Mass Medical Society’s Dr. Alain Chaoui on Joint Harvard Study on the Crisis of Physician Burnout

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Moderator: Welcome to Conversations on Healthcare with Mark Masselli and Margaret
Flinter. A show where we speak to the top thought leaders in health
innovation, health policy, care delivery and the great minds who are shaping
the healthcare of the future .

This week Mark and Margaret speak with Dr. Alain Chaoui, immediate past
president of the Massachusetts Medical Society who conducted a study along
with the Harvard School of Public Health , d etermining th at P hysician and
C linician B urnout is so prevalent in t his country , i t should be considered a
national emergency and what n eeds to be done.

Lori Robertson also checks in, Managing Editor of FactCheck.org looks at
misstatements spoken about health policy in the public domain, separating
the fake from the fa cts. And we end with a bright idea, that’s improving
health and wellbeing in everyday lives.

If you have comments, please email us at [email protected] or find
us on Facebook or Twitter, iTunes or wherever y ou listen to podcast. You can
also hear us by asking Alexa to play the program Conversations on
Healthcare. Now stay tuned for our interview with Dr. Alain Chaoui , here on
Conversations on Healthcare.

Mark Masselli: We are speaking today with Dr. Alain Ch aoui, immediate past president of
the Massachusetts Medical Society and co - author of the new report on the
healthcare crisis, a physician burnout in American healthcare. Dr. Chaoui is a
Primary Care Physician in private practice in Peabody, Massachusetts. He
holds a teaching position at Tufts Boston University and Boston College
School of Nursing . Dr. Chaoui received his medical degree from A in Shams
University in Egypt. He completed his residency at Akron City Hospital . Dr.
Ch aoui, welcome to Conversations on Healthcare .

Alain Chaoui: Thank you so much Mark.

Mark Maselli: You ha ve been collaborating with a number of organizations , really focusing
specifically on the nation's doctors a nd I wonder if you could help our
listeners understand the scope of clinic ian burnout and how it's affecting
public health .

Alain Chaoui: In 2018, at our annual meeting of the MMS. I was speaking with Dean
Michelle Williams of the Harvard School of Public Health that physician
burnout was a major problem impacting physicians, pa tients and in fact the
whole healthcare system . A fter some preliminary research herself s he agreed
that physician burnout is an important issue and needed attention. She then
asked Dr. Ashish Jha, the Director of the Harvard Global Health Institute , who
im mediately understood the magnitude of the issue and t hen he began to
work with us on the report .

A s you know a bunch of studies from Mayo quoted that the burnout rate is
up to 54%, which is one out of two doctors suffer from symptoms of burnout .
74% of ph ysicians have shown at least one symptom of the burnout

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overtime . Some of the se symptoms , Mark are like emotional exhaustion,
depersonalization, low sense of personal accomplishment. There i s also a
recent study entitled Medscape National Physician Burnout Depression and
Suicide , the report 2019 , is really full of data. I a m on the frontline , I am a
family physician in private practice. My neighbor across the hall who retired
from his practice in G astroenterology , he was a solo practitioner , who had an
exce llent reputation and his patient s loved him. He actually retired at age 60
and that's that trend now, physicians are used to retire in their 70s, now they
are retiring as early as 60s, 50s.

W ith one out of two physicians experiencing some level of burnout
symptoms , and seeing that the ir health system is not responding to these
needed changes a nd the physician shortage expected down the pike . And this
amount of retirement that really pointed to a public h ealth crisis , because it's
definitely affecting our p atient s .

Margaret Flinter: Dr. Chaoui, you have noted that in fact clinician burnout is not a new
phenomenon , but that p a ce of burnout has accelerated significantly over the
past decades and the change in people being self - employed versus employed
by other s , loss of control , the shift from people going to the hospital in the
morning , in the practice , in the afternoon, having all that other social
engagement largely transformed by hospital s , managing the hospital . B ut the
things that we hear most often about relative to burnout seem to be things
that we ought to have been able to fix , the Electronic Health Record impact ,
E HR fatigue , the reporting demand s , the amount of documentation that
needs to be done, that if somebody is doing the thousand clicks per vis it , they
wonder sometimes , how much this has to do with quality versus how much it
has to do with payment . Talk with us a little bit about how those very
tangible things like the E HR fatigue or reporting demands are contributing to
the problem.

