The EHR Isn’t the Cause of Doctor Burnout; Alienation from the Patient Is - Cover

The EHR Isn’t the Cause of Doctor Burnout; Alienation from the Patient Is

There is a national narrative that electronic health records (EHRs) are causing doctor burnout and wrecking medicine. I am a 64-year-old orthopedic surgeon, and I have practiced medicine for over 30 years. My sons are doctors in training, and they recently asked me whether medicine was better before electronic health records. This is what I would tell them:

The Doctor’s Note and the EHR

In the 1990s, the federal government introduced evaluation and management coding guidelines. These rules were made as an attempt to control the unsustainable growth in national healthcare spending. The idea was that, by increasing the amount of documentation required for a doctor to get paid, less money would be spent. Documentation would prove that the doctor did the work and prevent the doctor from overcharging. The result was an arms race of increasing computer-generated documentation countered with growing regulatory requirements. Spending was not controlled. Insurance companies followed the government’s lead and expanded the documentation burden on the doctors.

Before the coding guidelines, a seasoned attending physician would study the patient, recognize the subtle physiological and social elements of the patient’s condition, and write a cogent note. After the imposition of the guidelines, physicians were forced to include a myriad of required data points, thereby making the note longer and harder to read. The longer note did not always serve better patient care and could obscure critical clinical thinking. A student’s note is known for its length, completeness, and lack of clinical insight. A detailed student note reflects the effort to teach a young mind not to forget all of the elements that must be considered when assessing a patient.

When I was a doctor in training, nobody read the students’ notes to fully understand what was wrong with a patient and how he or she should be treated. The next person to care for the patient would read the more concise and pertinent note from the attending physician and seek any supporting data as needed. Coding guidelines set a precedent that the purpose of the doctor’s note was as much about complying with regulations and getting paid as it was for patient care.

When EHRs first came out, there was great enthusiasm for reducing paper and liberating doctors to concentrate on patients. In the pre-EHR days, I remember sitting in a chart room with a tall stack of paper charts to sign. I do not miss that experience! With the physical paperwork burden diminished, why then is there so much talk of doctor burnout? And why is the EHR considered a contributor?

Serving Compliance, Not the Patient

Good doctors want a good record, and they know that they have an obligation to create one. But, while there is potential for the time spent with the EHR during a patient visit to add value by orienting the doctor to the patient’s situation and history (including previous work done at outside medical venues), a lot of current electronic record-keeping serves regulatory compliance and billing imperatives. The specter of being found guilty of fraud when required elements are not included in the note becomes a distraction and a source of unsettling anxiety for the doctor trying to concentrate on a patient. 

Now our doctors are becoming sick themselves. By some estimates, burnout symptoms affect 40%–50% of practicing doctors. A current hypothesis is that the EHR is a significant cause of this doctor burnout. The EHR, in many respects, is a strawman for the burden of regulatory compliance. To get paid, doctors are increasingly distracted and diverted from the thing that they love, which is taking care of their patents.

Why is it that a doctor may feel discouraged after four hours in a routine contemporary clinic, yet the same doctor working 10 to 12 hours a day on a medical service trip is exhausted at the end of the day but filled with joy? It is because, in the service trip venue (often in an underserved area of the world), doctors are doing what they were born to do, and they feel that. They are allowed to concentrate on their patients and not so much on record keeping. Putting hard-won talents to work in the service of sick and injured patients makes the practice of medicine the most gratifying of endeavors. Leading a team to treat a patient and the patient’s resulting gratitude rewards doctors and gives them a restorative sense of purpose and personal agency. The doctor will be at his or her best when patient care and great teamwork in the service of the patient consume his or her attention.

Doctors are, by nature, strong and resilient. You want your doctor to be healthy and resilient. When asked to do more to care for their patients, most doctors will. And yet, we are learning that this talented group can be hurt, not so much by too much work, but by distraction and alienation from their patients. If at their core doctors did not care about their effectiveness in treating their patients, they would not suffer the existential pain of not being at their best. Doctors burn out because of what they expect of themselves and how well they perceive that they are doing.

Medicine is hard, and young doctors must learn to accept failing their patients sometimes. That is the hardest lesson young doctors must learn. The thing that gives strength to the doctors is the perspective they gain over time that they are helping most of their patients most of the time. After many years, good doctors realize that what really saves them is the innate human will to live, the incredible healing ability of the human body, and, most importantly, the grace of their patients. Alienation from their patients deprives doctors of the one thing that can sustain them. Doctors have emotional bank accounts, and when the withdrawals exceed the deposits, they go bankrupt—they burn out.

An EHR that Doctors Will Value

Having a personal interest in realizing the potential of the EHR for over 20 years, I now see a way forward. My organization is involved with the Arch Collaborative, which is studying provider satisfaction with EHRs.

Ideally, an EHR should quickly orient the doctor so that a patient knows that the doctor has some understanding of his or her situation. The EHR should teach the patient about what is wrong with them and what the doctor is recommending. It should give the doctor insights into the patient’s social situation if needed so that the chances of successful treatment increase. The EHR has the potential to do all of these things.

I believe that, by measuring the experiences of a large number of doctors, the teams that support them, and even that of the patients, the most effective elements and designs of a useful EHR can be identified and reliable workflows to gather needed data can be defined. The collaborative measuring of thousands of doctors’ EHR experience will, I believe, lead to the identification of guiding principles that EHR vendors can then incorporate into their products.

Collaboration Among Providers Can Lead to Solutions

I would tell my sons that I am hopeful. I think the government regulators and health care payers can adjust the burden that has been hurting our doctors. In my opinion, the government should lead—decisively and soon. I also think that, by collaborating with thousands of providers across many institutions and countries, we will develop an improved understanding of what an EHR should do and how it fits into the interaction between the doctor and the patient. I believe that the process of gathering data, orienting the provider, teaching the patient, and managing effective care with an EHR can be improved to the point that its usefulness becomes akin to something as appreciated as indoor plumbing.

I hope that our increasing awareness of physician burnout will cause us to think critically about the genesis of this malady. I hope that we successfully refine technology to enhance the practice of medicine, adjust the burden of regulation, and prioritize the doctor’s relationship with the patient to improve the well being of our doctors and their patients. I think all of these things are possible.

     Photo cred: Adobe Stock, Robert Kneschke