Hassles and Happiness

Survey Finds Keys to Physician Angst, Satisfaction

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Cover Story — January 2014

Tex Med. 2014;110(1):14-20. 

By Crystal Zuzek
Associate Editor

In a perfect world, physicians could devote ample time to providing quality care to every patient in an environment free of regulatory and administrative hassles. During office visits, they could talk directly to patients without the intrusion of electronic health records (EHRs), and they could fully focus their attention on practicing medicine in their patients' best interest.

Regrettably, the current health care landscape is far from perfect. Physicians have long voiced concern about the state of medical practice and made no secret of their growing discontent with government mandates and insurance regulations. Now they have scientifically valid data to support their dissatisfaction.

The American Medical Association sponsored a yearlong RAND Corp. study of physician professional satisfaction ending in September 2013. The study, "Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy," highlights information gathered from 30 physician practices in Texas, Colorado, Massachusetts, North Carolina, Washington, and Wisconsin. 

Last year, AMA convened an advisory committee of representatives from government, academia, medical practice, and business to discuss the research project, its design, and its implementation. 

The study emphasizes the importance of delivering quality care in determining physician satisfaction. 

"To put it simply, if physicians feel they're giving high-quality care to their patients, they have a high level of satisfaction. We've always known this, but the study shows quality care is tied to physicians' ability to have a stake in practice management and business decisions, to the practice's economic sustainability, to professional collegiality and respect, and to a personal rapport with patients," said Texas Medical Association President Stephen L. Brotherton, MD.

In Texas, RAND chose family physicians practicing at Parkway Primary Care near Austin to participate in the study. RAND researchers visited Parkway's two Pflugerville clinics last spring and interviewed practice owner Shane Keller, MD, and his partners, Tina Philip, DO, and Travis Bias, DO, about factors that influence their professional satisfaction.

Dr. Philip primarily discussed professional autonomy with the researchers. She says she chose a small, physician-owned practice because it allows her to set her own schedule and practice medicine the way she desires. "I do not feel micromanaged or that I have to adhere to practice guidelines I do not agree with."

Instead, her frustrations stem from administrative and financial burdens insurance companies place on physicians.

"The rules and regulations of insurance … severely limit and control the way I practice medicine. Often, these regulations interfere with my ability to provide what I feel is quality care for my patients. Obtaining approvals for imaging studies or prior authorizations for medications is an inefficient use of time for me and my office staff and further delays care for the patient," she said.

The irritations Dr. Philip cites surfaced in the RAND study. The physicians surveyed commonly expressed dissatisfaction when payers hindered the quality of care they provided, due either to not covering medically necessary services or to preauthorization requirements.

"Ultimately, most physicians went into medicine to care for patients. When there are so many roadblocks in the way of rules, regulations, and what amounts to busy work, it gets in the way of physicians providing care to their patients, which is what all of us would rather spend our time doing," Dr. Philip said.

EHRs emerged as a prime source of stress and dissatisfaction among physicians who participated in the study. Dr. Philip, like many physicians, recognizes the potential of EHRs to improve patient care, but says they increase physicians' workload and drive a wedge between them and patients. 

Dr. Brotherton says the RAND study unveils a pervasive feeling of resentment among physicians. 

"Physicians undergo years of extensive training and education only to be relegated to the level of a clerk. The study tells us physicians are spending way too much time inputting data in EHRs, dealing with insurance company hassles, and handling other administrative duties." 

The beauty of the RAND study is that it's physician-centered and presents an objective examination of real-world problems practices currently face, Dr. Bias says. 

"Adequately addressing the problems detailed in the report will result in happier physicians and patients. Organized medicine can use the information from the study to focus on advocacy efforts and policy development that could reduce early retirement and burnout among physicians," he said.

AMA plans to develop resources to help physicians improve practice effectiveness, efficiency, sustainability, and professional satisfaction by using study findings and input from other sources, including its members and experts in physician practice design. 

Canary in the Coal Mine

F. Jay Crosson, MD, vice president of the AMA's Division of Professional Satisfaction, Care Delivery and Payment, was an architect of the study.

"AMA wanted to have an in-depth, scientifically robust analysis done to reveal the exact sources of physicians' unhappiness so that the organization can develop solutions that foster professional fulfillment while promoting economically sustainable practice models," Dr. Crosson said.

Practices participating in the study first completed a questionnaire assessing their organizational structure, EHR use and capabilities, and participation in innovative payment models. RAND researchers then interviewed 220 participants (108 practicing physicians and 112 practice leaders and clinical staff) in person. They sent a final survey to 656 physicians in all 30 practices and received 447 responses. 

