Issue link: https://beckershealthcare.uberflip.com/i/289185
21 Clinical Integration & ACOs sabotaging the very values it spends so much time endorsing — physician collaboration, teamwork, alignment and trust — for the sake of efficiency. This bait-and-switch is not wholly up to hos- pitals. For instance, tight budgets don't make physician socialization any easier, at least in the traditional sense. Ms. Pierce says she's seen fewer hospital-hosted physician dinners, galas and balls. Those that do occur are scaled back, and fewer physicians attend. Physician rapport may be changing, but there's a silver lining: Ms. Ferron and Ms. Pierce are seeing hospitals get more aggressive about physician en- gagement. In one month alone, leaders from three hospitals called Ms. Pierce, seeking to implement or revamp their physician relations programs. "It's def- initely a top-of-mind issue with hospitals," she says. Hospitals haven't always taken a gentle-handed, holistic approach to physician affairs. Even five years ago, a hospital administrator was more likely to focus on correcting the behaviors of physicians who caused the most problems or disruption, such as refusing to cooperate with other provid- ers. Those behaviors still aren't off the hook, but more leaders are working to address the underly- ing issues, says Ms. Ferron. The physician, the patient and the EMR Surely, part of a healthy physician culture comes down to how physicians interact with their peers. But physicians are also experiencing pressures on the relationship that means most to them of all: that with the patient. Paul Rothman, MD, CEO of Baltimore-based Johns Hopkins Medicine and dean of the Johns Hopkins University School of Medicine, is optimistic but recognizes the challenges facing physicians. "From my perspective, a great physician culture is one that allows physicians to feel like they have the time and resources to do what's right by their patients," says Dr. Rothman. "As we get efficient, and as we try to get healthcare costs out as we re- form the system, probably the biggest risk is when the physician-patient relationship — which is unique and, I would argue, essential for healing — is put under the test." When physicians say they are short on time, it's not an excuse. A 2013 study at Hopkins found first-year residents in internal medicine spent just 12 percent of their time interacting with patients. That amounted to eight minutes to each patient, each day. More than 60 percent of their time was spent on indirect patient care. Forty percent of their time was spent behind a computer. When their industry is in midst of a systemic re- form, things like eye contact can seem trivial to leaders and physicians. But nothing, even a blink, is inconsequential in healthcare. Nonverbal cues affect the system as a whole. A recent study published in the International Jour- nal of Medical Informatics found physicians who use EMRs, as opposed to paper charts, look at their patients less. While not necessarily a surprise, the finding is nonetheless troubling given the proven correlation between physicians' eye contact and patients' perception of empathy. Study authors have connected the dots: If patients feel like their doctors aren't being empathetic, they may be less likely to return for care, meaning they are less likely to adhere to medical advice or seek out care again, much less stick with the same providers. That doesn't sound efficient. Dr. Rothman says healthcare is in an interim pe- riod, as physicians ease into new workflows and patterns with EMRs. Eventually, he says, technol- ogy will be leveraged to improve health. But what about now, while the broader workforce has yet to reach its prime for efficient EMR use? "I think it can have a detrimental effect to the time physi- cians spend with patients," he says. Such cognizance in the C-suite has prompted some changes at Johns Hopkins. For instance, the system redesigned exam rooms to curb the phenomenon of wandering physician eyes. Now, when a physician is documenting the patient visit on the EMR, his or her back does not face the pa- tient. "It's those little things you can facilitate to show the EMR does not have to come between the physician and patients," says Dr. Rothman. The physician assistant will see you now It's ironic that one way healthcare can gain effi- ciency tends to spark the most visceral of reactions. The relationship between physicians and mid-level providers has proven to be a contentious one. The debate over physicians, mid-level providers and their respective roles in care delivery is symp- tomatic of a systemic problem that has garnered little consensus among national physician and nursing groups. The argument is likely to ruffle feathers, as it comes down to how professionals define their work and view themselves. There is no easy solution, and early efforts to reach one are somewhat anemic. For example, the National Health Care Workforce Commission, formed in 2010 under the PPACA to address such issues, has yet to receive funding. Dr. Rothman prefers to focus his attention on "physician-provider" interactions more than phy- sician-physician interactions. He finds himself in a unique position, as the CEO of a health system that employs roughly 2,800 physicians and as the dean of one of the top-ranked medical schools. He's also an MD-holder — a rheumatologist and molecular immunologist — but he approaches scope of prac- tice issues with more logic than nostalgia or bias. "As we think about how we'll take care of 15 mil- lion to 30 million more people under the Afford- able Care Act, it will be more than a physician workforce taking care of people," says Dr. Roth- man. "The healthy organization now only allows enough time to facilitate interactions between phy- sicians, but also other providers in the workforce." Dr. Rothman doesn't see much of a schism be- tween physicians and mid-level providers at Johns Hopkins. That may be due, at least partly, to the organization's status as one of the most presti- gious academic medical centers in the country. But provider in-fighting is all too real for many other hospitals. For instance, about two-thirds of physicians said if a physician and nurse practitio- ner provided the same service, physicians would do it better, according to a May 2013 survey from the New England Journal of Medicine. Seventy-five percent of nurse practitioners disagreed with that statement. "In the old days, there was enough time that a physician could be the predominant care provider. Now you just can't do that," says Dr. Rothman. "It's a change, and academic medical centers and medi- cal schools are really partnering with schools of nursing and pharmacy to ensure education about building a team, managing a team and interact- ing well with other providers is taught in medical school. It has to be patterned early on," he says. But it's not just students who should be primed on these abilities — Dr. Rothman said residents and attending physicians should exhibit the spirit of collaboration for attendees at all levels. Rather than spending their money, time and en- ergy on physician alignment, hospital leaders may find themselves better off by devoting more time to alignment between clinicians of all degree types. What does physician alignment matter, after all, if the internist doesn't want to work with the physi- cian assistant? Conclusion There may be two ways to look at the healthcare landscape from here on out: This as the new nor- mal, or this as an awkward adjustment phase in which physicians get up to speed. Dr. Rothman is rooting for the latter. "Physicians didn't grow up with an iPhone at their hip," says Dr. Rothman. "They are having a little harder time, but healthcare providers are pretty smart and dedicated people. They want to help patients, so I think we'll come out of the transition with a better system." Either way, health system leaders should think twice before viewing physician engagement through a superficial lens. Hospitals may become more ef- ficient in certain ways through EMRs and height- ened physician productivity, but little things — like an empty physician lounge or physician eyes glazed over by computer screens — add up. Dr. Rothman may be optimistic because he knows this; bullish- ness can stem from a place of preparation. He un- derstands what healthcare has to gain and lose by becoming more efficient, and he's working to limit the latter as much as possible. n