|
|
| |||||||||||||||||||||||||||||||||||
Sinsky has become a nationally known innovator in primary care, promoting practice reforms to help office-based physicians "work smarter, not harder" to avoid burnout.1 Her low-tech approach emphasizes teamwork, careful analysis of necessary tasks, and using support staff to ensure that doctors' time is spent only on activities requiring their expertise. Medical Associates Clinic and Health Plans, the 114-physician practice where Sinsky and her husband, internist Thomas Sinsky, are partners, was found by the National Committee for Quality Assurance to meet standards that will soon be used to recognize practices as "patient-centered medical homes." Job satisfaction among the group's physicians is high, and turnover rates are low. Members of the executive committee "have allowed creativity. Tom and I get an idea and we just try it," said Sinsky. "A huge part of physician satisfaction and retention is to have some control over your environment."
Creativity is needed as physicians and managers struggle to make professional life sustainable for the country's shrinking pool of primary care doctors. The general internists, family practitioners, and geriatricians who provide primary care to adults face a growing population of elderly Americans with chronic conditions. But their compensation is a fraction of what many specialists earn, and fewer and fewer U.S. medical school graduates are entering these fields (see bar graph) — making it increasingly tough to replace primary care physicians who retire and intensifying the pressures on those who remain.
|
Sinsky's experimentation with efficiency strategies was apparent at a recent checkup. Before entering the exam room, Sinsky paused for a "mini-huddle" with the nurse who had compiled the results of the patient's recent laboratory tests — ordered after her previous visit — and taken her vital signs and a brief history. Sinsky's two nurses do extensive advance work to organize each appointment: they print out the latest test results and progress notes, update and list the patient's medications, note any preventive measures that are due, include any recent notes from consultants, and write a brief intake note specifying the reason for the encounter — all on a sheet or two that Sinsky can refer to easily, leaving her more time to talk with the patient. Elsewhere, physicians often spend many minutes paging through the record searching for information. Sinsky's nurses also brief her orally about anything unusual that's on the patient's mind. The current patient, Ms. S., who has diabetes, "is going to Weight Watchers, but she gained seven pounds and she's frustrated," warned the nurse.
"We have a lot to talk about," Sinsky greeted Ms. S. She praised her patient's weight-loss efforts and congratulated her on her well-controlled blood pressure. Concerned about low serum glucose values, she instructed Ms. S. to test her blood glucose three times a day, record the results, and adjust her insulin dose accordingly. She inquired about exercise-related symptoms, performed a brief exam, responded to a low serum potassium level by reducing a diuretic dose, ordered tests of serum potassium and thyroid function to be done before a follow-up visit in a month, and checked off additional tests to be done before a subsequent visit. A receptionist would arrange for these tests at checkout. Sinsky then dictated a note, checking with Ms. S. to make sure she understood her self-management plan. With a brisk but empathetic approach, Sinsky addressed multiple problems and completed her charting surprisingly quickly.
Scheduling routine laboratory tests before appointments and ending each visit by planning the next one are simple strategies that the Sinskys introduced several years ago, and they're surprised that few other physicians use such strategies. "Our patients really expect to get their labs" in advance so that they can discuss the results during their visit, Chris Sinsky said. "When people do the lab tests afterwards, there's a mountain of work to be done." Sinsky also orders prescriptions with sufficient refills for a year, minimizing telephone calls.
Primary care physicians commonly spend hours each day reviewing test results, following up on abnormal values, entering information into electronic medical records (EMRs), and performing clerical work. EMRs can improve communication and efficiency, but they often burden physicians with data-entry responsibilities. Physicians in the Dubuque practice dictate their notes, and members of the support staff take care of data entry. Doctor–nurse "teamlets" cooperate in case management, with each doctor's primary nurse (a registered nurse or licensed practical nurse) responsible for reviewing laboratory results and deciding which ones merit physicians' attention. Nurses also perform routine monitoring tasks for patients with chronic conditions, such as examining the feet of diabetic patients and checking their urine for microalbumin.
Recently, a patient with a history of breast cancer had an abnormal mammogram, and a biopsy was recommended. On her own initiative, R.N. Deb Althaus called the woman's breast surgeon and arranged for her to see him immediately after seeing Sinsky to discuss the result — allowing Sinsky to focus on her patient's emotional reaction to the finding. Althaus's contribution is "important for the patient, important for my own efficiency, and it's totally within her skills," Sinsky said. Nurses also take all calls from patients and communicate with family members, nursing homes, and others involved in patient care. Coordination between visits "is a major part of what the patient-centered medical home is," said Thomas Sinsky, "and the nurses are really crucial to that."
The Sinskys said that at many practices, managers have drastically cut nursing and clerical support staff to save money, rendering doctors less productive and more likely to burn out. Each internist in the physician-owned Dubuque practice decides how many patients to see each day (the average ranges from 17 to 25) and how many nurses he or she needs (generally, 1.25 to 1.75 full-time equivalents per physician) and pays their salaries out of the earnings he or she generates. The practice has had no difficulty in filling nursing vacancies despite the nursing shortage. Although many practices rely on medical assistants instead of paying nurses' higher salaries, Chris Sinsky said her nurses' training makes it possible to have a smoothly running patient-care team. "You would never have the surgeon go into the operating room and collect all the tools for his or her trade," she said. "Primary care has lost that. We're just on our own in this room with all these things we're supposed to do. It's not focused on doctor work — we're doing all the other work ourselves."
