Physician Wellness & Burnout

A lot of attention is being directed towards Physician Wellness, and its opposing condition, Physician Burnout.  And with good reason: evidence is mounting that highly stressed physicians may not provide high quality patient care.  Physicians with burnout are more likely to self-report medical errors, have lower empathy scores, and have higher job dissatisfaction, which in turn results in lower patient satisfaction and a lower likelihood that patients will follow treatment recommendations.  As we begin to understand the etiology and consequences of burnout, it becomes even more important to pursue prevention strategies.

Resilience is the burnout antidote.  Three general themes arise when examining what determines resilience among physicians.  First, there are job-related sources of gratification: finding meaning in relationships with patients and success in practice, in terms of efficacy (diagnostic, therapeutic, etc.).  Second, there are practices or routines that physicians use to counteract stress, which include engaging in leisure-time activities, professional development, establishing boundaries between work and life and ensuring time with family and friends, and self-reflection, to name a few.  Third, there is the adoption of certain attitudes, such as acceptance or realism (not engaging in wishful thinking), self-awareness, and recognition of when change is needed.  I mentioned in a previous post that the ACP Board of Governors is pursuing a theme of “Restoring the Narrative”.  This relates to the first theme, finding meaning in practice.

You might also remember that I distributed a questionnaire to explore some of these themes and the sources of burnout that you encounter.  We will be reviewing the results of the survey at the Annual Chapter Meeting on October 30, so I hope you will be there!

Notably, ACP has established a new criterion for the Chapter Excellence Award: “the chapter has a practice satisfaction and/or physician wellness program which may include programs that promote resilience and practice efficiencies.”  The Connecticut Chapter is developing a Physician Wellness Committee, and we are interested in your ideas about what form this might take.  If you want to be involved with the committee, let me know!

Last, I refer you to the work of Drs. Christine Sinsky and Mark Linzer, who have been pioneers in this area:  Christine Sinsky, In Search of Joy in Practice; Mark Linzer, Epidemic of Physician Burnout presentation.  For those of you in the New Haven area, look for Dr. Sinsky to appear at Yale Medical Grand Rounds the first week in October.





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ICD-10 is coming…

As I write this, the ICD-10 Countdown Clock on the CMS website reads 54 Days, 14 Hours, 22 Minutes, and 13 Seconds (no, 8 Seconds, 5…). The fact that this clock exists gives you some idea of the import of this transition and the anxiety it is provoking. ICD-10 refers to the International Classification of Disease, tenth edition, published by the World Health Organization (WHO). ICD-9 has been in use since January, 1979. WHO started work on ICD-10 in 1983, but did not finish until 1992. Other countries started implementing it in the late ‘90s. In fact, the United States is one of the few developed countries that has not yet made the transition. We made the change from ICD-9 for coding and classifying mortality data from death certificates in 1999. The Department of Health and Human Services proposed in 2008 that we begin using ICD-10-CM, the Clinical Modification and ICD-10-PCS, the Procedural Coding System, for reporting. The recommendation became rule with an implementation date of October 2013. That got pushed back twice, and now we are finally staring down the drop-dead date of October 1, 2015.

Hopefully, your preparations to manage the transition are well underway. If not, CMS suggests the following steps: talk with your practice management vendor; be sure systems have been upgraded to the 5010 standards; discuss implementation with billing services and payers, including discussing with payers if contracts are affected; identify necessary changes in workflow and address staff training needs; conduct test transactions in advance of the October 1 deadline to be sure they are successfully received.  [CMS ICD-10 Basics]

ACP provides resources to address the ICD-10 transition: check them out here.


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Chapter Member Spotlight: Chris Sankey

Here is another installment in our continuing series highlighting Connecticut Chapter members who have been involved with ACP at the national level. Christopher B. Sankey, MD, FACP is an Assistant Professor of Medicine and academic hospitalist at Yale University. He is the Physician Editor for The Brief Case, a clinical vignette series that appears in ACP Hospitalist.  Dr. Sankey writes:

“One of my greatest clinical interests to date has been the development of clinical vignettes and mentorship of students and residents in this process. In true “friend-of-a-friend” fashion, I discovered that ACP Hospitalist was looking to develop a section in their publication devoted to clinical vignettes. In speaking with Jamie Newman at Mayo, we decided to have me helm this new section, entitled “The Brief Case”. The Brief Case comes out in ACPH every other month, and typically features an “installment” (5-6 cases) from a medical center or hospitalist group (usually an academic center), along with an individually-submitted case (usually a community-based provider). The goal of the Brief Case is to give clinical pearls that are relevant to the practicing inpatient provider.

