available online that address some of these issues. We have some on change management, we have one on recruiting and retaining medical assistants. We have a saving time playbook, which provides practical tips on some of our core practice fundamentals. You can read these toolkits online. For many of them, there are related podcasts and webinars. For those who prefer to listen as they drive or exercise or do other things, you can hear an interview with the author of the toolkits. Then when you want to, you can dive deeper into the resources online.
Vargo: I know you were the founder of Steps Forward, share with us latest stats and numbers on that.
Dr. Sinsky: Happy to. Since Steps Forward began, which was about five-six years ago, maybe just a little longer, we've now had 1.3 million unique users of these resources. I think part of why they are so widely used is that we have intentionally made them for physicians by physicians and we have made them actionable, practical, one-stop resources where a physician or practice manager can go and learn how to do some aspect of improvement. Maybe it's holding team meetings, having daily huddles, how to do pre-visit laboratory testing to improve the flow in your practice. There is a toolkit on each of those topics. We have now over 70 different toolkits. The toolkits come with step-by-step guidance on how to implement the innovation in your environment. Then, there are downloadable tools that would supplement that to make it easier for you. For example, in the team meeting toolkit, there's a downloadable agenda in a Word document. You can download that, then you can modify it to your own needs. We've tried to make it as simple as possible for busy physicians and practice managers to just get started.
Vargo: Indeed, with over 1 million users, individual and unique, we recognize that probably not only are physicians accessing those tools and resources but clearly many practice administrators as well. Those handy downloadable PDF checklists, we know that those make offices run much more smoothly and we work really hard to format things so that it really does help implementation. With regards to administrators, in your experience, how can they help improve practice culture? More importantly, really restore autonomy to the physicians so that they're actually doing what they most love and want to do, which is to spend time and care for their patients.
Dr. Sinsky: Great question. There are a number of things that administrators can do, some very practical and some almost theoretical. On a practical basis and linking back to our conversation about the Steps Forward toolkits, a practice manager or administrator can sit down with a team and have them go through our practice assessment tool. It's a series of about 12 questions. When you go through that, you get the opportunity to reflect on, well, how do we handle laboratory testing? How do we handle things like team meetings? You can see various levels of sophistication in the answers and you can therefore see, “Oh, we're sort of beginning on the journey or we're a little further along but now I see where we can be going.” We have the practice assessment tool, which can be a conversation starter for administrators and practice leaders who want to move toward a more efficient and satisfying model of care.
Then on the theoretical, I think there are a few things that leaders can do. One is to realize that a task is not always safer if the physician does it. In fact, oftentimes it is safer to delegate some of the tasks to an upskilled team member. For example, many practices have found that by having the nurse or medical assistant research the inbox messages and then bring those to the physician with the backstory, makes the management of that inbox message more efficient and makes the result a safer, better result than if the inbox message went straight to the physician without any preceding research and support.
Vargo: That raises a point, Chris. Oftentimes physician practices may not realize that they do not have to do all this work. They may be fearful of specific regulations or some myths or beliefs that they think they have to do something a certain way and that they themselves have to be the one that's entering all this information. I know that led you to begin with our other initiative on dispelling regulatory myths. Do you want to talk a little bit about that work and what it is intended to do?
Dr. Sinsky: Sure. This is one of my favorite initiatives at the AMA, Debunking Regulatory Myths. We currently have nine myths that we have posted. With each one of them, we post what the common misunderstanding is and then we very clearly state what the reality is. Then we discuss that a little bit further and then we provide links to the official language that supports this interpretation. Often time, that language comes directly from CMS, other times it comes from The Joint Commission.
We have some on whether commercial plans are required to adopt the new 2021 Evaluation & Management codes, which have made it much simpler for physicians to document their outpatient services. Indeed, they are required to adopt them. We discuss that. We address the question of whether a nurse or a medical assistant can enter orders into the electronic health record at the direction of the physician. In fact, they can. We provide information about how long a prescription duration might be made available. So I think a lot of the burden that physicians experience on a day-to-day basis comes from an over-interpretation of existing regulations. You can go to our Debunking Regulatory Myths page and find some clear answers and you can also suggest your own topics for further clarification in the future.