Primary care physicians at Kaiser Permanente Colorado are experimenting with other ways of responding to mounting demands. For several years, for instance, a group of about a dozen elderly patients have attended monthly sessions at their suburban-Denver medical office to check in with physician Pierre Onda and nurse practitioner Ann Kingdon, to hear speakers discuss health or lifestyle topics, and to socialize. Recently, Onda raised the possibility of ending the sessions, but group members objected vociferously. So the "cooperative health care clinic" (CHCC) has merely been shortened from 3 hours to 2, with a speaker scheduled for the first hour and Onda and Kingdon available for individual consultations during the second. Participants pay $10 — which is $10 to $20 less than they'd pay for an individual appointment — and appreciate the benefits of frequent checkups and the opportunity to address their health concerns and "lift their spirits," as one patient put it.
The idea of such appointments was introduced at Kaiser Permanente's Colorado locations more than a decade ago and has been tested in a randomized trial.2 Among patients 60 years of age or older with at least one chronic condition and a history of frequent visits, group participation was found to reduce hospital admissions, emergency room visits, use of services, and medical costs. Participants reported greater satisfaction with their physician and better quality of life. Kaiser Permanente also offers walk-in group sessions, usually run by a nurse practitioner and a pharmacist, for patients with high blood pressure or diabetes. Managers noted that it is far easier to introduce and test such "alternative encounters" in a prepaid health plan than in a private practice, where insurers might not pay for them.
Yet Onda said he's under pressure to reduce waiting times for individual appointments, so group sessions may not be the most efficient use of his time. Not all Kaiser Permanente primary care physicians offer CHCCs, and only a minority of patients who are invited decide to participate. Typically, no more than 20 of a physician's 2000 or so patients regularly attend a CHCC. "My comfort zone is one on one," Onda said. Nevertheless, "I like the idea of trying to do things differently if we can definitely show that the outcomes are better."
Kaiser Permanente Colorado employs approximately 300 primary care physicians, 77% of whom see patients less than full-time. Despite extensive support, the workload and stress of primary care have rendered it "not sustainable full-time" for many physicians, said Smith, the associate director for primary care and service. Turnover among Kaiser Permanente's primary care doctors is much higher than among specialists, and Smith struggles to recruit enough primary care internists to replace those who retire or leave the area, much less add physicians to keep up with demand. "We're unable to fill our positions as quickly as we need to," he said. Doctors' "panels have grown, and we've been working really hard to get them back down." It takes 10 months to fill a vacancy for a general internist, as compared with 2 months to hire a physician assistant, so in the past 6 months, the organization converted six physician positions into slots for nine physician assistants or nurse practitioners.
In another attempt to streamline care, managers at Kaiser Permanente have been encouraging primary care physicians to increase their e-mail interactions with patients and substitute telephone appointments for some face-to-face ones. Patients are urged to sign onto the organization's Web portal, where they can view their laboratory results and e-mail their doctors. So far, about 34% have done so, and more than 80% of those users have communicated with their doctors by e-mail. When patients call to book an appointment, operators ask whether they would prefer a telephone appointment, which often can be scheduled sooner. (However, neither e-mail nor telephone interactions are permitted unless the patient and physician have first met face to face.) In June 2008, the number of provider–patient encounters was 17% greater than the monthly total a year earlier (94,200 versus 80,798), with telephone visits and e-mail exchanges accounting for the increase (see line graph).
|
Balch's colleague Cindy Ireland, an internist, said there's a "huge demand" for telephone appointments, but she prefers e-mail. "The problem with the phone is that you call them about one thing and there's always another and another," she said, whereas e-mail inquiries tend to be more focused. Physicians at Kaiser Permanente Colorado are expected to respond to patients' e-mail messages within 24 hours, and they do so in 92% of cases, Smith said. On the day I visited, Ireland was double-booked with appointments throughout the day and had five telephone appointments scheduled after 5 p.m., as well as half a dozen new messages from patients. "The concern is whether we'll be able to handle the demand," she said.
That concern haunts both practitioners and managers, as they try to plan for a shortage of primary care doctors that will probably get worse before it gets better. Kaiser Permanente Colorado is trying to make its EMR system easier to use, and it recently began testing Sinsky's preappointment planning strategy. Said internist Michael Chase, the organization's associate medical director for quality, "We're all wrestling with the same issues and looking for solutions."
No potential conflict of interest relevant to this article was reported.
Source Information
Dr. Okie is a national correspondent for the Journal.
References
| |||||||||||||||||||||||||||||||||||
This article has been cited by other articles:
HOME | SUBSCRIBE | SEARCH | CURRENT ISSUE | PAST ISSUES | COLLECTIONS | PRIVACY | HELP | beta.nejm.org Comments and questions? Please contact us. The New England Journal of Medicine is owned, published, and copyrighted © 2009 Massachusetts Medical Society. All rights reserved. |