The Brief Case has been a great success. We have had a tremendous interest from institutions and individuals alike; the volume became so substantial that I enlisted the assistance of recent Yale IM grad and current Montefiore Hospitalist Jamie Galen to be my deputy editor.”

Dr. Sankey will be featured at our Annual Chapter Meeting on October 30; he will be presenting a workshop called “Case Writing for the Busy Clinician: Opportunities and Obstacles.”  This interactive workshop will provide “hands-on” experience. Activities will be aimed at all levels of training and prior experience with case writing. The goals of the workshop are to identify essential elements of a case, overcome common obstacles, identify the appropriate type and venue for submission, and assist attendees in the preparation of an outline of a draft for submission. Dr. Sankey will share his own experience, ranging from how he published his first clinical vignette to his experiences as an editor, in order to guide participants on a relevant, practical path towards a successful case write-up and submission. Pearls will be highlighted to help improve the likelihood of a fruitful submission.

The latest installment of The Brief Case can be seen in the July issue of ACP Hospitalist.

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Restoring the Narrative

This year, the Board of Governors is taking up the theme of “Restoring the Narrative” to medical note-writing. I think most of us recognize adoption of the EHR as a factor accelerating the loss of narrative, although this process was already well underway. In fact, the time pressures placed on clinicians have probably done as much, or more, to erode the narrative from the medical record. But templated EHR documentation, with its discrete inputs and generic presentation, has effectively buried the narrative. If we hope to improve patient care through better communication, restoring narrative will be an important factor. Eliminating extraneous content to truly achieve EHR use that is meaningful (as opposed to Meaningful Use) should be an objective worth striving for.

A related theme is that of the patient’s voice. In addition to the factors mentioned above, the rise of data has also inadvertently minimized the patient’s voice in construction of the medical history. As Bradby et al state: “There is no suggestion that medical professionals intend to disregard patients’ narratives or to deem them inadmissible to clinical decision-making, particularly given that medical students continue to be taught to listen to their patients. Rather, the epistemology of epidemiologically-informed, statistically significant evidence that underpins the interpretation of results from tests and assays trumps the nature of patients’ stories as a form of knowledge at almost every turn.”(1)

Every day, we encounter and try to reconstruct patient stories. Communicating these stories in a manner that is more pertinent and relevant will lead to better patient care. I welcome your comments about “Restoring the Narrative”!

1) Bradby H, Hargreaves J, Robson M. Story in health and social care. Health Care Anal. 2009 Dec;17(4):331-44.

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Supreme Court Upholds Subsidies in King v. Burwell Ruling

On Thursday, the Supreme Court handed down its long-awaited ruling in the King v. Burwell case.  At issue was whether or not the IRS could continue to extend tax-credit subsidies for health coverage purchased through exchanges established by the federal government under the Patient Protection and Affordable Care Act (because the legislation specified state-run exchanges only).  Had the Court ruled the other way, the ACA would have been seriously threatened, as 34 states have federally-run exchanges.  Connecticut would not have been affected directly, because we have a state-run health insurance marketplace.  But nationwide, over 6 million people would have lost tax credits in excess of 1.7 million dollars; on average across these states, premiums would have climbed close to 3-fold.

The legal decision, with Chief Justice Roberts writing for the 6-3 majority, turned on semantics and interpretation of the language of the ACA.  What did Congress intend?  Would they really want to withhold subsidies where states refused to set up their own exchanges, and federal marketplaces were required?  To what end – to punish the states?  The plaintiffs had an implausible story: that Congress intended only state exchanges, not a federal exchange, to receive subsidies in an effort to strong-arm the states into creating them.   The minority objectors (Scalia, Alito, Thomas) derided the loss of the meaning of language in a shrill response:  “Words no longer have meaning,” Scalia wrote, “if an Exchange that is not established by a State is ‘established by the State’.”  Justice Scalia would look to abandon common sense, as if Congress meant to undo everything the law was established to create in the first place, if only someone could find a linguistic technicality and bring it to light.

