Burnout happens when humans are pushed beyond reasonable expectations to perform in an environment that requires perfection. A person or group can experience professional and personal burnout anywhere, at any time. Processes that pose unnecessary mental clutter within a working environment have burdensome consequences no matter who you are. In the healthcare universe, physician burnout has been a concern long before the pandemic started in 2020. Physicians complained of onerous electronic health record (EHR) software, the perpetual increase of documentation and paperwork demands, and too many patients to care for with too little time. With the onset of COVID-19, fewer clinicians were responsible for more acutely ill patients than ever before. While staffing issues have not improved much, there have been attempts to simplify documentation requirements and improve EHR usability. An area contributing to clinician unhappiness that is still ripe for intervention is the removal of outdated or unnecessary patient care.
A recent study found that on average, “[t]he mean time required for a [primary care physician (PCP)] to provide guideline-recommended preventive, chronic disease and acute care” to a typical panel of patients was 26.7 hours per day. That was not a typo. The average PCP would need more hours than there are in a day to treat their patients in the clinic properly. The researchers estimate that preventive care alone would take 14.1 hours per day. While team-based approaches to care would help, following every prevention-based guideline is still not tenable.
Despite the unbelievable numbers referenced above, these overwhelming data do not account for all care provided by physicians. The authors only performed calculations on care that is “guideline-recommended.” What about those clinical actions performed despite the lack of evidence-based effectiveness? There are still a vast number of treatments, lab tests, and imaging studies that have not been proven to be effective, or even worse, have been shown to be potentially dangerous. For example, the American College of Cardiology recommends that physicians “[a]void performing electrocardiography (ECG) screening as part of preoperative cardiovascular risk assessment in asymptomatic patients scheduled for low-risk non-cardiac surgery.” Yet, this is still a frequent test ordered as part of routine preoperative evaluation. These ECG orders can lead to unnecessary work, increased costs, and even patient harm, as all abnormal results will likely be followed up with more tests and physician visits.
This superfluous and potentially problematic care is so concerning that prominent clinical groups such as the American Academy of Pediatrics and the American College of Physicians created an initiative called Choosing Wisely®. Their website is a one-stop shop listing hundreds of medically unnecessary tests, treatments, and procedures that physicians should consider before recommending. To be clear, no one is saying that ECGs, for example, should never be ordered. Instead, the suggestion is that routine ECGs should not be ordered before every surgery, but only when clinically indicated.
Ordering fewer tests and performing fewer procedures will surely move us toward less physician burnout. However, many other parts of clinical practice are worthy of decluttering. For instance, some compliance folks have interpreted federal and state regulations in a way that minimizes flexibility and maximizes repetitive actions and requirements of practicing clinicians. Do physicians need to write an order for an ear wash or pulse oximetry? Must doctors attest to privacy policies every day or even every week? The American Medical Association (AMA) has produced an excellent guide that notes that “[i]n an effort to reduce unintended burdens for clinicians, health system leaders can consider de-implementing processes or requirements that add little or no value to patients and their care teams.”
The AMA understandably has a lot to say about EHRs and other technology. Passwords should not need to be reset frequently, auto-logouts should be customized to the user and location to minimize interruption while acknowledging security needs, and inbox notifications should be reduced to exclusively matters that only a physician can handle. Oh, and reduce clicks and hard stops; let’s not forget those oldies but goodies!
It is important to call out the title of the referenced AMA toolset: “De-implementation checklist.” The word de-implementation is becoming more popular in both scientific literature and mainstream media. Based on our experience in trying to convince physicians to stop offering outdated or unproven treatments and tests, we now realize that simply informing people that steps or procedures they have been doing for years are unnecessary will not move the needle. Instead, we must actively work to undo their muscle memory and outdated training.
De-implementation should be considered the same way we plan and study the implementation of new technologies or recommendations. There are proven methodologies and techniques to start a complex set of actions for a given group of people. We now must develop the same methodologies and techniques to stop those actions. In my next blog post, I will explore how the science of de-implementation is advancing and how we should evaluate its success (or lack thereof).