Raising The White Flag

It’s become clear that the new imperative is to find novel ways to support practices with top-of-licensure tactics and provide effective decision-support tools that make every member of the care team more efficient.

Faced with Complexity and Resource Constraints, Physicians are Raising the White Flag.

When I began my practice, managing patients with chronic conditions such as heart disease was relatively straightforward. A patient with heart failure, for example, was invariably taking digoxin, furosemide and potassium chloride, and management consisted primarily of periodic titration of those agents. In contrast, the same patient today is a candidate for several drug categories, each of which offers survival advantages. That same patient may also be a candidate for other interventions such as implantable defibrillators and cardiac resynchronization therapy that have been demonstrated to effectively address symptoms, reduce hospitalizations and increase overall life expectancy.

These advances in treatment options are good news for patients, but there’s a flip side and it’s driving physicians to raise the white flag.

As care options increase, MDs need more time to analyze each patient’s unique needs and decide on an appropriate approach. Once a diagnosis is made and a course of treatment has been prescribed, each therapy requires professional monitoring. Even patients who feel well require more visits and more complex care than they did in the past. Aging patient panels, often burdened by multiple chronic conditions and medications, further increase the need for closer monitoring and more complex care. Physicians are struggling to capture all the information that’s relevant to the patient’s visit as quickly as possible so they can spend their time where it will matter most, but it’s not easy.

It’s not surprising, then, that physicians are moving toward longer patient visits. What were traditionally 15-minute patient intervals are now commonly lengthened to 20 or even 30 minutes. That carries implications at both the personal and population levels. Without additional hours in a day, physicians simply can’t see as many patients, which in a fee-for-service world impacts their compensation. It also increases the number of physicians needed to care for the population as a whole.

All of these changes are adding new challenges on the front lines as we try to balance quality of patient care with the quality of physicians’ professional lives. So we look for ways to innovate.

Many practices are considering new approaches to help manage the burden, such as adding physician’s assistants (PAs) and nurse practitioners (NPs). Certainly, there are advantages to having multiple levels of care providers who are each practicing at the top of his or her licensure, but the reality doesn’t always play out as well as the concept, and results can be mixed. Many patients still want to see their physician, even for a visit that a PA or NP could manage effectively. In some cases, patient visits with a PA/NP might actually take longer than a physician visit because these providers don’t have the same level of training so may not be as efficient.

While there are still challenges to overcome, the concept has merit if it allows physicians to spend more time with complex patients, while patients with simpler needs can be treated by other practitioners for some or all of their visits.

In a similar vein, new options such as convenience care, telehealth and virtual care are architecting new channels to the consumer that expand the reach of care. For a slice of the population that is generally healthy and may simply need care for a single episode such as a sprain or one-time illness, these advances can help reduce pressure on physicians. For other segments of the patient population, though, convenience care doesn’t effectively support their needs for consistent, ongoing monitoring. What’s worse, we’re counting on those patients to figure out which segment they fall into.

The proliferation of these new treatment approaches can be seen as symptomatic of a healthcare system that has been stretched too far. In fact, a recent report suggests that MDs with panels of 2,500 patients need about 22 hours per day if they follow guidelines related to preventive care and chronic disease management1, along with performing routine tasks. One consequence? Doctors are burning out.

According to a 2011 study published in the Archives of Internal Medicine, burnout affects an estimated 25% to 60% of all physicians2. In addition, a study published in Academic Medicine found that approximately 15% to 20% of physicians will personally suffer from mental health problems at some point in their careers3.

As physicians burn out, they tend to retire early. That exacerbates the shortage already projected by the Association of American Medical Colleges (AAMC), which says that the U.S. will face a shortage of between 46,000 and 90,000 physicians by 20254. To respond to this impending shortfall, AAMC emphasizes the importance of continuing to innovate and be more efficient in the way care is delivered.

It’s become clear that the new imperative is to find novel ways to support practices with top-of-licensure tactics and provide effective decision-support tools that make every member of the care team more efficient.

Because surrender simply isn’t an option.

1 Ann Fam Med September/October 2012 vol. 10 no. 5 396-400

2 Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population

Arch Intern Med. 2012;172(18):1377-1385. http://archinte.jamanetwork.com/article.aspx?articleid=1351351

3 Bucking Burnout: Cultivating Resilience in Today’s Physicians,


4 New Physician Workforce Projections Show the Doctor Shortage Remains Significant


J. Siemienczuk, MD