By RONALD DIXON
Week after week, I hear from colleagues in diverse specialties about how exhausted they are from practicing medicine.
It’s no surprise that they are looking for careers outside of medicine. The demands and strain are unsustainable.
So it’s also no surprise that a recent survey showed 40% of primary care clinicians are worried that their field won’t exist in five years and that 21% expect to leave primary care in three years as a result of COVID-19-related burnout.
While COVID-19 is the tipping point, this burnout is the result of the relentless and mounting administrative burden placed on us by electronic medical records (EMRs), coding and billing requirements and prior authorizations. And then it is exacerbated by uncertainty mounting in the primary care field, with new medical care entrants popping up everywhere — from retail pharmacies to digital health startups — aiming to create their own primary care model, replacing rather than working with existing ones.
Where it All Began
The roots of this burden began three decades ago with the advent of an acronym that few outside of the healthcare world know of today — the resource-based relative value scale (RBRVS). This payment system, launched in 1989 and subsequently adopted by Medicare in 1992, led to what we know now as the foundation of the U.S. healthcare payment system.
The RBRVS system assigns procedures a relative value which is adjusted by geographic region. Prices are based on physician work (54%), practice expense (41%) and malpractice expense (5%).
Since the initiation of the scale, the relative value of specialist work has remained much higher than primary care. This disparate compensation, in combination with most health maintenance and patient supportive tasks delegated to primary care, has led to significant fatigue.
Compounding the administrative burden is massive uncertainty — a more recent stressor which reached its highest point this year. COVID-19’s evolution provides uncertainty. Evolving payment models provide uncertainty. And then there are other entrants into the primary care space, including technology giants (Google, Amazon, etc.) aiming to bring new models to replace rather than support traditional primary care models. More uncertainty atop administrative burden amplifies day-to-day stress.
Let’s not forget that the essence of primary care is relationships (longitudinal conversations over time) — and that this burden and subsequent burden fundamentally interfere with our ability to have those conversations.
A Formula to Save Primary Care
I believe there is a formula that can reduce burnout risk and ultimately save the essence of primary care, the “hub” of our health care ecosystem that guides patients to the care they need. The formula consists of three principles, intertwined and essential for sustainability.
- Be subtractive. Remove work from primary care doctors and nursing staff’s plates immediately. Anything that does not require their attention should be delegated to others.
- Leverage technology. EMRs contribute to burden — specifically, the messaging function where patients communicate with their doctors or practices. Harness the power of asynchronous communication and virtual care to help navigate patients to the right outcomes. Now here’s the part that will change the status quo — take the physician and nurse out of the link unless there is an action item that requires that level of expertise. (Ultimately, achieving point No. 1.)
- Use a clinical team pyramid that harnesses clinical navigators to manage delegated tasks with software that integrates with clinicians’ EMRs. This again returns us to the first point: taking administrative work off the plate of practice MAs, nurses and doctors is the fundamental step toward improvement.
I am tremendously concerned about doctor burnout. Primary care physicians feel like mice on a wheel with no exit. If changes aren’t made soon, our next public health issue will be greater healthcare costs and worse patient outcomes, with patients left piecing together an even more fractured system of care.
Dr. Ronald Dixon is an internal medicine physician, digital health entrepreneur, and population health advocate.
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