Rx for Delivery System Transformation: Satisfied Doctors Who Find More Joy in Practice

Aug 20, 2013, 4:32 PM, Posted by Susan Dentzer

Susan Dentzer

In my last post, I wrote about what would best motivate physicians to transform health care: carrots, sticks or something else. The case for “something else” was made in a series of innovation sessions presented at a recent American Board of Internal Medicine (ABIM) Foundation forum. They focused on evolving health care delivery models aimed at increasing quality, decreasing cost and enhancing patient-centered care.

Readers of Daniel Pink’s book Drive will be familiar with his thesis about “Type I” human behavior: the kind that is less concerned with “the external rewards to which an activity leads and more with the inherent satisfaction of the activity itself.” Many innovations presented at the forum echoed that theme—augmenting the satisfaction that doctors get from focusing most of their attention on helping patients.

Engaging doctors: At the forum, Craig Sammit, the CEO of Wisconsin-based Dean Health noted that “extrinsic” motivators, such as showing doctors how their relative performance data stacked up against their peers, had substantial impact in spurring improvement. But he observed that the measures that were most effective in transforming the way care is delivered  at Dean were those that helped make the organization “the best place for a physician to work.”

A major push toward “participatory management” at Dean brought half of the system’s doctors into governance and leadership roles. And as various studies have found, engaging physicians in such activities as “Lean” quality and process improvement built a sense of accomplishment, professionalism and teamwork.

Sammit (who will soon move to become executive vice president at California-based HealthCare Partners) also explained that he had learned firsthand that “organizations with the greatest physician satisfaction are those where leaders walk around and solve physicians’ small problems.” Even something as simple as placing computer printers in each exam room for physicians to use, Sammit noted, goes a long way to increasing satisfaction and morale.            

Beating Back Bureaucracy: Two other innovations described at the conference have scored early successes by scaling back various bureaucratic burdens placed on physicians, such as the time and energy spent on making entries in patients’ electronic health records.

At Medical Associates Clinic, a 115-physician multispecialty practice in Dubuque, Iowa, internists Christine and Tom Sinsky pioneered a Collaborative Care Model that forges close working relationships so that doctors can share those burdens with registered nurses.

At the Sinskys’ practice, a nurse accompanies each patient from the beginning to the end of a clinic visit, acting as guide, advocate and health coach. The nurse handles tasks ranging from obtaining “vitals,” such as blood pressure readings, to performing medication reconciliation and recording the patient’s history. 

The nurse manages prevention issues, such as giving immunizations and scheduling cancer screenings, and coaches the patient on lifestyle issues such as weight loss, exercise and smoking cessation. Later, when the physician joins the appointment and performs the exam, the nurse continues making entries in the record, and engages in a “three-way conversation” in which the doctor, nurse and patient together craft a care plan. After the visit, the nurse reinforces the plan and provides further education and self-management support.

A key goal of the model is to increase the time during which the physician provides “undivided attention to the patient,” the Sinskys note. Early results show that “physicians report feeling less harried, and able to provide more attention to the patients’ concerns, as they spend less of the visit on administrative tasks.”  

Partnerships: A similar approach, recently piloted at two practices (one general internal medicine and one in geriatrics) that are part of UCLA Health, pairs physicians with so-called “physician partners”—trained bachelor’s degree-level personnel or licensed vocational nurses who also handle many administrative tasks during patient visits. Among other duties, the partners transcribe doctors’ comments into the medical record, complete lab and referral requests, schedule follow-up appointments, update medication lists, and provide written visit summaries to patients. 

Early results show that, with the assistance of these partners, physicians were actually able to reduce the amount of time they spent with patients, as well as their prep time and after-visit time normally spent on tasks such as completing the visit record. At the ABIM Foundation forum, David Reuben, one of the doctors who worked with a physician partner, speculated that the ability to see more patients could produce sufficient revenue to cover the cost of employing the patient partner.

As the Sinskys and several colleagues wrote in a recent article in the Annals of Family Medicine, such “shared-care” models hold the potential of “improved professional satisfaction, and greater joy in practice” for physicians. That possibility aligns with Pink’s notion of Type I behavior as a “renewable resource” that rests on a sense of autonomy, mastery and purpose. 

“It is the motivational equivalent of clean energy: inexpensive, safe to use, and endlessly renewable,” Pink writes. In other words, it’s the sort of energy that could enable physicians to go the distance in transforming America’s health care system and achieving the Triple Aim.