RAND analyzed information collected on the dimensions of professional satisfaction and factors that might influence professional satisfaction. 

Joseph P. Annis, MD, of Austin, a member of the AMA Board of Trustees, says the study indicates politics, profits, and economics propel physician dissatisfaction.

"Physician dissatisfaction could be the canary in the coal mine regarding quality of care. It would behoove hospitals, payers, and EHR vendors to work to eliminate unnecessary hassles that contribute to dissatisfaction among physicians," Dr. Annis said. 

Susan Rudd Bailey, MD, of Fort Worth, vice speaker of the AMA House of Delegates and a past TMA president, says the study's findings show that "medical practices need help now. I believe this first-of-its-kind study on satisfaction provides hard data that will help jump-start efforts to solve the problems identified."

The study concludes that:  

  • Physician practices need resources for internal improvement.
  • As physician practices affiliate with large hospitals and health systems, paying attention to professional satisfaction may improve patient care and health system sustainability.
  • When implementing new payment methodologies, the predictability and perceived fairness of physician incomes will affect professional satisfaction.
  • Better EHR usability should be an industry-wide priority and a precondition for EHR certification.
  • Reducing the cumulative burden of rules and regulations may improve professional satisfaction and enhance physicians' ability to focus on patient care. 

Armed with sound data, AMA can work with EHR vendors, government leaders, and other stakeholders to help physicians overcome obstacles to providing quality patient care, Dr. Bailey says. 

In addition to AMA, specialty societies, TMA, and county medical societies work to defend the patient-physician relationship. Dr. Annis encourages Texas physicians to support these and other organizations that protect physicians and the practice of medicine.  

Under Pressure

RAND selected a variety of practice sizes and ownership models for the study and included single subspecialty, primary care, and multispecialty practices. Dr. Bias thinks researchers chose Parkway Primary Care because it's a small, privately owned primary care group, a setup he says is becoming a rarity. In fact, the study found that leaders of smaller, independent practices describe feeling pressure to join larger systems, sensing that it may become more difficult in the future to remain independent from these systems as a consequence of health system reform.

Dr. Bias affirms that concern, worrying the personal touch patients relish from practices like Parkway Primary Care may one day disappear as economic pressure to join larger entities mounts. 

"Our patients enjoy the one-on-one attention they get from our group, and we enjoy the autonomy and control involved in being part of a small practice. But administrative and regulatory hassles combined with growing patient volumes threaten the viability of setups like ours," he said.

Dr. Keller says small groups are on shaky ground, especially when factoring in the economic uncertainty posed by health system reform.

"Most issues in our small practice revolve around appropriate distribution of resources and staff due to increasing requirements on our practice. Meaningful use, Physician Quality Reporting System requirements, and the Patient-Centered Medical Home model are all concepts primary care physicians have always tried to implement in our daily practice. The overall concepts of data gathering certainly will help our patients, but it is difficult to carry out completely at times due to the lack of resources," he said.

Parkway Primary Care's small size also makes it difficult to effectively negotiate higher payment rates with insurance companies, Dr. Keller says.

Still, doctors in physician-owned practices or partnerships are more likely to be satisfied than those in practices owned by hospitals or corporations, according to the study. TMA Practice Consulting offers help for physicians who wish to keep or open their own practices. To inquire about practice setup services, call (800) 523-8776, or e-mail TMA Practice Consulting

Other findings from the study include: 

  • Excessive productivity quotas and limits on time spent with each patient are major sources of physician dissatisfaction. The cumulative pressures associated with workload were described as a "treadmill" and as being "relentless," sentiments especially common among primary care physicians.
  • Physicians describe the cumulative burden of rules and regulations as overwhelming, draining time and resources from patient care.  

It's important to note the indicators of professional satisfaction that emerge from the study, Dr. Annis adds.

"Time with patients, influence over the practice environment, and a stable revenue stream make physicians happy. The study also indicated that physicians still experience moments of joy when interacting with their patients," he said.

Perceptions of collegiality, fairness, and respect are key factors affecting physician professional satisfaction. Within the practices RAND studied, frequent meetings with other doctors and other health professionals fostered greater collegiality and satisfaction. Researchers say physicians report being more satisfied when their practices give them more autonomy in structuring clinical activities, as well as more control over the pace and content of patient care. 

Texas physicians mostly agree with the opinions in the AMA survey, but they have somewhat different concerns. Every two years, TMA surveys Texas physicians to identify emerging issues and develop data to support advocacy efforts. Each month throughout 2012, TMA emailed a portion of the survey, including questions related to professional satisfaction, to physician and resident members and nonmembers. 