Alain Chaou i: Margaret, I would also note that there are other reasons and thus we
encourage each healthcare system to survey the ir physicians to learn what
are the se drivers that are causing burnout ? You know E MR is just one of
them . As you pointed out, the E HR is a leading cause of burnout. As you
know, the demand for a prior authorization , i n the past prior authorizations
were made to control cost and we used to do prior authorization for high
cost radiology . Now prior authorizations are for everything that as well a s the
quality reporting and documentation that take away from our patient time ,
because you know the patients is the reason why we went in to medicine .
And that's a very intimate space between the patient physician that has been
in truded by all these non - patient related functions a nd it hurts the patient -
physician relationship and thus reduce the clinician satisfaction with their
work.

Not one physician complained about having to see too many patients. What
is demoralizing is the fact that I have to do a l ot of time consuming work that
has nothing to do with patient care. The truth is, the E HR is not user - friendly.

20190617Chaoui

There was a recent article : Death by a Thousand Clicks , EHR has added two
hours of data by physicians for every one hour of p atient time. We als o call it
“ pajama time. ” Another point you mentioned is the prior authorization. It
takes an additional 15 hours per week per physician . S o all the cumulative
effect on the physician community as the literature has clearly shown is ,
clinicians are choosing to retire early or change to part - time or they decided
to continue to work and be dissatisfied and that's not sustainable.

Mark Masselli: We ha d the opportunit y of having Dr. Don Rucker on who is the N a tional
Coordinator for Health IT , h e says helps on t he way Margaret .

Margaret Flinter: Yeah.

Mark Masselli: Really talking about how they advanced , API enabled solutions in the like,
but you know, if I look back 1983, 75% or more of the practices were owned
by physicians , private practices owned by physici ans . And if you look now it's
less than half. I a m wondering if they have move d from employers to
employees and they lost control of the practice .

Alain Chaoui: Yeah.

Mark Masselli: How does that figure in to the analysis ?

Alain Chaoui: The loss of autonom y is actually one of the main reasons of physician
burnout . I w ill say Mark that the E HR's are here to stay , I mean, I actually like
the idea of E HR is a lot safer for our patients . But the companies that make
them have little or no incentive to work toget her , to make them
interoperable. The E HR's were originally created as a billing tool and we
would like to move it to a more user - friendly tool that w ill actually h elp
physicians deliver great care and communicate with each other , for the care
of their pati ents.

O ne of the promising solutions to make E HR more user - friendly would permit
software developers to actually develop some apps that can operate with
those certified E HR systems . Y ou mentioned the word API which is
Application Programming Interface , whi ch allows two different computer
programs to talk to one another . In healthcare we are having this problem
with lack of interoperability and that's not good for the patient , that's not
good for the healthcare as a whole because it is unhealthy for the pati ent to
receive radiation twice or labs twice and it's more expensive to duplicate the
work. So that's why those APIs allow those two computers to speak with one
another.

Y ou mentioned also about you know physicians being employed , some of the
stud ies show that burnout is a lot less in private practice physicians because
they do have some control over their schedules over how many patients they
can see per hour . F or example in my office , I work as a team s o when I take
care my patients I feel like my whole s taff work at the top of their license a nd
they actually have me take care of the patients and the patients are actually
more satisfied and I am more satisfied with my ca re .

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Margaret Flinter: We. Dr. Chaoui, I am so glad you have ended on that note because it's
exactly what I was thinking about , with team - based care , which doesn't
happen automatically , you know it’s a training unto itself. I was thinking also
Mark about replacing prior authorizations with e Consults rather than filling
out a lot of paperwork , just to make something happen. There has certainly
been a proliferation of wellness programs with varying degrees of success,
but I think it was Dr. J ha from the Harvard School of Public Health pointed
out , we a re not going to fix this problem of physicia n burnout by doing more
yoga . Y et what evidence is there , that programs that help to alleviate stress
among physicians and all clinicians might actually play part of the role in
helping us move forward in addressing this very real concern .

Alain Chaoui: So , Margaret I want to tell you about a gentleman that I got to meet Dr. Tait
Shanafelt has been working on this issue for about 20 years. He is the Chief
Wellness Officer at Stanford . Tait taught us that the key leadership behavior
to help reduce burnout , a re to inform , inquire and develop and recognize the
problem . And leaders need to keep the ir staff informed , they need to ask for
their suggestions and how to improve their work unit and facilitate the ir
career development and recognize a job well done.

