In a commentary on physician burnout in The Washington Post on June 1st, Daniel Marchalik, MD, a urologist and medical director for physician wellbeing at MedStar Health in Washington, DC, described the OR as “a safe space” for physicians.
(Short diversion: The main storyline of his commentary has to do with a long-time friend of his who burned out in an academic oncology practice, left for a non-academic position where she received more support, and has been happier as a result.)
The OR as a Safe Space
Why might the OR be a safe space for physicians? As Dr. Marchalik points out, “the OR has been uniquely immune to the pressures and transformations of healthcare.”
It’s harder to be harassed by phone calls, insurance companies, and data entry requirements of electronic health records.Surgeons are spending their time fully focused on what drives their professional fulfillment – operating.The surgeon is supported by a team of professionals each practicing at the top of their license.
I get it. My first job in healthcare was as an OR orderly. I transported patients from their hospital bed to the surgical suite, wrapped instruments, mopped operating room floors between operations, and was a human arm or leg holder while the nurses scrubbed a limb with Betadine to reduce infection. (Full disclosure – this was back in the 1970s.)
Later, as a family medicine resident and practicing physician, I recall enjoying opportunities to assist in the OR, in no small part because it was an environment where the result made a real difference, a team worked together, and someone else had my beeper in case it went off while I was scrubbed in.
Is the exam room a safe space for physicians?
Definitely not. The OR is far safer.
I speak frequently to audiences large and small about preventing burnout and commonly use this same example. No surgeon would consider going into an OR alone to perform an operation – for obvious reasons – yet we send physicians into exam rooms all day long, subjecting them to toxic work environments and exacerbating burnout.
There is no good reason that the exam room can’t also be a safe space, protecting physicians practicing in outpatient settings from the drivers of burnout. Yet the reality is just the opposite for the vast majority of physicians today.
The question is how did it get this way and why hasn’t this been fixed? There are a number of reasons:
While the exam room is now increasingly complex, it did not use to be that way. In the days of Marcus Welby, when patients had fewer chronic diseases, diagnostic and treatment options were less complex, and there was no EHR, the physician’s purpose was to care for the patient. Now we care for the EHR, the “unclosed care gaps”, and diagnostic and billing code accuracy, all of which distract us from our primary purpose. Administrators resist placing support teams in the exam room, concerned that this will increase expenses that will make it difficult to maintain the financial performance needed to “keep the doors open and the lights on.” Despite sources of evidence that team care is at worst cost-neutral, and in most cases improves financial performance, they are slow to invest in this proven solution. Hiring up the team takes work. It’s hard to hire qualified medical assistants and nurses. It takes some time to train the team to actually work as a team, realizing the full benefits of this new approach. And finally, we physicians are often reluctant to change our ways, despite our suffering, finding it hard to trust that others will not make mistakes and potentially result in patient harm.
It’s time to “make primary care safe again”
Burnout is toxic for clinicians and organizations.
Burned out clinicians reduce work hours, make more errors, and are at increased risk for depression, substance abuse, family dysfunction, and suicide. Organizations allowing burnout to fester harm patients, clinicians and other workers, and experience worsening financial performance.
We know that team care reduces the drivers of burnout:
loss of control
breakdown of community
absence of fairness