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The Weight of The White Coat: Battling Burnout
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Released: September 10, 2024

John Marshall
John Marshall, MD
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THE WEIGHT OF THE WHITE COAT: BATTLING BURNOUT

How Do Middlemen Impact Our Practices? [00:00:00]

John Marshall, MD: Welcome back everybody to Oncology Unscripted. It is August and if you're lucky like I am, August is vacation time for me. I am at this beautiful place somewhere in the south, somewhere near a golf course and an ocean; a little river flowing right over there, some egrets and an occasional pelican flying by. There are fruity rum drinks, most evenings, which makes for a very pleasant time away from work. So, I'm on vacation, and I hope you guys have gotten some time away.

We're going to focus on in the second part of our series of three programs on the middlemen in our lives. The last episode, which many of you have commented on and have watched, is around pharmacy benefits managers; their role in our healthcare system and how they've inserted themselves and made a bunch of money and not necessarily adding value.

Today, we're going to riff a little bit along the electronic medical records, certainly a middle thing in our lives that many of us are sort of frustrated by. And then our next episode will focus on clinical research organizations that I know many of you can be frustrated about, as well.

Silent Crisis: Can You Admit You're Burned Out? [00:01:27]

But, to set up this EMR vacation setting. I think we ought to talk a little bit about the concept of burnout. Now I'm on record as having officially burned out. It was in, really, 2018, 2019. I didn't really know it. I just thought I was grumpy because I had good reason to be grumpy. But it was actually my wife and my daughter who noticed that I just wasn't my same old self. I had lost my sparkle. And I thought a lot at that time about my own personal burnout: therapy, I ended up taking a sabbatical, my wife and I wrote a book. We had to get away for a while in order to deal with that. 30 years of being an oncologist is a big deal.

And then I started to look into this issue of burnout and realized that lots of us in our space have a lot of burnout. There's some studies that have been done and basically looks at, sort of, not only our burnout, but how are we dealing with burnout. And given that I'm on vacation, I thought it would be kind of useful to look at some of the data for us around vacation. And we don't take very much vacation. And when we do, we actually work. Like this morning, I actually have already seen four patients in tele visits. God help us. So even though I'm on vacation, I'm still working. And I bet many of you do that the same way.

So, in this survey. 60 percent of us as physicians, we're only taking 15 days or fewer per year. That's terrible. With 20 percent of us, one in five, taking only five vacation days a year. And most of us, when we're on vacation, like me right now, 70 percent of us work every day of a typical vacation. We do something. We check email; we do something while we are on vacation. And a third of us will spend more than 30 minutes a day on work while on vacation.

Now, looking at subspecialties, oncologists are a little bit better because 60 percent of us were taking about three to four weeks of vacation. But you get more vacation than that!

Is Relaxation Worth Sacrificing RVUs? [00:03:46]

I know as well as you know that we're disincentivized to take vacation, right? Because we are RVU-driven, and every week I'm not getting RVU's, I'm actually getting less money. So, if I take vacation, I'm actually making less money.

Now, the other thing that sort of started happening more recently is this concept of paid time off PTO, right? Didn't used to be called that. It used to be called vacation. If you're in a business where when you're on vacation, you're paid, you're supposed to call it PTO. For those of us who don't have that sort of tracking system, we call it vacation. but it still makes me feel guilty, I guess.

Are Your Patients and Staff Mad When You Go on Vacation? [00:04:32]

Now, one other perspective that I learned the hard way when I took my sabbatical is just how angry patients get when we're on vacation. Our staff also is angry at us when we're on vacation because we're not immediately available and they depend on us in order to, you know, do the day-to-day stuff we have to make decisions here and there. And our patients, particularly when we take a longer vacation, do get kind of fussy at us. Well, you know, as soon as you get back, let me get in to see you, or I need to see you right away. So right before and right after vacation, we clearly pay the price, by, you know, all the catching up that we have to do when we are away.

PROMISES UNFULFILLED: THE EMR PARADOX

Do You Love or Hate Your EMR? [00:05:17]

Now, the new one that I think is the most kind of creepy of all is that of course our patients have access to their electronic medical record, right? Our topic for today. And so, they can look up their results or they can wait on, you know, they can find what their CT scan showed or their CEA level or whatever it is. They can see and now they know this result. You're on vacation. You don't really want to get into the discussion. They've got to wait until you get back. And of course, that just generates more anxiety for everybody. You have to decide whether to stop everything, pick up the phone and call Mrs. Smith and tell her about her scan and talk it through. Wait till you get back or do as I did this morning and schedule four tele visits with your patients while you're on vacation in order to catch them up and make sure they're okay. Which for me in the end was a good trade off. I feel better about what I did. I'm happy for the patient. I won't have to get creamed when I get back, but I had to eat vacation time in order to do it.

Now, I'm old enough, maybe some of you out there are old enough, to remember charts. They could get really thick in some patients, and you would carry them around if a patient was inpatient. Often in our shops, you could find the chart up on the floor, which is not where it was supposed to be, or they couldn't quite find it. Or the last person just stuck something in the chart, and you didn't know whether the result was going to be there or not. So, we didn't really like our charts either. They were inefficient and we were hoping that the electronic medical record was going to be this, this great savior. But in many ways, it has become the primary thing that we do is enter data into the EMR.

More EMR Screen Time Than Patient Time—Is This Your Reality? [00:07:12]

It's very, very common—I catch myself all the time, really common with the younger physicians, is that they stare at the EMR the whole time. The patients over there, they're staring at the EMR. And they're just typing right and entering in data and not really paying attention to the patient over here.

