Much has been written about physician burnout. We are exhausted just reading about burnout. What is missing from the narrative is: first, that burnout can affect different specialties in different ways and second, that it has a particularly deleterious impact on primary care. It has been quantified. Recent work published by Christine Sinsky, MD, and colleagues suggests that the annual cost of physician turnover in primary care is $979 million, of which $260 million is attributable to burnout.
In addition, there is also an economic value associated with a thriving patient-provider primary care relationship and, conversely, a price when it deteriorates or is replaced by another form of clinical care. But there is also the unquantifiable but strongly felt personal toll not only for providers but also for patients. And as bad as we thought things were a few years ago, COVID-19 has made them worse. As we emerge from the pandemic, it is crucial that we move away from the isolating effects of the pandemic and use the experience to inform a new relationship-based model of primary care.
Relationships
The practice of medicine has always been based on relationships. But not all practitioners rely on relationships the same way primary care providers do. First, there are the relationships we develop with our patients. Certainly, there are cardiologists who have been seeing patients with chronic heart disease for several years. There are dedicated nephrologists who spend years working with diabetic patients and dermatologists who treat skin cancers that come back year after year. But in primary care, these long-term relationships with patients are not the exception; they are what the practice itself is based on. Many primary care providers have had patients in their practice for 20 or 30 years. This degree and importance of continuity is unique to primary care.
There are also relationships between colleagues. At its core, primary care is a collaborative practice. All medical care is collaborative – no surgeon we encountered works alone. But by nature, primary care is more intensely relational than other practices. Primary care providers are at the center of the patient care network. We coordinate their care between specialists, interpret test results, develop treatment plans in coordination with other physicians, and ensure that the patient’s wishes are respected throughout the process.
Yet the focus of primary care has become largely administrative, sending results electronically, clarifying and approving refills, responding to patient messages, filling gaps in care, dealing with billing requests and, of course, documenting everything before midnight. One primary care provider we know referred to her job as a “daily hamster wheel.” The result: It is increasingly rare to have those magical moments between a primary care worker and a patient where time flies because we listen to each other attentively, testify and offer an unwavering presence and commitment to longitudinal care. . Instead, exchanges increasingly consist of a two-sentence request in Arial font (“My knee still hurts. I need an ortho referral.”) followed by a response in one word (“Done”). Our greatest skills are listening, connecting and collaborating within and across highly complex systems. It’s a skill we rarely use.
COVID-19[feminine]
COVID-19 has had a profound effect on healthcare workers. And the impact on “frontline” workers, such as clinicians in emergency departments and intensive care units, has received the most attention. Indeed, our friends and colleagues in these specializations have done inspiring work just to keep their patients breathing. We applaud the sustained effort, especially in the face of unsustainable work realities. However, what may go unnoticed is that no one in the health sector has been spared by COVID-19. In primary care, we have seen our long-term patients die prematurely. We answered a thousand questions about vaccines, masks and experimental treatments. We’ve been asked to be the arbiters of marital disputes over whether it’s safe for the family to attend an out-of-town gymnastics competition or take a beach vacation. Primary care has always been about people’s lives and their complicated realities. It requires a relational response more than ever. In addition, our relationships with our colleagues and our patients have suffered. Before COVID-19, you could call a busy specialist and ask them to sneak in for an emergency. Now even our colleagues don’t have time for us. The specialist’s backlog is as long as anyone’s. Resources are dwindling and patients are looking to us to manage not only their evolving conditions and discomfort beyond the reach of primary care, but also their expectations for timely access to care.
Beyond COVID-19
As we continue to respond to this global health crisis, there are sure to be new protocols or redesigns that claim to incorporate the lessons of the past two years. But we primary care providers are concerned that these efforts fall short of what is so urgently needed. We are concerned that whatever happens next, our response does not in fact address pre-COVID-19 conditions.
It’s time for health systems and providers to have honest discussions about the future of primary care. We believe that these discussions should follow the following path:
1. Admit the nature of the problem
As stated, there is no shortage of literature describing the challenge of physician burnout. For example, consider the recent report released by the Surgeon General on the burnout crisis in health care and the recent attention from the National Academy of Medicine instructing the profession to take a systems approach to combat burnout. ‘burnout. But there is a lack of understanding about what actually causes burnout and what the pre- and post-COVID-19 landscapes have in common when it comes to these lingering causes. Limited studies have loosely linked the quality of our relationships – both with our patients and with our colleagues – to burnout, and while more research is needed, as an industry we must accept, acknowledge and proclaim that the lack of strong relationships contributes to burnout, then and now.
2. Prioritize relationships
We understand the underlying business drivers of healthcare: the need for revenue, efficiency and customer satisfaction are essential to keep the drivers of healthcare running. However, when these forces collide with persistent disconnection, isolation, and diminished sense of purpose, they create an unsustainable recipe for provider burnout and, ultimately, long-term decline. term of patient care. We approve of the new solutions proposed before COVID-19 that prioritize the economy of relationships. Others have called for a “relational rescue” or the co-creation of a “thriving human-centered healthcare system in the post-COVID-19 era” – and we agree.
3. Focus on team resilience rather than individual resilience
One of the reasons so many well-meaning solutions to burnout have failed is that they focus on individuals. In the New England Journal of Medicine, Pamela Hartzband and Jerome Groopman noted that “solutions have largely targeted the physician, offering exercise classes and relaxation techniques, snacks and social hours to decompress, better access to childcare, leisure to enrich free time and ways to increase efficiency and maximize productivity”. .” We understand that these solutions are implemented with the best of intentions, but they largely fail because they focus on individual vendors, instead of fostering among those vendors a sense of connection to a community and a larger goals.
We would much rather do a team retreat and have time to chat over coffee with the nurse we rely on than having free access to a meditation app. We would rather our work focus more on discussing difficult cases with colleagues, building and implementing innovative solutions, than building time into our days to increase our own efficiency (which is, too often , the code for “email return time”). When providers say they’ve had enough and they’ve had enough, don’t respond with offers for new resiliency training, salary bonuses, or vacations. We don’t want to come back from vacation to a place of work focused on mapping and returning emails. We want to get back to patients and colleagues with whom we can talk and learn. Understand that the relational aspects of our work are most important to us and to patient outcomes.
Additionally, we have heard time and time again that the response to burnout is largely associated with a need for autonomy in the workplace. To be clear, we’re not asking to be left alone to get our work done smoothly. Rather, with all of our might, we desire the time, space, and support to regain our sense of identity, purpose, and connection with our peers and patients. We ask for the time needed to be a community of healers.
4. Do not use the current pandemic emergency as a basis for health care reform
As states ease restrictions and we head into an “endemic” phase of the COVID-19 emergency, there has been a temptation to apply lessons learned during the pandemic to further change primary care. Some of these lessons will make sense: No one should have to scrounge for personal protective equipment. But over the past two years, we’ve superimposed isolation and distance on a specialty that had already become too isolated and too distant.
At the center of patient care
Of course, we’re not suggesting that focusing on these big themes will solve our entire health care system, or even primary care itself. Pay equity, systemic inequities, staffing ratios and lack of support for fellow nurses are just some of the salient issues we need to address and prioritize. However, to achieve the best patient outcomes, our system must put primary care at the center of patient care. Instead, it too often dismisses the needs of primary care providers themselves. It’s a formula for burnout. We have known that for years. And in a time when primary care providers are in short supply, we need to close these gaps and make primary care practice ever more interconnected, human and relational.
Author’s note
All three authors consult for Intend Health Strategies; however, there is no financial relationship between this organization and the content of this article.
