Restoring the joy in medical practice

Internist Ann Cordum, MD, belongs to a seemingly endangered species of primary care doctors-those who enjoy their work and look forward to coming to the office every day.

It hasn’t always been that way for Cordum. She spent the first quarter century of her career in clinical and administrative positions with large healthcare systems, where she found herself growing increasingly frustrated with bureaucracy, too-short patient visits, and answering to managers who were MBAs rather than MDs.

So in 2015, Cordum decided to strike out on her own. She and another internist opened a direct primary care practice in Boise, Idaho, with the goal, she says, of “having no intermediary between myself and the patient.” The result has been exactly what she hoped for in terms of her approach to practicing medicine. “Now it really is joyful,” she says. “I like going to work and even when I’m not at work, I’m always available. I feel like it’s my pleasure to help the patients with their needs.”

Burnout, alienation increase

Doctors’ use of terms like “joyful” and “pleasure” when talking about medical practice has grown increasingly rare in the last decade or so. Studies and surveys consistently show rising levels of burnout and alienation within the medical profession. For example, in the Physicians Foundation’s 2016 Survey of American Physicians, 54 percent of respondents rated their morale as “somewhat or very negative,” and 49 percent said they “often or always experience feelings of burnout.” Only 37 percent said they harbored positive feelings about the future of the medical profession.
The reasons behind these feelings have been well documented. They range from frustration with EHRs and time spent obtaining prior authorizations to anger over government mandates and payers’ “take it or leave it” attitude in contract negotiations.

Carving out more patient time

And yet, in spite of all the obstacles, it is still possible for doctors to enjoy their work. The key, according to practice consultants, psychologists, and physicians, is spending more time doing what doctors are trained to do and gives them pleasure: treating patients.

While that sounds obvious, the challenge lies in finding the time for it. To start with, many doctors-particularly those working for hospitals and hospital systems-usually have little control over their schedule or working conditions and often must wrestle with the system’s bureaucracy to get patients the care they need.

But even doctors in independent practice often find it difficult to carve out more time for patients, given the range of administrative tasks and quantity of paperwork pulling them away from the exam room.

“A lot of what’s driving doctor unhappiness is that more and more is being expected of them than in the past, and this has compressed the amount of time they have to spend with patients, while the documentation burden has gone up,” says Cynthia “Daisy” Smith, MD, FACP, vice president of clinical programs for the American College of Physicians and part of the ACP’s Physician Well-being and Professional Satisfaction initiative.

Smith cites a 2016 study in Annals of Internal Medicine that found that for every hour doctors spend in face-to-face clinical time with patients, they spend nearly two hours on “EHR and desk work in the office,” according to the authors, and another one to two hours of personal time on computer and clerical work.

Rethinking approaches to medical practice

But the barriers to finding, or rediscovering, joy in medicine aren’t all external, experts say. Sometimes it requires physicians to rethink how they approach their work, says Gail Gazelle, MD, FACP, a former hospice physician who now coaches doctors on issues of professional satisfaction and work-life balance.

Gazelle notes, for example, that many physicians are perfectionists, a personality attribute that is important for success in medical education and training but can contribute to frustration and anxiety as a practitioner. “If you spend hours [on patient notes] perfect because you believe that every note has to be, but you only have so many hours in a day, you can see how the math doesn’t add up, and helps to explain why so many physicians struggle to keep up with documentation demands,” Gazelle says.

That drive for perfectionism, Gazelle adds, goes hand-in-hand with how many doctors learn to deal with problems they encounter in their practice: by working harder. “Many of us were taught that to be a good doctor you just power through, and don’t pay attention to your own needs,” she says. “And we know, given the high levels of burnout in front-line specialties, that is not an effective strategy in the long run.”

Another impediment to professional satisfaction doctors sometimes face-especially older physicians-lies in the attitude of supreme authority instilled during their education. “When I was in medical school 40 years ago, there wasn’t a lot of emphasis on team care,” says Louis Snitkoff, MD, FACP, chief medical officer of Community Care Physicians, a multi-specialty practice in the Albany, N.Y. region. “You were trained that everything the patient needs, or happens to the patient, is your responsibility, and it’s a tremendous burden.”