Respondents to TMA's survey say the biggest concerns for Texas physicians are ensuring economic viability of their practices and maintaining adequate payment — particularly from Medicare — to cover rising practice costs. Dr. Bias, who currently accepts new Medicare patients, says he shares his Texas colleagues' unease. 

"Small private practices lack the volume of providers and revenue streams to weather financial storms. Improving payment from private and government payers would help us gain the resources we need to survive and would improve physician professional satisfaction and patient care," he said. 

TMA offers tools and services to help physicians survive and thrive in the current health care landscape. TMA plans to launch its Physician Services Organization (PSO) early this year. The PSO will arm practices with the strategies and services they need to succeed in an accountable care environment, while remaining independent if they so choose. (Read "Most Valuable Players.")  

Cumbersome, Costly EHRs

The RAND study found physicians feel current EHR technology interferes with face-to-face discussions with patients, requires them to spend too much time performing clerical work, and degrades the accuracy of medical records by encouraging template-generated notes. They also worry that the technology costs more than expected and that different types of EHRs cannot "talk" to each other, preventing the sharing of critical patient medical information when needed. 

Efforts are under way to improve information sharing across different systems through health information exchanges (HIEs). For more information on the progress of HIEs in Texas, visit the TMA website, and read "Vital Connections: HIEs Improve Patient Care" (October 2012 Texas Medicine).

"In virtually every practice, physicians had significant issues with EHRs. There seemed to be an overall sentiment that EHRs may have the potential to help physicians take care of patients, but they also require physicians to spend a lot of time accessing and entering patient information," Dr. Crosson said. 

Texas physicians have their own stories about EHR hassles.

David Fleeger, MD, an Austin colorectal surgeon and a member of the TMA Board of Trustees, is one of eight surgeons in a subspecialty group that implemented an EHR in 2010. His group spent six months to a year customizing EHR templates to apply to the practice and conform to physicians' workflow.

"We used to pay for dictation services. We eliminated that cost, but now we spend more time every day completing our charts," he said.

Abilene family physician Allen Schultz, MD, treats a wide range of diseases, many of which are easy to recognize but some of which are subtle. He worries that constantly evolving technology and regularly scheduled EHR software upgrades may have unintended consequences that harm patient care. 

"This increases my concern for missing a clue that might negatively affect my care for a particular patient," said Dr. Schultz, a member of TMA's Ad Hoc Committee on Health Information Technology.

Indeed, Dr. Schultz says his colleagues often bemoan EHRs' erosive impact on the physician's interaction with the patient. 

"Although it's nice to get a good medication history electronically and to know my prescriptions are arriving at the pharmacy as promised, I fear the increased administrative requirements and complexity of the Medicare and Medicaid EHR incentive programs may tip the balance. The hindrances and detrimental effects could outweigh any improvements we've made through this transition," Dr. Schultz said.

Jonathan W. Williams, MD, a Burkburnett solo family physician and member of TMA's ad hoc HIT committee, says EHRs aren't just a nuisance in medical practice; they intrude into the sacred patient relationship he has spent years nurturing. Dr. Williams does acknowledge EHRs have some beneficial attributes.

"We generate good records, can easily flag issues with patients, and our records are well-organized," he said. 

Yet EHRs present unique challenges for solo physicians practicing in rural areas. An early adopter of EHR technology, Dr. Williams started using an EHR system in 2002. In the past 11 years, he says he has spent more than $500,000 installing and upgrading hardware and software and paying his vendor monthly fees for tech support.

Information technology costs are rising as physician practices adopt and implement EHRs, according to the Medical Group Management Association's Cost Survey Report: 2013 Report Based on 2012 Data. Since 2008, medical practices' annual IT expenditures per full-time physician have climbed about 28 percent, from a median of $15,211 in 2008 to a reported $19,439 in 2012.

Since he first implemented an EHR system, Dr. Williams says his vendor has either been bought by another company or merged with another company five times. The primary reason he continues to forge ahead with electronic records is due to his participation in the Medicare EHR incentive program. He attested to Stage 1 meaningful use in 2012 and 2013. So far, he has earned an $18,000 incentive payment.

TMA has tools and resources to help physicians implement EHRs and achieve meaningful use. The EHR Implementation Guide, the EHR Product Comparison Tool (TMA member login required), the Medicare and Medicaid EHR Incentive Comparison, the EHR Incentive Program Eligibility Tool, and Medicare and Medicaid incentive program instructions are available on the TMA HIT webpage

EHR Standards Needed

The importance of the physician satisfaction study is that it documents what physicians have been saying for years, Dr. Fleeger says. 

