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

RISING EXPECTATIONS OF PHYSICIANS AND PRACTICES

Society expects more and more of physicians and practices, particularly in primary care. Patients want their health to be better, to be seen in a timely fashion with empathy, and to enjoy a continuous relationship with a high-quality clinician whom they choose.³ A patient-centered practice has been described as, “They give me exactly the help I need and want exactly when I need and want it.”⁴ Yet for primary care, society has not provided the resources to meet these lofty benchmarks.

PHYSICIAN BURNOUT

The wide gap between societal expectations and professional reality has set the stage for 46% of US physicians to experience symptoms of burnout. Widespread across specialties, burnout is especially prevalent among emergency department physicians, general internists, neurologists, and family physicians.⁵ In a 2014 survey, 68% of family physicians and 73% of general internists would not choose the same specialty if they could start their careers anew.⁶ Professional burnout is characterized by loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment and is associated with early retirement, alcohol use, and suicidal ideation.^5,7 According to a recent RAND Corporation survey, the principal driver of physician satisfaction is the ability to provide quality care.⁷ Physician dissatisfaction, therefore, is an early warning sign of a health care system creating barriers to high-quality practice.

We have heard physicians making such statements as:

“The joy of practicing medicine is gone.”

“I hate being a doctor…I can’t wait to get out.”

“I can’t tell you how defeated I feel…The feeling of being punished for delivering good care is nerve-racking.”

“I am no longer a physician but the data manager, data entry clerk and steno girl… I became a doctor to take care of patients. I have become the typist.”

In a 2011 national survey, 87% of physicians named the leading cause of work-related stress and burnout as paperwork and administration, with 63% indicating that stress is increasing.⁸ Forty-three percent of physicians surveyed in 2014 reported spending over 30% of their day on administrative tasks.⁹ Physicians spend more time on non–face-to-face activities (eg, letters, in-box management, and medication refills) than with patients.¹⁰ Even when in the exam room with patients, primary care physicians spend from 25% to 50% of the time attending to the computer.¹¹ Between 2009 and 2010, primary care physicians at a Veterans Affairs facility spent 49 minutes per day responding to inbox-type alerts in addition to documentation of care provided. One-half of such alerts have little clinical significance or could be handled by other team members; 80% of the text in the alerts is unnecessary. The volume of alerts and texts overshadows important information that requires action. Moreover, the alerts create interruptions known to adversely affect patient care.^12,13

A 2013 survey of 30 physician practices found that electronic health record (EHR) technology has worsened professional satisfaction through time-consuming data entry and interference with patient care.⁷ Emergency medicine physicians spend 44% of their day doing data entry, with 4,000 EHR clicks per day; only 28% of the day is spent with patients.¹⁴ In a 2011 survey, over three-quarters of physicians reported that the EHR increases the time it takes to plan, review, order, and document care.¹⁵

STAFF BURNOUT

Burnout affects not only physicians, but also other members of the health care workforce. Thirty-four percent of hospital nurses and 37% of nursing home nurses report burnout, compared with 22% of nurses working in other settings.¹⁶ On the front lines of practice, receptionists have a stressful job, with 68% experiencing verbal abuse from patients.¹⁷ Most receptionists feel that physicians fail to appreciate the complexity of their work. Sources of stress include finding appointments for patients and feeling caught between doctors’ and patients’ demands.¹⁸ A 2013 survey of 508 employees working for 243 health care employers found that 60% reported job burnout and 34% planned to look for a different job. Complaints included heavy patient loads, small staffs, and high stress levels.¹⁹

Physician and staff dissatisfaction feed on each other. “It’s really rough to be around a burned-out doctor. They’re cynical, sarcastic, and wonder, ‘what’s the use anymore?’” It can go the other way, too. A burned-out staff member may not be doing his or her job, resulting in more stress for the already overworked doctor.²⁰ Adequate numbers of well-trained, trusted, and capable support staff with low turnover predict greater physician satisfaction.⁷

CARE TEAM WELL-BEING AS A PREREQUISITE FOR THE TRIPLE AIM

Burnout among the health care workforce threatens patient-centeredness and the Triple Aim. Dissatisfied physicians and nurses are associated with lower patient satisfaction.^16,21 Physician and care team burnout may contribute to overuse of resources and thereby increased costs of care.^22–24 Unhappy physicians are more likely to leave their practice; the cost of family physician turnover approaches $250,000 per physician.²⁵ Dissatisfied physicians are more likely to prescribe inappropriate medications which can result in expensive complications.²⁶

Physician burnout is associated with reduced adherence to treatment plans, resulting in negatively affected clinical outcomes.²⁷ Burnout also leads to lower levels of empathy, which is associated with worsened clinical outcomes for patients with diabetes.²⁸ Patient safety is threatened by nurse dissatisfaction; many nurses report that their workload causes them to miss important changes in their patients’ condition.¹⁶ Dissatisfied physicians are 2 to 3 times more likely to leave practice, thereby exacerbating the growing shortage of primary care physicians and complicating the achievement of a healthy population.²⁹

Practices working toward the Triple Aim may increase physician burnout and thereby reduce their chances of success. Higher scores on a patient-centered medical home assessment may be associated with greater clinician burnout in safety-net clinics.³⁰ More EHR functionalities—email with patients, physician order entry, alerts and reminders—intended to promote the Triple Aim are associated with more burnout and intent to leave practice.³¹

Group Health Cooperative implemented primary care reforms in the early 2000s aimed at improving Triple Aim performance. The unintended consequence was increased physician burnout and resultant quality reductions and cost increases. In 2006, Group Health changed direction, focusing first on clinician work life by increasing visit length and reducing panel size. Burnout dropped substantially with significant gains in clinical quality, patient experience, and cost reduction. The Group Health story demonstrates that without addressing the work life of those providing care, Triple Aim measures are likely to worsen.³²

ADDRESSING THE FOURTH AIM

How can health care organizations work toward the fourth aim, improving the work life of clinicians and staff? For primary care physicians the following list suggests some practical steps:

• Implement team documentation: nurses, medical assistants, or other staff, present during the patient visit, entering some or all documentation into the EHR, assisting with order entry, prescription processing, and charge capture. Team documentation has been associated with greater physician and staff satisfaction, improved revenues, and the capacity of the team to manage a larger panel of patients while going home earlier.^33,34

• Use pre-visit planning and pre-appointment laboratory testing to reduce time wasted on the review and follow-up of laboratory results³⁵

• Expand roles allowing nurses and medical assistants to assume responsibility for preventive care and chronic care health coaching under physician-written standing orders^33,36

• Standardize and synchronize workflows for prescription refills, an approach which can save physicians 5 hours per week while providing better care³⁷

• Co-locate teams so that physicians work in the same space as their team members; this has been shown to increase efficiency and save 30 minutes of physician time per day³⁸

• To avoid shifting burnout from physicians to practice staff, ensure that staff who assume new responsibilities are well-trained and understand that they are contributing to the health of their patients and that unnecessary work is reengineered out of the practice^2,39

In the longer run, to address the chasm between society’s expectations and primary care’s capacity, more financial and personnel resources should be dedicated to primary care. One study estimates that a 59% increase in staffing, to 4.25 FTE staff per physician, is needed to achieve the patient-centered medical home.⁴⁰