From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider

The authors have hit the nail on the head. It is vital to involve the passion of the health care workforce if Triple Aim is to be achieved. Here in the province of Saskatchewan, Canada - we initiated our transformational journey several years ago with our overarching aims being we call the "Four Betters" - Better Health, Better Care, Better Value and Better Teams. Read about our ongoing health care quality journey at: BetterHealthCare.ca

Competing interests: None declared

The update from Dr. Mary Smith at Group Health Cooperative in Washington State is greatly appreciated. We are quite aware of problems at Group Health and at many other institutions. Burnout is like a forest fire; it keeps flaring up. We used the Group Health example to show that without attending to burnout, Triple Aim metrics do not improve and can indeed worsen, and that concern with burnout helps Triple Aim measures to get better. Group Health has been an illuminating example of that important lesson. Your experience confirms that organizations must maintain a continual focus on preventing burnout.

Best wishes, Tom Bodenheimer and Chris Sinsky

Competing interests: None declared

I completely agree with the comments posted. Until the expectations and workload are changed, there is no chance of improving burnout.

Just an update, as a family physician who works at Group Health which is mentioned as a success story in the article, our gains have now been reversed. The home model of longer patient visits and lower panel size was not sustainable, I assume financially, and the powers that be have increased our panels and patient visits per day. With talk of increasing patient visits further. However, the extra virtual work that was added when we reduced our panel size and daily visits, of phone visits and emails etc, has not been reduced. Therefore we are working harder than ever on the hamster wheel... and getting burned out.

The authors may wish to revisit Group Health to correct their article, this change occurred over a year ago.

Competing interests: None declared

Drs. Spinelli and Christensen eloquently described the problem of physician alienation from our beloved care of our patients. Thank you.

It is not surprising that their letter comes from one of the many high-performing health systems in Minnesota, unquestionably the leading place in the United States for primary care renewal. However, I worry that without confronting the mismatch of population demand for primary care and our capacity to meet this demand, burnout will be difficult to conquer. It will certainly require well-trained teams with standing orders that empower others to share the care with physicians, thereby adding capacity without further burdening physicians [1].

Thomas Bodenheimer

1. Bodenheimer T, Smith MD. Primary care: proposed solutions to the physician shortage without training more physicians. Health Affairs 2013;32:1881-1886.

Competing interests: None declared

In their article From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider,(1) Drs. Bodenheimer and Sinsky highlight a silent but not unknown problem confronting healthcare redesign for improvement--the impact of rapid change and job expectations on the wellbeing of the physicians and staff who are implementing the changes.

For many years, Dr. W. Edwards Deming told us that a critical component to process and quality improvement was attending to and protecting "joy in work" for employees.(2) Physicians find "joy in work" by seeing patients. They want to do what is right for patients, they want the broader healthcare system to be successful, and they want to be an integral feature of that success. Unfortunately, many feel they are perceived as replaceable widgets in systems bent on converting all work to measureable process control tasks that are not supporting their professional imperative for compassionate, personal patient care that creates "joy in work" for them. In a profession that is now becoming acquainted with metrics for improvement, digitization of data, shifting professional roles and decreasing emphasis on the time spent in direct, face-to-face patient care, physicians feel they have been left behind. In this environment, until a metric for the wellbeing of the healthcare workforce is regularly incorporated into process planning and monitored performance dashboards, improvements will be limited and may not be sustainable.

Our organization has recently embarked on a significant investment in the vitality of our workforce and the way we deliver primary care. The new design depended heavily on development, planning, and implementation by practicing clinicians. In reviewing our plans, we were gratified to discover that we had included many of the suggestions Drs. Bodenheimer and Sinsky offered in their article.

In a system as complex as health care, where we have learned we must measure quality, service and cost, usually in multiple ways, to describe the whole picture, we have learned that another balancing metric is needed for physician/provider wellbeing. We have been and will continue to measure and monitor the wellbeing of all clinic staff, physicians and non-physicians, regularly and repeatedly.(3) This measure is reported to the physicians, managers and leaders along with patient experience, productivity and quality scoring, and is incorporated into their considerations as they make real time adjustments to the new practice model. We look forward to gaining a deeper understanding of wellbeing and burnout as seen through the lens of longitudinal change in a novel practice design initiative.

1. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Annals of family medicine. 2014 Nov;12(6):573-6.
2. Neave HR. The Deming Dimension. Knoxville, TN: SPC Press; 1990.
3. Spinelli WM. The phantom limb of the triple aim. Mayo Clinic proceedings. 2013 Dec;88(12):1356-7.

William M. Spinelli, MD, MPA, Research Fellow, Allina Health, Division of Applied Research.
Rodney Christensen, MD, President, Allina Clinics.

Competing interests: None declared

We thank Drs. Epstein, Watkins and Antonucci for their thoughts. Each emphasizes the importance of professional satisfaction.

We empathize with the anger and frustration evident in the responses of Drs. Watkins and Antonucci, and believe that the solutions to professional burnout lie in action for both the short term and long term.