We've seen a clear fall off on physical examination because it's all there. You don't need to examine the patient. Everything is right there. We collect money, we bill, based on how much we documented in this EMR. And, you know, what's interesting is the EMR is not really that great at being able to find the data, right? So, I think about genetic tests, for example. they could be scanned in somewhere, and they could be in the right portal where I could find it, or they could be under, like, outside records, page 37 of 130 of somebody's outside records. So, I can't find the genetic data. So even though it may be supposed to be in there, I can't find the data that's in there. So, we've separated ourselves from our patient. We're totally driven to entering data. And the world is really excited about this data that we're creating.

Who Owns the Valuable EMR Data? —Certainly Not Us or Our Patients… [00:08:27]

The reason I think of the EMR as a middle person, a middleman, is that the data that we are entering has value, worth something, because it's clinical outcomes, it's behavior and usage and money spent and, opportunities for improvement in healthcare. So, I have been jokingly calling us physicians, you know, highly paid data entry specialists because that's kind of who we are. What we enter into the EMR has value to someone else. We're being paid to enter the data. Someone else can mine that data in order to make money off of it, to watch us, to oversee us. You know, it becomes a new way of tracking our own metrics, our own benchmarking, how good are we, how fast are we, what's our charge lag, all the different things that we have to do so. It’s an oversight of us. It's how we get paid. It's how we interface with the patients. It’s someone else's value in the end.

So, the EMR is a big deal. We spend tons of time entering data focusing on it. We spend tons of time trying to find information for our patients. Our health care systems value that data very much, and third parties value it very much. But, in essence, we have to recognize that we're in this awkward ménage à trois between our patient, the physician health care team, and this computer system that runs our lives. So, we need to think about how to make a better world around the EMR. To make it more efficient, to make it more clinically friendly, to make it shareable across all health care systems. I think we'd go a long way to improving our health care out there.

EMRs AND BURNOUT: A CRITICAL INTERSECTION

How Much of Our Burnout Can We Really Blame on the EMR? [00:10:27]

So, we're focusing on burnout. We're also focusing on the middleman, the electronic medical record. Why are we focusing on these two? Because clearly they are linked.

We did a quick literature search and found a bunch of articles that focus on burnout and the electronic medical record. I'm going to put my readers on to share with you one conclusion from one of these papers. it says, "the volume and organization of data, along with alerts and complex interfaces requires substantial cognitive load and results in cognitive fatigue. Patient interactions and work life balances are negatively affected by the time requirements of the EHR tasks during, and, of course, after clinic hours patient portals and, EHR messaging have created a separate source of patient care outside of our face-to-face visits. It is often unaccounted productivity and not reimbursable." It's no wonder that we're burning out.

As I told you, I am a burnout victim, if you will. Maybe a recovering burnout person. I'm always on the verge of it at this point, but I've learned a little bit better how to manage it. Vacation can help, by the way.

But, 59 percent of respondents in a survey that was taken did report some symptoms of burnout, and this was compared to only 34 percent back in 2013. So, essentially a doubling of those who are complaining of some symptoms of burnout. Now we are burning out with high levels of emotional exhaustion. And if you think about oncologists, we bring a lot of emotion into our patients. Patients are very emotional themselves. We deal with very high-end kinds of critical moments for patients’ lives that we're walking along with them. So we there's no way we can't not feel that day in and day out. And we feel burned out regularly, right? And that's really up, quite a lot from even just 10 years ago. So, we're getting more and more burned out, more and more, influence of that burnout on our emotional well-being ourselves.

My health care system just did its annual and maybe it's every other year survey saying they care about my well-being. And so, they've sent out a survey. They set a deadline, September 9th, to fill out this health care form, and they basically claim that what we're going to give them is going to give them a better idea about how to support our well-being and professional fulfillment. Now, this is the same group that's also monitoring me and tracking each of our performance levels and our Press Ganey scores and all of the different components that we are judged by in today's electronic world are. You know, they're going to have this other data that says that that's stressful. So, I'll be very interested to see this. I'm sure your health care systems have done the same thing. How do you bring those two things together. How do you take what stressing us out is the monitoring that you're doing but continuing to monitor us in a way that balances that out so that we get to a place where we can maintain our careers long term, avoid burnout, or at least manage the burnout in a way that's healthy and positive, and mentoring those that are, behind us, if you will. And, and making for a better overall product for our patients and for our teams around us.

Closing Out Your Vacation—Is it the End or the Beginning? [00:14:17]

As you might have already figured out, the problem with vacations is that they do end. You have to get on that thing back there and fly home. I already looked at my week ahead, it's very, very full, with patients, of course, and meetings, and catching up. That stuff I didn't do over the last week, and it is a stressful week as you look ahead. But I have to say that the tradeoff for the break from all the action and doing what we do as oncologists, administrators, researchers, all the things we do, the break from that was so totally worth it. So, I encourage you out there to make sure and take all of your vacation. Your partners will cover for you. The RVUs, in the end, you won't remember, the vacations, you will. So, make sure, don't trade off those RVUs for those days away. Take those days away. Enjoy your family. Make your life better. Avoid that burnout.

And by the way, our lack of burnout and our progress and our innovation, maybe some of which comes during a vacation, will one day make it so you got cancer cured.

Until next time. See you later.

This transcript has been edited for clarity.