The reason we say we don't need more yoga Margaret , is that we know
physicians and medical students are more resilient and less depressed than
the general public when they start their careers . But there i s something in the
industry that's burning us out at an alarming rate a nd that ’ s a systemic issue .
And honestly all the yoga i n the word will not fix it. Once somebody is deeply
burned out , they really don't have the bandwidth to even participate in
wellness programs .

One of my co - chairs at the Physician Burno ut Task Force , Dr. Steve n Defossez,
he and I are big proponents to what is known as an organizational culture of
health , that is he alth for all the employees and the patients, the
communities, the environment . W hen we think of health we a re really
thinking of all five dimension of health , which is your emotional health,
physical and mental and reaching to one's full potential. A n effective Chief
Wellness Officer in conjunction with a thoughtful wellness program should be
able to help individuals throughout the organization , to improve in all five
dimensions of health .

Mark Masselli: We are speaking today with Dr. Alain Chaoui, immediate past president of
the Massachusetts Medical Society and co - author of the New Report on the
Health Crisis of Physician Burno ut in American Health care . Dr. Chaoui, I really
want to have you talk to our listeners about why this is a health crisis for our
patients . The average citizen in America makes around $45,000 a year and
Forbes Magazine says that the highest paid job in Amer ica are physicians
around $200,000 . And they may be listening to this and say , I suffer
emotional exhaustion at my job and a sense of burnout. Why is this a
national crisis that an average citizen should be concerned about ?

Alain Chaoui: Mark , when we talk about money and w h en physicians graduate from med

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school , they graduate with a ton of debt , the average is about $250,000 of
debt before they even start th eir c ar eer . The art and science of medicine is
the quintessential calling which historically allowed physicians to have a high
degree of autonomy and a lifetime of practicing to become independent
masters of their craft. There is evidence that loss of the autonomy drives
burnout and when this happens, our patients feel it . A nd our patients are
affected b ecause when we talk about the sacred bond , the patient - physician
relationship , whenever I am in the exam room , th e patient knows when I a m
not well . The consolidation of the medical system and the corresponding you
know corporatization of medical practice which is having the physicians lose
th eir autonomy and have to become employed , that also increase s physician
burnout and a lso a ffect s patient .

W hen we speak to the lack of autonomy , the decision - making and patient -
physician relationship is impeded by all these influences and it causes more
burnout. I feel that mountains of useless paperwork is typically perceived as
meaningless and it does not help our patients and it doesn't help ou r
physicians . Examining the patient ; listening to the patient instead of clicking ,
wasting a lot of their time on unnecessary trivia that someone else can do for
them.

Margaret Flinter: I know th at as a professor of medicine , you spent a considerable
amount of your time training the next generation of physicians and around
the faculty of the Boston College School of Nursing . So I know you are
engaged with nurses and nurse practitioners, probably as well . So you have a
st
great perch on the new clinicians , who are coming int o our 21 century
m odel of c are . I think about our new cli nicians coming into practice. Mostly
they a re not taking call , huge difference in terms of what we used to see as a
major cause of burnout , they are incredibly effective at advocating for
flexible hours , t hey have a team that supports them that is trained to a far
higher level than years ago in terms of the work that’s been done with
medical assistance , the role of RNs in primary care . They are pretty good at
setting their boundaries .

So you have entire generation of people who really got caught up in
enorm ous and sweeping and stressful changes , Electronic Health Record
changes in practice ownership . Is there any research that's going on looking
at , i s this particularly severe and accentuated in the generations of incredible
people who devoted their lives to a particular model and got caught up in all
this change , and does it spend the generational divide s?

Alain Chaoui: I have been blessed to teach and work with medical students NPs and PA s
students . I believe this new generation is going to be the answer fo r fixing th e
healthcare system. They are very smart , t hey are very tech - savvy and they
value a work - life balance. I would admit that when I was at the beginning of
my career and then till today I m ean work is very , very important to me . I did
get to miss a lot of my famil y’s times . S ome of the reports will show that by
2025 , we will have a shortage of 90,000 physicians , Margaret. And teaching

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medical students NPs and PA s student is a very important part of my practice .
I believe by preparing the new generat ion of clinicians , by teaching them how
to work smarter and as a part of a team they would be a lot more prepared
to lead the change for a better healthcare for our patients in our country.