Practice re-engineering to eliminate unnecessary or misdirected work at the microsystem level can begin today in most practices, helping to reduce the burden and the burnout. The AMA-Rand study (1) demonstrated that physicians are most satisfied when they have time to engage with their patients and when they are doing work for which they are uniquely qualified. Physicians are less satisfied when performing administrative tasks that could be done by others or that don't need to be done at all. Our suggestions for team documentation, pre-visit lab, streamlined prescription management, expanded roles for staff and co-location (2,3) allow physicians to do work more closely matched to their training and can save several hours of physician time per day.

In the long run we believe it is also important to address the mismatch between policy and technology on the one hand and the needs of the patient and the care team on the other. Dr. Epstein points to the importance of macro-system changes, such as modifying financial incentives to align more closely with our aspirations and values, and individual acts to improve resilience, such as cultivating mindfulness, compassion and relationships.

We believe that professional satisfaction is an important driver of other values in healthcare, such as patient experience, population health and total costs of care. We propose that as a best practice organizations regularly measure professional satisfaction and explicitly implement workflow and workplace initiatives to mitigate burnout among physicians and staff.

Christine A. Sinsky, MD, FACP, Vice President, Professional Satisfaction, American Medical Association.

1. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy. Rand Corporation 2013. http://www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_RR439.pdf. Accessed Jul 15, 2014.
2. Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D,Bodenheimer T. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11(3):272-278.
3. Bodenheimer T, Sinsky CA. From triple to quadruple aim: Care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576.

Competing interests: None declared

Dear Dr. Antonucci,

Thank you so much for your letter in response to the article "From Triple to Quadruple Aim (Ann Fam Med 2014;12:573-6)." You are so correct: the fundamental problem with primary care in the United States is serious underinvestment in primary care practices, including a major shortage of primary care clinicians which creates panel sizes that are too large for good care and a healthy worklife. The potentially downward cycle of primary care burnout (plus the primary care-specialty income gap), discouraging medical students to enter primary care careers, could lead to panel sizes growing even larger, thereby creating more burnout. While the Quadruple Aim article suggests some tried-and-true remedies to improve both patient care and clinician/staff satisfaction, the solution we really need is a smaller panel size, which allows us to take good care of patients without destroying our joy in medicine.

As your excellent practice has proven, there is more than one way to strive toward the triple aim. Keeping the practice small, without an elaborated team and with low overhead, is a model that is working well. The opposite model is a large and well-organized team -- with standing orders, workflows, training, and clearly defined roles and team structures -- that shares the work that does not require a medical degree with everyone on the team. Too many practices -- for example the private practice that consumed my life for 22 years -- have many staff members but are poorly organized and do not work. Yet a growing number of excellent team-oriented primary care practices can be found around the United States, though these practices are still struggling with physician overwork. Is one of these models superior to the other? Only time will tell. However, while I agree with most of your letter, I must disagree that the practice with larger teams is more costly to the healthcare system. Primary care accounts for a tiny 6% of total healthcare costs; solutions to high costs must target specialty care and procedure overuse and hospital (both acute and long-term) care.

We wrote yet another article about burnout because improving all those metrics we are tasked to measure is often done at the expense of our own well-being. Seeking the Triple Aim without worrying about the healthcare workforce is a short-sighted strategy.

Sincerely, Tom Bodenheimer

Competing interests: None declared

While the disheartening statistics on the quality of clinicians' work life and its effects on burnout and quality of care are clear, I believe that there are some underlying principles that should be articulated in addition to the clear and prescient suggestions by Drs. Bodenheimer and Sinsky.

The first principle is that people work harder and more effectively when they feel engaged, that is, when work fulfills intrinsic psychological needs. These include purpose, relationships, autonomy, competence, and potential for growth. The confluence of multiple megatrends, e.g. changes from physician owner to physician employee, growing complexity of medical practice, abandonment of hospital rounds, fragmentation of health plan policies, visit payments, and rushed visits amidst an aging cohort, is thwarting fulfillment of these needs producing alienation. The introduction of electronic health records has not proven to be the hoped-for panacea. Christina Maslach, who did the pioneering work on burnout, calls it "an erosion of the soul."[1] It is more than overwork, and the solutions should not only foster efficiency but also a sense of shared purpose. The other day, a physician colleague talked about his work as "widgets." RVUs, for most of us, do not confer meaning. For Maslach, the opposite of burnout is engagement. It is not just well-being or stress reduction. Engagement in work can be measured and can be considered a quality indicator.[2]

Second, the toxic combination of high responsibility and low sense of control is a prescription for burnout and heart disease.[1] Clinicians have diminishing control over the workplace, such as who is hired, the layout of the office space, the characteristics of the electronic health record, scheduling, referral networks and prescribing. With the call for standardization is some need for clinicians to have a voice. Even small changes can yield big differences.[3]

Third is the need for self-awareness, individually and collectively. One cannot respond well to stresses without some awareness of their early manifestations.[4] Whether self-awareness comes through group discussions or mindfulness skills, providing time to help clinicians to be more mindful of their interior lives appears to have benefit in terms of burnout and quality of care.[5-8] With self-awareness comes greater resilience.[4]