Getting back to basics

So how can doctors find more time to spend with patients, and thereby find-or rediscover-the joy of practicing medicine? For Cordum and her partner, the solution has been to remove as many barriers as possible between themselves and their patients, starting with insurance companies, which is why they have chosen the direct primary care model for their practice.

“If you are on an insurance panel, your contract is with the insurance company, not with the patient, and that’s a conflict of interest for me. It goes against my oath to work for the patient and not someone else,” she says. Besides, she adds, “I get intimidated with all the third parties and contracts and 1-800 numbers, and it takes away from having meaningful time with my patients.”

Not accepting third-party payments has brought the additional benefit of not being required to use an EHR. Instead, Cordum uses a Microsoft Word-based system to record her notes and other pertinent information. “It’s perfectly adequate [and] costs me nothing so I can keep costs down,” she says.

Using the DPC model also allows her to keep her patient panel between 400 and 500 patients. “We know our patients, and we know what’s important to each of them, their goals and their values,” Cordum says. “Also, we don’t have intermediaries and barriers to patients’ ability to reach us and spend time with us. When the patient calls our office, we call them back ourselves.”

Cordum notes that the DPC model hasn’t freed her entirely from the administrative hassles of medical practice. Some of her patients have health insurance, which means she must still get prior authorizations for some drugs she prescribes and prepare bills for these patients to submit for reimbursement. But the amount of work and time required for these tasks is far less than what her colleagues with insurance contracts contend with.

“When I decided on this model, it was for simplicity and removing anything onerous or complex and bringing it back to the patient and the doctor,” she says. “And I’m having fun with medicine again. I get to do house calls, I get to do walking visits with my patients. And if something isn’t working, I don’t have to go through three committees. I just change it and make it better.”

Teamwork and scheduling control

Of course, most independent practices have payer contracts and thus operate under more constraints than Cordum. But even under those circumstances, doctors can take steps to increase their patient time and reduce their frustration level, experts say. Among these are: streamlining practice workflow, strengthening collaboration among practice staff, and reassigning tasks not requiring an MD to other providers or staff members.

The ACP’s Smith recommends that practices hold regular staff huddles, establish protocols and standing orders wherever appropriate, and utilize pre-visit planning. “Have someone from the staff look at the patient’s chart and anticipate what needs and questions that patient is going to have,” she says. “Some practices even go so far as to order labs ahead of time so all the administrative needs are addressed before the patient comes in and the doctor can focus all his attention on the patient.”

At Community Care Physicians, improving physician satisfaction took the form of negotiating an agreement with one of the practice’s major payers, with whom it is in a shared-savings arrangement, to eliminate prior authorizations for complex imaging procedures. “Even though it’s not all our payers, it’s still a huge thing for morale, and has really helped reduce the burden on our physicians and staff,” says Snitkoff. 

Allowing doctors some say in patient scheduling can also help to increase their satisfaction, particularly when it comes to who they see at the beginning and end of the day. “We’ve found the bookends of the day can be some of the most stressful for physicians, particularly those who are juggling competing demands at home and at work,” Smith says. For example, a parent needing to pick up a child at daycare will feel less stress knowing the last appointment of the day is for something minor and straightforward, like a urinary tract infection.

“If you can give clinicians some flexibility over that first and last slot of the day, that really seems to ease anxiety and makes people feel like they have more control,” she says.

Allowing primary care doctors more flexibility in their schedules and time with patients was the goal of an experimental program at Virginia Mason Medical Center, a Seattle, Wash.-based hospital system. Launched in 2016, the program increased patient appointment lengths for some physicians and nurse practitioners in outpatient settings to a uniform 30 minutes, rather than Virginia Mason’s standard 15- or 20-minute allotments.

“Some of that [the reason for the pilot] was to try and give us back time with our patients,” explains Carrie Horwitch, MD, FACP, who oversaw the pilot program. “It also simplified our scheduling, so that the provider didn’t have to figure out if that patient needed a longer or shorter appointment.