"With this data, we can go to EHR vendors, to the government, and to quality measurement organizations with proof that physicians aren't simply averse to change. Rather, physicians recognize many EHRs aren't well-designed and need to be redesigned for maximum efficiency. It's to vendors' advantage to make EHRs user friendly," he said.

The AMA-sponsored study suggests better EHR usability should be an industry-wide priority and a precondition for EHR certification. A big part of the problem with EHRs, Dr. Fleeger says, is lack of workflow standardization. 

"I compare it to the auto industry 100 years ago. Every automobile was different. Now, each car has the same basic features that allow everyone to feel comfortable driving it. It took 100 years for that to happen, but the EHR industry doesn't have that kind of time," Dr. Fleeger said.

He calls on the federal Office of the National Coordinator for Health Information Technology (ONC) to create workflow and usability standards for EHR vendors as a requirement for certification.  

"I think we will get more standardization as the EHR industry matures. I hope that will make it easier for physicians to document and to glean important clinical information from EHRs," he said. 

Migrating patient records from one EHR product to another isn't easy either, according to physicians. To help remedy the problem, Dr. Williams would like to see the industry establish data portability standards that make it simple for all physicians to move patient records from one EHR system to another, regardless of vendor. 

"If a vendor goes out of business or a physician decides to use a different company, it should be easy for physicians to take their electronic records with them," he said. 

To foster improved usability and remote accessibility, Dr. Williams says the government should require a third-party entity to certify that EHRs meet certain minimum standards.

"These are practical solutions. Right now, physicians must navigate a maze of pitfalls and constantly changing criteria," Dr. Williams said.

TMA submitted an 11-page comment letter to ONC on its proposed EHR technology standards and certification rules in May 2012. In the letter, signed by Joseph Schneider, MD, chair of the TMA ad hoc HIT committee, TMA cited an example of the hefty expenses one Texas physician faced when forced to transition to another EHR system. An EHR vendor discontinued a product the physician had purchased nine months earlier.

"The new product that the vendor recommended cost twice as much as the product initially purchased. Because of the price difference, the physician shopped around and decided to switch to another company. The cost for the physician to migrate only nine months of patient data was $12, 000," Dr. Schneider wrote. 

To solve the problem and reduce the price associated with transferring data, TMA recommended the Centers for Medicare & Medicaid Services (CMS) and ONC require vendors to tag key data elements that would typically be moved in an EHR transition. At this time, such a requirement isn't part of the rules.

The letter also recommended requiring EHR vendors to follow established procedures and guidelines for user-centered design (UCD), a process that takes into account EHR users' needs, desires, and restraints at each stage of product design. 

"TMA believes that lack of adherence to established guidelines, principles, and best practices for the safe development of health IT software is a significant avoidable risk to safe patient care. It would be more valuable to ensure vendors embed established UCD processes into their product development life cycle through ONC requirements as proposed. Third-party UCD evaluations might be a better fit if done through the already established EHR certification process," Dr. Schneider wrote. 

Though not mandated by the government, this type of work is being done in Texas. ONC awarded a four-year, $15 million Strategic Healthcare IT Advanced Research Projects-Cognitive (SHARP-C) grant to The University of Texas School of Biomedical Informatics in Houston to assess and test usability of EHRs. 

The school's National Center for Cognitive Informatics and Decision Making in Healthcare (NCCD) is working to overcome physicians' immediate and long-term cognitive challenges in HIT adoption and meaningful use achievement. 

NCCD researchers are focusing on EHR usability by testing how well EHRs handle realistic health care scenarios and then providing feedback on challenges to vendors. Their work can help vendors develop EHRs that are usable, useful, and optimized to fit physicians' workflow.  

Playing It Smart

On top of identifying problems that currently plague physicians, the survey sheds light on matters that are likely to hinder physicians in providing quality care in the future.

"We can't just focus on current problems. In the words of Wayne Gretzky, 'A good hockey player plays where the puck is. A great hockey player plays where the puck is going to be.' We need to follow his principle and look at issues that will be problems five to 10 years from now," Dr. Crosson said.

He says the survey makes it clear that evolving payment models need to be examined. While some physicians in the study are happy with the traditional fee-for-service payment setup, many expressed dissatisfaction with its emphasis on volume of care rather than quality. 

Alternative payment models mentioned in the study include concierge medicine, bundled payments with hospitals, and a continuum of risk-bearing models designed to reward physicians for managing the care their patients receive. 

While many physicians seem willing to embrace new payment models, they worry the transition period may disrupt their cash flow. Dr. Crosson says widespread acceptance of new payment methods among physicians is an opportunity for them to have a direct role in managing the cost of health care.  

Crystal Zuzek can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.




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