Vargo: Thank you for walking through that. I do agree. I think physicians often feel like they don't want to be running afoul of specific laws or regulations but don't have the real understanding. The AMA is really helpful in this and just in terms of cutting through the noise, cutting through potential misunderstandings and just providing that exact language, I think it's been very helpful, a really important initiative.
Dr. Sinsky: Carol, there's one more tool that I think physicians in private practice and in other settings can find helpful. That is a de-implementation checklist that we've also made available at the AMA. It is an effort to allow leaders to reduce some of the unintended burdens on clinicians that come from over and interpretation or come from policies that might have made sense at one point but are no longer necessary. A practice manager could sit down with this list and look at what are the things we're doing in our EHR that we could stop doing, or that we could simplify that would reduce the burden on our clinical staff? What are the things within our compliance realm that we are doing that maybe we don't need to be doing any longer? It's a two-page list of suggestions for things to look over and de-implement.
Vargo: Thank you. That's great. We've talked a lot today about how physicians can take some steps within their own practices to reduce some of this administrative burden that is leading to burnout. We also know that the AMA is working very hard to interact with people external to the physician practice environment to try to remove some of those obstacles. Obviously, all the work we do with our advocacy unit, with CMS around reducing regulatory burden, clearly all the work that we've been doing around prior authorization, so I don't want our audience to think that, oh, this is all just something that a physician practice has to solve. The AMA fully understands that there are many stakeholders involved in these conversations and we continue to have dialogues and pursue every strategy we can to reduce the burden on physicians. I don't know Chris, if you had anything additional or any other thoughts you wanted to add to that?
Dr. Sinsky: I do, thank you. Because I think that the 2021 Evaluation & Management coding documentation changes have to be among the most substantial improvements that I have seen from a regulatory point of view over the three decades of my career. That having the level of service determination be driven by medical decision-making alone rather than by history and/or exam means that you can document what will be helpful to you or the next physician caring for the patient in terms of history and exam but you no longer have to count bullet points under the exam and you no longer have to artificially try to create duration time, context, modifying symptoms for a care episode, for which those dimensions don't make sense.
One can also bill by time but when you're billing by content, the changes have been so substantial and they decrease the cognitive workload that the physician has to carry in their brain as they're caring for the patient. No longer have to be thinking about how many bullet points for history, how many bullet points for exam am I doing. I just find that to be an extraordinary change. Carol, you're absolutely right. The work you've done and the work with our advocacy colleagues at the AMA was a big part of that.
Vargo: Right. As we're coming to a close, I just want to note that, clearly, your work over the last three decades, actually being in practice and really understanding what it is like for a physician in an independent practice is so crucial
. Thank you so much for everything that you are doing for the AMA and for our members and others who reference AMA resources every day. It's invaluable experience. We keep chipping away at the problem. To your point about E&M documentation, significant win and the AMA is providing a lot of resources for physicians on those changes but change takes time. Implementation is hard. The AMA and you were working together really hard to make it somewhat less difficult for a physician to implement these tremendous changes.
Chris, as we're wrapping up today, is there anything else you'd like to share with our physician and other listeners around burnout and next steps that they can take?
Dr. Sinsky: Sure. I think it's really important to recognize that burnout is a solvable problem, that you have to invest time to save time. If you invest two hours on a given day to determine how to save 10 minutes every day for the rest of the year and year after year, that's going to pay off big
Vargo: Absolutely. Chris, thank you so much for all your hard work, clearly, and the perspectives that you've shared with us today, particularly around how burnout can impact private practice physicians, as well as ways that they can improve well-being and professional satisfaction for them and their staff.
Dr. Sinsky: My pleasure. Happy to be with you today. Thanks so much.
Vargo: You too. For more information about the resources that were discussed today, visit [the AMA website] to support your practice's sustainability. I am Carol Vargo and until next time, this has been Thriving in Private Practice. Thank you so much for listening today.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.