The Why, What, How Of The Never-Ending Crisis

Since 2018, Atrómitos has sponsored the Greater Wilmington Business Journal’s Health Care Heroes awards event.

This year is no different. I attended the 2022 Health Care Heroes ceremony a few days ago, where we celebrated the community of Wilmington, North Carolina’s dedicated healthcare and administrative professionals. It is always an inspiring event, and I appreciate the opportunity to recognize those that contribute to the health and well-being of everyone in the community.

While this event is significant for the recognition it provides, it has also made me think about the widespread provider shortage crisis. Let’s be very clear. The crisis is not new. When I began my career more than 2 decades ago, we discussed provider shortages – especially primary care, nursing, and behavioral health – and the reasons for them.

A distinction from the discussion around provider shortages then and now is the acknowledgment of the spread of provider burnout and the resulting loss of workforce – but also the impact it has on swaying others from joining the profession. COVID brought provider burnout to the national forefront. But it wasn’t COVID that caused provider burnout. It certainly has exacerbated it, but it’s not the cause.

Many have sounded the alarm bells on the issue of provider shortages for decades. And they continue to do so. I fear that because the system has continued to limp along and mostly work, it gives those in a position to make changes the cover they need to not act. And as is the case with so many issues facing the country, we’ve already done the easy things. Now it’s time to do the hard things.

Why?

Let’s take a step back. Why is more than 50% of the healthcare workforce suffering from burnout?

1. Electronic Health Records (EHRs). We’ve discussed this many times before, so I won’t do so in detail again. I note it, however, because using EHRs was meant to ease the administrative burden for providers while enabling their clinical decision-making with more information in an easily accessible format. While we have seen benefits from EHRs, the burden is certainly beginning to outweigh any benefit. There is much work to be done to improve EHR implementation and utilization.
2. The Pace. Providers often have very little time to engage with patients, with 10 to 15-minute appointments scheduled back-to-back. As a result, providers are persistently behind and running from one patient to another. They also cannot truly engage with their patients and spend the time needed to understand what is going on; forget about having truly meaningful shared decision-making with the patient about what steps to take. This was my personal experience a month ago after I finally got my son an appointment with a new pediatrician. However, the appointment was so brief that three of the issues we wanted to discuss with the physician had to be tabled until our next appointment which would not be for a month. The frustration he felt was evident. If, though, providers continue to be paid in a way that incentivizes volume (the more widgets you make [patients you see], the more money you make), it is to be expected that the pace won’t slow – and has the potential to get even worse. We’ve been flirting with fundamentally changing how health care is paid for in this country for a very long time. Is now the time? How ‘bout now? Maybe now?
3. Chaotic and sometimes violent settings. Violence in healthcare settings has always been a problem. One of the more surreal moments in my career was developing an active shooter policy and procedure for a hospital system a decade ago. However, since COVID, the AHA reports that “violence against hospital employees has markedly increased — and there is no sign it is receding.” Recently, a group of provider organizations warned that Emergency Departments are at a breaking point. Talk about a chaotic environment. While the ED is the picture of chaos in healthcare (just watch any medical television drama that takes place in or around the ED), this chaos exists throughout the healthcare system. Different payers require different processes and procedures. Different programs require different paperwork and reporting. And then, of course, staff shortages result in further chaos.
4. Culture of the healthcare organization. We all know that the success of an organization is based entirely on its culture. And yet so many organizations have really poor cultures. This is true in healthcare. No matter the size of the organization – large healthcare system to small community practice – the organization's culture is a key factor in whether providers experience burnout. The MEMO—Minimizing Error, Maximizing Outcome—Study found that “unfavorable organizational culture” was strongly associated with provider burnout. When an organization treats its workforce like cogs in a machine – and many of them do – burnout is the only outcome to be expected.

What?

What does this all mean for patients? It means higher dissatisfaction with their healthcare experience; poor outcomes, including death; medical errors; and lack of access to needed care and services. This lack of access is, in turn, driving the higher utilization of EDs, which is further exacerbating the staffing shortages in the hospitals. It’s a vicious cycle that is getting worse.

For providers, burnout means “emotional exhaustion, depersonalization or a diminished sense of personal success, substance abuse, depression, post-traumatic stress disorder (PTSD), and suicidality.” No wonder providers are leaving the profession in droves.

For healthcare organizations, it means lost investment through recruitment, training, and professional development when providers leave and lost revenue as the capacity to see patients is reduced. It can mean loss of licensure when state and federal regulatory agencies determine that the healthcare setting is unsafe because of insufficient staffing, and it can mean reduced quality performance, which in turn affects all aspects of the healthcare organizations operations: staff recruitment, competitiveness in the market, payment from insurers, and so on.

How?

How do we address this? Left unaddressed, the system will no longer limp along, mostly working – it will collapse.

I see two fundamental changes that must occur, and they seem to drive each other.

First, we must change the way that healthcare is paid for. A price per widget is not only problematic from an overall healthcare cost perspective, but it is driving so many of the causes of provider burnout: pace, lack of autonomy, long work hours, EHR, and other documentation requirements.

Second, healthcare leadership must seriously evaluate and change the culture of their organizations. I’ve been doing this work long enough to know the financial imperative of healthcare – you can’t do the necessary things without money. But treating your employees like cogs in a machine, driving them harder and harder to do more and more is not the way. And let’s be clear, I’ve seen employment contracts of enough healthcare organizations to be aware of just how poorly employees at all levels in the organizations are treated.

Administrative and financial leadership, you must (must) engage your clinical staff in more meaningful ways. You may not like what they have to say, but you must hear it, appreciate it, and act upon it. Oh yes, it is more complicated when you do, but it will prevent much pain, suffering, and heartache down the road.

So, I ask:

1. Healthcare organizations – what are you doing to address the provider burnout in your organization, and how will you end the cycle?
2. Payers (commercial and public) – what are you doing to address provider burnout in your networks? How are you changing payment and quality reporting programs to enable meaningful patient and provider engagement and healthcare delivery?
3. Businesses – what are you doing to demand more from your insurers so that they are incentivized to address provider burnout and ensure an adequate and effective healthcare workforce?
4. Policymakers and legislators – what are you doing to change laws and regulations to shift the healthcare market in a direction that ensures sustainability by establishing a healthy, adequate healthcare workforce?