Introducing a new metric for determining clinicians' scheduled patient hours
A long-time challenge for clinical administrators and a vexing issue for physicians in an outpatient-oriented specialty (e.g., peds, internal medicine, and the various medical subspecialties) is what is an appropriate number of hours to be scheduled to see patients if one is considered a "full-time" clinician.
Over the years I've seen (and used) many different approaches -- the number of clinic sessions (generally, 4 hours per session), number of patients per day, a fixed number of scheduled hours -- but none of them have seemed sufficiently precise; or, for that matter, viewed as consistently "fair" due to differences in type of setting, patient population, and specialty. One size does not fit all.
The advent of the EHR brought with it resultant benefits: a single, searchable repository of patients' current and historical clinical data. The EHR also had tremendous downsides: clinicians having to essentially become data-entry clerks, having to hunt in multiple spots to find pertinent clinical data, dealing with a rising tide of in-basket management and burgeoning post-clinic "pajama time". In brief, the centrality of the EHR to clinical practice has only added to the challenge of arriving at a reasonably objective basis for determining what should constitute a 40-hour patient schedule for an ambulatory practitioner.
Now comes Christine Sinsky, MD et al with an evidenced-based methodology, the PSH40 (patient scheduled hours per 40-hour week). Writing in the October 16 issue of the Journal of the American Medical Informatics Association (https://doi.org/10.1093/jamia/ocae266), the AMA's Dr. Sinsky and her colleagues used Epic's Signal data log to study 186,188 ambulatory physicians across 395 organizations from November 2021 through April 2022 stratified by specialty. Not surprisingly, the research team found there were differences based on specialty and institutional setting, when comparing academic and non-academic settings as well as safety-net and non-safety-net organizations.
There are multiple benefits that should flow from the advent of the new specialty-specific PSH40 metric; for example, arriving at patient scheduled hours that are objectively evidenced-based and more likely to be viewed as "fair". It will also give clinic managers greater insight into how potential changes in support staffing might affect physician productivity and clinic operations. Additional research may further refine the data including removing possible artifacts/limitations in vendor-based data logs. But perhaps the biggest benefit of moving to PSH40 is potentiating greater work-life balance and, by extension, less burnout for physicians. Here's an excerpt from the article that speaks to this latter point:
Why do workload and work hours matter? Work overload is associated with negative outcomes for individuals. Working more than 55 hours per week is associated with higher rates of heart disease and stroke among the general population.23–25 In addition, working more than 52 hours per week for 10 years is associated with poor self-reported general health (28% higher relative risk), cardiovascular disease (42% higher relative risk), and cancer (2% higher relative risk) compared with those working 35-51 hours per week.26
Longer physician work hours are associated with higher rates of burnout,12,13,27,28 which in turn is correlated with higher rates of divorce29 and disease.30–32 Physician burnout also impacts organizational goals, with lower rates of patient satisfaction,33,34 quality and safety35,36 and higher rates of medical errors,37–39 physician turnover33,40,41 and costs of care.42,43 Given the current physician shortage in the United States,11,44 long work hours and the resultant burnout and turnover are a long-term threat to physician workforce capacity and retention.
There's yet another benefit that is of particular interest to my colleague Paul DeChant, MD, MBA, and me. Readers of this blog are likely already familiar with Maslach and Leiter's 6 drivers of burnout:
1) Work overload
2) Insufficient control
3) Lack of recognition or reward
4) Breakdown in or an absence of a sense of community
5) Perceived unfairness
6) Conflicting values (between the clinician and their employer)
Clinic administrators and health system executives who appreciate the importance of using an objective, evidenced-based method for determining a 40-hour patient scheduled week are likely to have more engaged and aligned clinicians. Those who fail to appreciate this will likely find that they are -- however unintentionally -- tripping at least 4 and perhaps 5 or even all 6 of the drivers referenced above and further exacerbating the clinician-executive schism that exists in far too many hospitals, clinics, and health systems.
Solutions for Hospitals, Health Systems, and Medical Group Practices: Leadership-Driven Changes
The locus for curing clinician burnout and staffing shortages runs through the C-suite. Here are examples of leadership-driven changes to the workplace that my colleague Paul DeChant, MD, MBA and I often recommend:
> Regard clinicians as knowledge workers who are given significant latitude to make clinical decisions without unnecessary administrative encumbrances or delays
> Consistently apply one or more of the improvement sciences (Lean, Six Sigma, operations research, agile, design thinking) in consultation with front-line staff to improve workflow and reduce delays, waste, inefficiency, and job skill mismatches
> Expect all leaders, but especially senior executives, to do periodic job shadowing of front-line staff (where observing and deep listening are emphasized) in lieu of "rounding" (a largely ineffectual, if widely practiced activity)
> Create and require leader standard work (LSW).
> Develop and deploy a sophisticated, deeply ingrained, and rigorous daily management system (DMS) supported by visual display boards or monitors
> Judiciously invest in AI/ML solutions -- selected, tested, and endorsed by front-line staff -- that eliminate or at least markedly reduce data entry, administrative requirements, and/or repetitive tasks that are non-value add
> Support near-continuous optimization and remediation of the EHR (there's no such thing as "it's all set")
> Get rid of superfluous or outdated policies, procedures, redundant approvals, and other stupid stuff (GROSS)
Ready to transform your hospital or workplace?
Are you frustrated by adversarial relationships between front-line clinicians and senior leadership? Organizational Wellbeing Solutions was formed to enable senior leaders to identify the specific drivers of clinician burnout in their organization; and to support leaders in designing and executing a comprehensive plan to stop clinician burnout, increase retention, and improve operating results. A hallmark of our consultancy is correcting the all-too-frequent distrust and alienation Clinicians feel toward the C-Suite generally and the CEO in particular. Let us help you help your organization and its clinicians develop a more trusting, aligned, and productive working relationship.
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