A growing number of primary-care doctors are burning out. How does this affect patients?


New burdens on primary-care doctors — including electronic health records — pose additional challenges. (Doug Chayka/For The Washington Post)
March 31

Martin Kanovsky, an internist in Chevy Chase, used to see patients every 15 minutes and worry at times about what he might be missing by moving so fast. In December, the 61-year-old doctor reduced his practice to a small pool of people who pay a premium for longer visits and round-the-clock access to him. “There’s no such thing as double-booking,” he said.

Janis Finer, 57, a primary-care physician in Tulsa, Okla., gave up her busy practice two years ago to care full time for hospitalized patients. The lure? Regular shifts, every other week off and a 10 percent increase in pay.

Tim Devitt, a family physician in rural Wisconsin, took calls on nights and weekends, delivered babies and visited his patients in the hospital. The stress took a toll, though: He retired six years ago, at 62.

Physician stress has always been a fact of life. But anecdotal reports and studies suggest a significant and rising level of discontent in recent years, especially among primary-care doctors who serve at the front lines of medicine and play a critical role in coordinating patient care.

Just as millions of Americans are obtaining insurance coverage through the federal health law, doctors like Finer, Kanovsky and Devitt are voting with their feet. Tired of working longer and harder because of discounted insurance payments and frustrated by stagnating pay and increasing oversight, many are going to work for large groups or hospitals, curtailing their practices, or in some cases, abandoning primary care or retiring early, experts say.

The timing couldn’t be worse. “The lack of an adequate primary-care infrastructure in the U.S. is a huge obstacle to creating a high-performing health-care system,” said David Blumenthal, president of the Commonwealth Fund, a health-care research foundation.

A 2012 Urban Institute study of 500 primary-care doctors found that 30 percent of those aged 35 to 49 planned to leave their practices within five years. The rate jumped to 52 percent for those over 50.

Stressed doctors, meanwhile, often mean anxious, dissatisfied patients. Many consumers report feeling shortchanged after waiting weeks or even months for an appointment, only to get a quick once-over and be told there isn’t time to address all their complaints in one visit.

“Your actual one-on-one with the doctor is getting to be less and less,” said Christine Miserandino, 36, of Valley Stream, N.Y., who sees many doctors to manage her lupus.

Worrying about mistakes

“I always felt I was cutting my patients off,” acknowledged Lawrence Gassner, a Phoenix internist who recently switched from seeing patients every 15 minutes to a “concierge” model where he sees a third of his previous caseload. “I went to bed many nights lying awake, worrying that I missed something.”

There are no hard national data on physician burnout. But nearly half of more than 7,200 doctors responding to a survey published in 2012 by the Mayo Clinic reported at least one symptom of burnout. That’s up from 10 years ago, when a quarter of doctors reported burnout symptoms in another survey.

A RAND study for the American Medical Association last year found that nearly half of surveyed physicians called their jobs “extremely stressful” and more than a quarter said they were either “burning out,” experiencing burnout symptoms “that won’t go away” or “completely burned out” and wondering if they “can go on.” Nonetheless, many still described themselves as satisfied with medicine as a profession.

Should the happiness of physicians — a fairly privileged lot — be of concern to their patients? Experts answer “yes,’” saying that unhappy doctors can make for unhappy patients.

Indeed, one of the drivers of physician dissatisfaction is their sense that they are shortchanging patients: that they are too rushed, don’t have time to listen and aren’t always providing good care.

Kanovsky said he used to worry about what might have eluded him because of his relentless pace. Now that he sees fewer patients, he said, he is more relaxed — and his patients are happier, too. Working with a consultant called MDVIP, which helps doctors switch to a concierge model, he went from 1,200 patients to 400.

“Being a doctor is a bit like being a parent,” he said. “At the end of the day, if you have one patient who’s unhappy, you’re unhappy.”

Patients of satisfied doctors are more likely to show up for their appointments and adhere to treatment for diabetes and high blood pressure, studies show. Another survey found dissatisfied physicians reporting more difficulty than other doctors in caring for patients.

And in another study, burned-out surgeons were more likely to report having made a major medical error in the past three months.

“What drives physician satisfaction is also what patients and payers want: delivering good care. And we’re less and less able to do that,” said Christine Sinsky, an internist in Dubuque, Iowa. “You spend less time listening to patients, getting to know them and thinking more deeply about their care.”

