• 1.

    United States Renal Data System (USRDS). End-stage renal disease. Healthcare expenditures for persons with ESRD. 2020 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States, Chapter 9. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (Bethesda, MD), 2020. https://adr.usrds.org/2020/end-stage-renal-disease/9-healthcare-expenditures-for-persons-with-esrd

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  • 2.

    Nair D, et al. Burnout among nephrologists in the United States: A survey study. Kidney Med 2022; 4:100407. doi: 10.1016/j.xkme.2022.100407

Essential versus Necessary: The Ongoing Story of Physician Burnout

  • 1 Charuhas V. Thakar, MD, FASN, is the Robert G. Luke Endowed Chair in Nephrology; Professor of Medicine; and Director, Division of Nephrology, Kidney C.A.R.E. Program (Clinical Advancement Research & Education), with the University of Cincinnati, OH.
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The effort conundrum

Let me dive right in! A traditional business plan equates one full-time equivalent (FTE) to 8 out of 10 half-day sessions of direct clinical work, which expects the physician to complete an average of 12 patient visits in a 4-hour clinic session (a typical visit is 15 minutes for follow-up and 30 minutes for a new patient). There are three recipients of the deliverables during a clinic visit: 1) the recipient of the clinical care is the patient; 2) the recipient of the professional billing is the practice plan; and 3) the recipient of most of the

The effort conundrum

Let me dive right in! A traditional business plan equates one full-time equivalent (FTE) to 8 out of 10 half-day sessions of direct clinical work, which expects the physician to complete an average of 12 patient visits in a 4-hour clinic session (a typical visit is 15 minutes for follow-up and 30 minutes for a new patient). There are three recipients of the deliverables during a clinic visit: 1) the recipient of the clinical care is the patient; 2) the recipient of the professional billing is the practice plan; and 3) the recipient of most of the work on electronic medical records is the health system/compliance. Clinicians are provided 1 full day to “catch up” on all of these three deliverables, yet each of these three deliverables is expected to occur within 24−48 hours of the visit to avoid disruption in clinical care or face system penalties. Implicit in this model is cannibalization of at least an additional 20% of personal time but without any effort or monetary credit for it.

There is a popular workaround across most academic institutions in the country, whereby the work hours per week are extended to 55−60 hours, which does not include on-call hours when taking calls from home. This workaround is made to “fit” the physician effort in an appropriate “spreadsheet box” in the annual departmental budgets. First of all, this hides the fact that most physicians actually work more than one FTE. More importantly, this effort only accounts for direct patient care time and excludes care coordination and electronic health record charting. The metrics of effort reporting are woefully incongruent with the actual effort needed to achieve the task, and for physicians and advanced practitioners, that “task” is delivering compassionate, high-quality, and safe patient care. Compassionate, high-quality, and safe patient care: These buzzwords are easy to write in a business plan or a vision statement, but somehow, we seem to have lost ourselves in translation. We are making the deliverer of this care an invisible entity: the clinician, the provider.

A majority of nephrologists serve in community-based practices and face yet another unique reality. We are probably among the few remaining, if not the only, subspecialties that still operate as “group practices,” which are not part of large, consolidated health care delivery systems. This leads to a syndrome of being “institutionally orphaned.” An average nephrologist will round at two to three hospitals to deliver inpatient care, likely across multiple health systems. This will entail different medical staff rules, electronic records, and compliance requirements. In addition, nephrologists will have their own office practice, for which they are responsible for managing. And finally, we deliver dialysis care, in which an average nephrologist spends at least half of a day per week driving between dialysis facilities. Additionally, there is the interface with dialysis corporations, which comes with its own advantages and disadvantages. It is our relationship with dialysis corporations that allows us to be fiscally sustainable and not be forced to be part of consolidated health systems, but that comes at a price of being stretched in multiple directions.

The fiscal conundrum

Medicare spends, on average, $100,000 per dialysis patient per year. Approximately 60% of this expenditure translates as a revenue source to hospitals. Less than 20% of this expenditure formulates as physician fee-for-service revenue (1). It is mathematically impossible to sustain a nephrology practice simply relying on professional fees. New payment models are crafted to save Medicare expenditures and reinvest part of those savings toward the providers. However, these models have a finite ceiling. Thus, it is essential that downstream revenues generated by hospitals and health care systems need to be reinvested across all disciplines. Without doing so, we will eventually erode the ability to deliver high-quality care to this complex subgroup of patients.

This paradigm of care delivery is simply not sustainable. It is almost guaranteed that we will face burnout and compassion fatigue—some of us sooner rather than later. In a recent Kidney Medicine article by Dr. Devika Nair and colleagues (2), they surveyed a large sample of nephrology providers to assess causes and impact of physician burnout. An astounding one in four physicians reported burnout. The primary drivers included electronic records and hours of work. The reported value of these factors far outweighed the monetary concerns.

The lines between essential and necessary have grown increasingly fuzzy, particularly over the last 24 months. Health care systems, academic institutions, and dialysis corporations need to wake up or need to be woken up to address this existential threat. The current path makes nephrology an “endangered discipline,” which will continue to face workforce challenges unless there are substantive core fixes. Moreover, while facing burnout ourselves, it is challenging to inspire our trainees; thus, we may compound the effect in terms of career interest in our discipline. We will be ignoring this physician burnout at our own peril and to the detriment of serving our valuable and vulnerable patients.

References

  • 1.

    United States Renal Data System (USRDS). End-stage renal disease. Healthcare expenditures for persons with ESRD. 2020 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States, Chapter 9. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (Bethesda, MD), 2020. https://adr.usrds.org/2020/end-stage-renal-disease/9-healthcare-expenditures-for-persons-with-esrd

    • Search Google Scholar
    • Export Citation
  • 2.

    Nair D, et al. Burnout among nephrologists in the United States: A survey study. Kidney Med 2022; 4:100407. doi: 10.1016/j.xkme.2022.100407

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