Thankfully, common sense prevailed on Thursday.

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IM 2015 – ACP’s Centennial

ACP just concluded its annual meeting and it was outstanding!  First, it was great to see so many CT Chapter members at the meeting.  It is a particular treat, for a program director, to see former trainees who are thriving in their practices and lives.  The annual meeting serves as a great opportunity for impromptu reunions.

The scientific offerings were superb.  The quality of the all of the sessions I attended was high; I learned about a wide variety of topics from medical care of the pregnant patient to health IT to medical history.  As always, the Thieves’ Market was very entertaining.  The annual meeting also provides an opportunity to get involved; next year, consider volunteering to review resident or student abstracts before the meeting or serve as a poster judge during the meeting – this can be very rewarding!  I had the chance to provide judging for one of the Doctors’ Dilemma rounds this year.  There was tense action with young women and men displaying very impressive rapid recall of knowledge.  Our CT Chapter champions, Yale University, fought valiantly but bowed out in the first round.

The Centennial Celebration also provided the opportunity to look back at what some very talented and dedicated internal medicine physicians have helped accomplish in advancing the state of the science and policy of health care.  We have the obligation to continue that work and push internal medicine further across the next century!

Congratulations to our marching Fellows: Francis Amoo, Steven Angelo, Catherine Arnold, Patrick Asiedu, Michael Ayepah, Pia Dogbey, Sujata Kale, Joseph Kittah, Sherry Kroll, Elizabeth Ofori-Mante, Onyema Ogbuagu, Olubunmi Otolorin, Lynne Savino, Alfred Vichot and Benjamin Yeboah.

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Introducing Chapter Members on National Committees: Julie Rosenbaum

As I have mentioned before, we have several members serving on national committees for the College, and I wanted to introduce you to what they are up to.  Julie Rosenbaum, MD, FACP, who is a faculty member of the Yale-New Haven Medical Center (Primary Care) Program, sits on the ACP Ethics, Professionalism, and Human Rights Committee.  Dr. Rosenbaum writes:

“Since April of 2014, I have had the honor of serving on the APC Ethics, Professionalism, and Human Rights Committee (EPHRC). Because of my long standing interest in medical ethics, I had often read the statements from this committee in Annals of Internal Medicine over the years. These have included such topics as online professionalism, physician-assisted suicide, and physician-industry relations. This is the committee which updates the American College of Physicians Ethics Manual, which is currently in its Sixth Edition.

The official charge of the committee is “to formulate principles and policies in ethics, professionalism, and human rights for the Board of Regents, uphold high ethical standards in medicine, and advise ACP’s Ethics and Professionalism staff.” The committee includes a Chair, who is a Regent of ACP, a Vice-Chair, who is a Governor and 10 additional members who include at least one Regent, at least one Governor, one Resident/Fellow member, one Medical Student, and one Early Career Physician member. Members are appointed for one year terms, renewable up to three times, and therefore a total term of four years. The Committee meets in Philadelphia two times a year, usually once in June and once in the fall. There is often a separate committee conference call in February and a brief meeting during the ACP Annual meeting.

The meetings occur in the Boardroom of ACP and are supported by an outstanding staff, led by Lois Snyder Sulmasy, JD, who is an expert in clinical ethics and health policy. Lois has been at ACP for several years and has incredible institutional memory and understanding of how the EPHRC works with other committees and supports the efforts of ACP generally.

During recent meetings, the committee has considered how to formulate ACP recommendations regarding direct payment practices with the Medical Practice and Quality Committee. We have discussed the novel ethical implications of electronic health record in conjunction with the Medical Informatics Committee. At each meeting, we receive updates from the Board of Governors and Board of Regents, whether about the recent Maintenance of Certification controversy or resolutions on how to disseminate information on gun safety to members of the ACP.

Participating in this committee has given me a new appreciation for the efforts of the ACP to advocate on behalf of physicians and our patients, and how a large organization works to advance its mission and uphold its standards. The meetings themselves are fascinating opportunities to consider the ethical issues of our day with like-minded colleagues from around the country, examine multiple aspects of difficult issues, and formulate clear responses and positions for ACP. I will have the honor of helping to present the Update in Ethics Issues at the ACP Annual Meeting in Boston in April. Hope to see you there!”

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