PHYSICIAN WORK ENVIRONMENT AND WELL-BEING Creating a “Manageable Cockpit” for Clinicians A Shared Responsibility For many clinicians, the work of health care has be- come undoable. The “cockpit” where physicians and other health professionals work now consists of a cacophony of warning alerts, pop-up messages, mandatory tick boxes, a Sisyphean inbox, and maddening documenta- tion. Paradoxically, many interventions intended to im- prove quality, safety, or value, when taken in totality, may in fact contribute to health system dysfunction by virtue of the cumulative impact on workload and consequent burnout. Although technology was meant to help, it has instead brought a wealth of new opportunities for admin- istrative oversight and compliance monitoring. Other industries that prioritize safety, such as the air- line industry, incorporate the time and cognitive work- loads of employees in the design of work. For example, a team of engineers protects the attention of pilots in the cockpit, seeking to prevent information overload by lim- iting the data displayed and requiring a “sterile cockpit” free from distractions when the pilot’s full attention is imperative. 1 Proposals for new alarms and warnings that individually offer the possibility of incrementally improv- ing safety may ultimately be rejected because of the cu- mulative negative impact on the pilots’ cognitive load. At present, the health care system in the United States has no mechanism for managing the stresses and liabilities associated with the momentum for more data and greater clinician accountability. There is no team of engineers whose job it is to ensure a sterile cockpit or even a “manageable cockpit” for clinicians: one that is free of information overload, distractions, interrup- tions, and cumbersome workflows that cumulatively contribute to a hazardous environment. No one is re- sponsible for analyzing and minimizing the aggregated administrative and cognitive burdens. Mandating performance measurement and captur- ing enough discrete data about individual clinicians are assumed to result in better care. Less appreciated is the central message of the Institute of Medicine’s report, To Err Is Human: Building a Safer Health System. 2 Pub- lished in 2000, the report emphasized that the major- ity of errors in health care are the result of systems fac- tors, rather than substandard performance by individual clinicians. What happens, then, when the system moni- toring individuals may itself engender a hazardous care environment? Although many of the root causes of quality and safety breaches are systemic, interventions are fre- quently directed at clinicians’ interactions with the pa- tients. For example, evidence-based health screenings are important; however, these recommendations should be considered in sum. In 2003, Yarnall et al 3 estimated that it would take a physician 7.4 hours per day to com- ply with all of the relevant prevention recommenda- tions of the time. At present, there are even more rec- ommendations. A sampling of those for a single primary care visit includes the following: assessment for fall risk, domestic violence, obesity, learning needs, tobacco use, medication adherence, substance use, and timeliness of referral appointments, as well as acquiring reports on eye examinations for patients with diabetes. Because the typical primary care visit is only 13 to 21 minutes, the pa- tient’s agenda is often crowded out. Similarly, many public health issues are not ad- equately addressed on a systemic level. Thus, the policy and regulatory focus is on the individual clinician, again putting physicians, not systems, at the sharp end of the accountability stick. For example, as a society we inad- equately address the food and beverage industries and their contributions to obesity, so we seek to hold clini- cians responsible for addressing obesity 1 patient at a time. We inadequately address the many factors that make medications unaffordable for some patients, but we seek to hold clinicians responsible for patient adher- ence to medication. Our efforts to control the tobacco industry are inadequate, so we mandate that clinicians counsel patients to stop smoking. The list could go on and on. At present, clinicians are also responsible for trans- lating the patient encounter into digital data for the use and convenience of payers, auditors, researchers, and policy makers. With the advent of electronic health rec- ords, it was assumed that physicians would add these clerical duties to their existing clinical responsibilities, without consideration of the costs. Heightened secu- rity concerns require multiple log-ins to electronic health records per patient and increasingly complex pass- words with shorter and shorter half-lives. Audit data for electronic records demonstrate that physicians spend nearly as much time on security tasks as they do review- ing patients’ problem lists. 4 Physicians in multiple spe- cialties spend nearly 2 hours on electronic records and other administrative deskwork for every 1 hour of di- rect clinical face time with patients. 4,5 The time pres- sures crowd out activities that are central to excellent patient care—engaging, listening to the patient, being empathetic, taking the time for careful medical deci- sion making, and communicating with others involved in the patient’s care. How can a manageable cockpit for clinicians be cre- ated? We offer these approaches: 1. Develop measures of a manageable cockpit that cap- ture the cognitive workload, time pressure, adminis- VIEWPOINT Christine A. Sinsky, MD Professional Satisfaction and Practice Sustainability, American Medical Association, Chicago, Illinois. Michael R. Privitera, MD Department of Psychiatry, University of Rochester Medical Center, Rochester, New York. Corresponding Author: Christine A. Sinsky, MD, Professional Satisfaction and Practice Sustainability, American Medical Association, 330 N Wabash Ave, Ste 39300, Chicago, IL 60611 (christine.sinsky @ama-assn.org). Opinion jamainternalmedicine.com (Reprinted) JAMA Internal Medicine Published online March 26, 2018 E1 © 2018 American Medical Association. All rights reserved. Downloaded From: by a University of Rochester User on 03/27/2018