Fourth, relationship-centered care (RCC) offers promise for restoring heart and soul to health care and provide vehicle for creating genuine climate of psychological safety and respect. This requires a concerted commitment to the principles of RCC applied to clinician-patient relationships, clinician-colleague (including staff) relationships, clinician-community relationships, and clinicians' relationships to self and to organizational dimensions that support it.[9-12]

Finally, compassion appears to be an antidote to burnout. Social neuroscience is providing an empirical basis for this assertion.[13-16] It might be worthwhile to place compassion as a principle underlying any changes in the structure of clinical practice. Compassion starts with the way clinicians are treated, how we treat each other, how we relate to our staff, how we treat our patients and, ultimately, how we treat ourselves.[17] It is very difficult to enact compassion in a system that does not recognize -- and may penalize -- its expression. Some health systems have made it an explicit goal -- and have devoted resources -- to building and promoting compassion. They see it as in their best interest -- clinically and financially.

Bodenheimer and Sinsky propose micro-systems changes to enhance the work environment. There are also two other dimensions: macro-system issues and individual factors. The macro-system issues are not just about how much funding is directed towards primary care, but also what activities within primary care are financially rewarded. Increasingly, they have more to do with check-boxes and less to do with patients. The individual issues are paramount. Without introspection about what provides depth, meaning, value and purpose, the absence of these will not be recognized until it is too late. Physicians and other health care professionals are seeking that kind of integration of who they are as people and what they do every day in practice. The solutions proposed by Bodenheimer and Sinsky are an excellent start and should be enacted, but as the clinical landscape continues to morph, the underlying principles will endure even if the effective solutions change.

1. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422.
2. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. The Lancet. 2009;374(9702):1714-1721.
3. Dunn PM, Arnetz BB, Christensen JF, Homer L. Meeting the Imperative to Improve Physician Well-being: Assessment of an Innovative Program. J Gen Intern Med. 2007;22(11):1544-1552.
4. Epstein RM, Krasner MS. Physician Resilience: what it means, why it matters, and how to promote it. Acad Med. March 2013;88(3):301-303.
5. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to Promote Physician Well-being, Job Satisfaction, and Professionalism: A Randomized Clinical Trial. JAMA Intern Med. Feb 10 2014.
6. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA: The Journal of the American Medical Association. 2009;302(12):1284-1293.
7. Weick KM, Sutcliffe KM. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco: Jossey-Bass; 2001.
8. Regehr C, Glancy D, Pitts A, LeBlanc VR. Interventions to reduce the consequences of stress in physicians: a review and meta-analysis. The Journal of Nervous and Mental Disease. May 2014;202(5):353-359.
9. Tresolini C, Force P-FT. Health professions education and relationship-centered care: Report of the Pew-Fetzer task force on advancing psychosocial health education. San Francisco: Pew Health Professions Commission; 1994.
10. Beach MC, Inui T. Relationship-centered care. A constructive reframing. J Gen Intern Med. 2006;21(Supp):l-8.
11. Dobie S. Viewpoint: reflections on a well-traveled path: self-awareness, mindful practice, and relationship-centered care as foundations for medical education. Acad Med. Apr 2007;82(4):422-427.
12. Safran DG, Miller W, Beckman H. Organizational dimensions of relationship-centered care. Theory, evidence, and practice. J Gen Intern Med. Jan 2006;21(Suppl 1):S9-15.
13. Halifax J. A heuristic model of enactive compassion. Curr Opin Support Palliat Care. 2012;6(2):228-235.
14. Solon O. Compassion over empathy could help prevent burnout. Wired.co.uk; 2012.
15. Klimecki OM, Leiberg S, Lamm C, Singer T. Functional neural plasticity and associated changes in positive affect after compassion training. Cerebral Cortex. 2013;23(7):10.
16. Singer T, Bolz M. Compassion: Bridging practice and science. Munich, Germany: Max Planck Society; 2013.
17. Germer CK. Cultivating compassion in psychotherapy. In: Germer CK, Siegel RD, eds. Wisdom and compassion in psychotherapy: Deepening mindfulness in clinical practice. New York, NY: Guilford Press; 2012. pp.93-110.

Competing interests: None declared

I completely agree with Dr. Antonucci's comments.

This article could be described as at best, a group of workarounds; at worst, it is dangerously close to blaming the victim.

It contains nothing about fixing the fundamental flaws in the system, only a series of tricks to teach hamster-physicians how to run a little faster on the treadmill.

This is exactly what administrators and bureaucrats want to hear: that the system is not the problem, we just need to retrain our hamster-physicians.

Practicing family physicians see red when, once again, we're told to apply band-aids to gaping wounds; we're infuriated when, once again, we get the Triple Aim shoved down throats and are blamed for problems we neither caused nor have the power to fix.

Just by getting up every morning and going to the office, we're living the Triple Aim. Get off our backs so we can move forward!

Competing interests: None declared