Part of what enabled Virginia Mason to free up time for longer visits, Horwitch explains, is its long-standing emphasis on team-based care and handing off tasks that don’t require a physician to other staff members. For example, patients who come in for opioid prescriptions first meet with a pharmacist, who provides information about the medication, ascertains that the patient is using it correctly, and checks the patient’s record in the state’s prescription monitoring program database.

“That sets up the appointment for the clinician so that we can really spend time with the patient, answer their questions, and see how they’re doing,” she says.

Horwitch notes that the program led to greater feelings of satisfaction among the participating clinicians, leading Virginia Mason to expand the option of uniform 30-miniute appointments to all its primary care providers. Its success, she adds, confirms her belief that much of what makes doctors unhappy is due to not having the time necessary to provide quality care to their patients.

“It’s why we’re in this profession and we stay in it,” she says. “To be healers and helpers of people."

Patient input helps physician design joyful practice

Like many primary care doctors, Pamela Wible, MD, was unhappy with the “assembly line” style of medicine she was practicing early in her career. She bounced among jobs at large clinics and hospital systems, where patient visits were short and long-term relationships were few. What’s more, she knew that patients were dissatisfied as well.

But while Wible’s feelings about the care she was providing were hardly unique, her response was: before starting her own practice, she convened a series of townhall-style meetings in and around her hometown of Eugene Ore., in which she asked people what their ideal medical practice would look like.

“I pretty much told them I would try to do whatever they wanted me to as long as it was legal,” Wible recalls. What she heard was not surprising. “People wanted a human-scale experience. “They wanted me to be on-time for appointments and in a good mood. They wanted me to address their medical problems and not rush them. They wanted me to be able to refer them to someone nearby to help them if I couldn’t.”

Armed with this feedback, the practice she opened in 2005 was one in which she was-and remains-not just the sole provider, but the only employee. “Solo in the truest sense,” she says.

Wible’s office space consists of 280 square feet that she rents in a wellness center. Since she doesn’t employ a receptionist, she greets patients herself and escorts them to the exam room. Appointments run either 30 or 60 minutes. “That allows us to cover a lot more territory” than in standard 15-minute appointments, she says.

Wible does her own billing of insurance companies, she adds, and generally is paid within two weeks. Thanks to her minimal overhead, she keeps about 90% of what she bills. “It’s a very easy, simple process,” she says. “The patient goes home happy and I’m able to live the life of a joyful doctor.”

Wible believes the process of inviting lay people’s help in designing a practice is one that can, and should, be adopted elsewhere. “It’s very empowering for a patient to walk into a facility they helped design,” Wible adds. “In the current medical model patients and physician feel they’re held hostage by a process that was designed with neither of them in mind, but is what I would call administration-centric. It’s built around what’s convenient for people at the top, whereas my practice was designed to be patient-centric. I’m working for my patients and not for other people, and that’s what brings me joy.”

Since opening her own practice Wible has spread her gospel of joyful medicine via blogs, seminars, and retreats for physicians. In addition, she has sought to draw attention to the alarming upsurge in physician suicides, which led her to being named a Medical Economics 2018 ChangeMaker in Medicine.

While acknowledging that most physicians don’t enjoy her degree of autonomy, Wible maintains there are steps doctors in larger practices, or those employed by hospital systems, can take to find joy in their work.

“They should read their statement from when they applied to medical school about why they wanted to be a doctor,” she says. “Or spend some time thinking about what brings them pleasure in their work.”

In addition, she notes, many doctors develop an affinity for treating certain diseases and/or classes of patients. “You can orient your practice no matter where you work to attract the subset of patients you really enjoy,” she says. “If you like working with women over 40 with fibromyalgia, you’ll have a lot more fun than if you spend your time treating men with bronchitis.

Wible thinks doctors can feel more positive about themselves, and their work, by looking for pleasurable incidents, however small, that occur during the course of a day.

“No matter how bad your day is there are usually moments of joy that sneak through that make you laugh or say ‘wow,’” she says. “We need to pause once in a while to think about those moments because even though we talk a lot about what we hate in our jobs, there are always things we love, too.”