‘I knew I had to be able to sleep at night’

That was the situation that confronted Finer, who loved — but ultimately left — primary care to work with hospital patients. Like many physicians, she did not want to be bothered with the business of medicine — dealing with insurers, hiring staff and making bank deposits — and sold her practice to a hospital.

But hospital administrators dictated the pace, telling her she needed to see 22 to 28 patients a day. “At one point, we were scheduled to see patients every 11 minutes,” Finer said.

She was supposed to suggest they schedule another visit if they had more than one or two medical complaints. But Finer worried that they wouldn’t come back.

“I knew I had to be able to sleep at night,” she said. “I was trained to dot every ‘i’ and cross every ‘t’ and leave no stone unturned.” And she found she was unable to do that while seeing so many patients.

At the same time, her income lagged far behind that of her peers in specialties. Salaries of primary-care physicians were around $220,000 in 2012, according to the 2013 Medical Group Management Association’s Physician Compensation and Production Survey, while specialists were averaging close to $400,000, with cardiologists and orthopedic surgeons earning more than half a million dollars.

Efforts to boost compensation for primary-care doctors, who are usually paid per visit and often not reimbursed for managing care outside of that, have largely been unsuccessful.

Richard J. Baron, president of the American Board of Internal Medicine, set out to document how much time a doctor spends managing care and discovered that on a typical day, he or she handles 18.5 phone calls, reads 16.8 e-mails, processes a dozen prescription refills (not counting those written during a visit), interprets 19.5 lab reports, reviews 11 imaging reports and reads and follows up on 13.9 reports from specialists.

“This is about meeting the patients’ needs,” Baron said. “But . . . it doesn’t generate revenue.”

‘I used to be a doctor, now I’m a clerk’

Perhaps the single greatest source of frustration for many physicians is a tool that was supposed to make their lives easier: electronic medical records.

Many do not merely dislike them — they despise them, said physician Mark Friedberg, a co-author of last year’s RAND study.

In 2009, President Obama committed billions of dollars to help defray providers’ costs of going digital. The goal was to boost coordination of care and to reduce errors and rampant duplication. Most primary care physicians got financial help from the federal governmentto make the transition — and will face penalties beginning next year if they don’t use the new systems.

But many physicians say that instead of speeding things up, digital records have slowed them down. They say the designs often frustrate meaningful interaction — with the doctor’s face often turned to the computer screen while the patient is talking.

Digital records often contain numerous, repetitive information fields but leave little room for the kind of personal, nuanced observation that was captured in an old-fashioned doctor’s note. And restrictions on who is allowed to input data have shifted many administrative tasks to physicians.

Using electronic medical records is more time-consuming for primary-care physicians than for specialists because they often are taking more comprehensive medical histories than specialists, tracking more tests and lab results, and filling in more fields.

“Many physicians said to us, ‘I used to be a doctor, now I’m a clerk,’ ” said Jay Crosson, a pediatrician and vice president of professional satisfaction for the AMA.

Meanwhile, the promise of electronic records — to reduce errors and duplication and facilitate communication across settings — has gone largely unfulfilled, as far as many doctors are concerned.

John Schumann, a primary-care doctor who teaches at the University of Oklahoma School of Community Medicine in Tulsa,sees patients at three hospitals, each with a different system. “None of them talk to each other,” he said. “That’s the kind of thing that drives doctors nuts.”

To ease the burden, some physicians have started using scribes: laptop-carrying assistants who follow them in and out of the exam room. Scribing is one of several proposals to provide greater support to physicians by giving more responsibility to nurses, health coaches and health educators. But adding personnel involves additional costs, which worries primary-care doctors trying to limit their overhead.

The trend line, meanwhile, is troubling. The Association of American Medical Colleges estimates the United States will be short 45,000 primary-care doctors in 2020, compared to 9,000 today. In 2010 there were 254,800 primary care physicians in this country.

Even a recent uptick in medical students who are electing primary care is not enough to avert the projected shortage. Meanwhile,experienced doctors are joining large groups or becoming hospital employees, which some argue reduces clinical autonomy and discretion — such as deciding how much time to spend with patients — and which may potentially drive up health-care costs because hospitals may tack additional fees on to their bills.

“They want a place to shelter from the storm,” Commonwealth Fund’s Blumenthal said.

Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.

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