Studies show that when the healthcare team allows each member of t he
team to function at the top of the license , burnout is cut in half , but the
quality of patient care is much improved . There is a study done at the
University of Colorado , a team - based care model that improve s job
satisfaction. W hen our healthcare system places too much burden on
clinicians , w e should not be surprised that the results are sub - optimal access ,
poor outcomes and increased burnout. But with team - based care models,
increasing patient a ccess , you will also have improved clinical quality , and
yo u cut the burnout in half.

Also, there are some studies that show that increasing the medical assistant
to clinician ratio to 2.5 to 1 and expanding the roles of the medical assistant
throughout the patient visit , can help the practices achieve what we cal led
the Quadruple Aim . Improve patient health outcomes , enhance the patient
experience and then lowering the cost of care and the total medical expense.
The fourth part is improved the work - life of physicians and their team .

I f I could end with this very i mportant message , at the end of the report t here
are six directives that I would love people to be able to read and understand ,
for the sake of our patients and our healthcare system , these will bring back
the joy into the practice of medicine , they will i mprove the access and the
quality of patient s care and signif icantly reduce the cost of care.

Mark Masselli: We ha ve been speaking today with Dr. Alain Chaoui, immediate past
president of the Massachusetts Medical Society and co - author of a New
Report on t he Health Crisis , a Physician Burnout in American Healthcare . You
can access the report by going to www.massmed.org or follow them on
Twitter at Mass Medical . Dr. Chaoui, thank you so much for your
commitment to the p ractice of medicine and for joining us on Conversations
on Healthcare t oday .

Alain Chaoui: Mark and Mar garet, thank you for having me on -- .

Mark Masselli: At Conversations on Healthcare, we want our audience to be truly in the
know, when it comes to the f acts about healthcare reform and policy, Lori
Robertson is an award - winning journalist and Managing Editor of
FactCheck.org, a non - partisan, nonprofit consumer advocate for voters that
aim to reduce the level of deception in U.S. politics. Lori, what have you got
for us this week?

Lori Robertson: Former Vice President Joe Biden recently changed his position on the
Hyde Amendment with his campaign saying, he supported it and within days
Biden, a democratic presidential candidate saying, he had changed his st anch.
Biden said, “If I believe healthcare is a right , as I do , I can no longer support

20190617Chaoui

an amendment that makes that right dependent on someone's zip code.”
What is the Hyde Amendment ? The 1976 measure is a federal ban on the
funding of abortion . It restri cts federal funding of abortion to only cases of
rape, incest or endangerment t o the mother's life . Since it restricts federal
funding it effects coverage of abortion under Medicaid , a federal state
program that primarily serve s low - income individuals.

The Kaiser Family Foundation explains that the Hyde Amendment was passed
as a rider to a Health & Human Services Appropriation B i ll and has been
renewed each year by Congress. The Affordable Care Act similarly included
language to block federal subsidies used to buy private insurance on the
market places from being used for abortion services . Under Medicaid some
states do use their own funding to pay for abortion beyond th ose exception s .
According to the Guttmacher Institute, 15 state s have polic ies t o cover a ll or
most medically necessary abortion through Medicaid . F our states provide
funding in cases of fetal impairment and four pay for abortions when there i s
a risk of long - term damage to a wom a n's physical health.

The Kaiser Family Foundation estimates that 14.5 million women of
reproductive age are enrolled in Medicaid. The Hyde Amendment also affect s
other federal program, including the Indian Health Service , the Children's
Health Insurance Program and Medicare . A nd that’s my fact check f or this
week, I am Lori Robert son, Managing Editor of FactCheck.org.

Margarent Flinter: FactCheck.org is committed to factual accuracy from the country’s
major political players and is a project of the Annenberg Public Policy Center
at the University of Pennsylvania. If you have a fact that you would like
checked, email us at www.chcradio.com , we will have FactCheck.org’s , Lori
Robertson, check it out for you, here on Conversations on Healthcare.

[Musi c ]

Mar garet Flinter : Each week C on versations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Vaccinations are
th
considered one of the great public health achievements of the 20 century,
reducing fatalities f or most common and fatal diseases by up to 99% . A s
recently as 2009, only 45% of the nation's preschool age children had
received all of their recommended vaccinations and boosters . R esearchers at
the Children's Outcome Research Program at Children's Hospital in Colorado ,
decided to take an in - depth look at the problem .

Dr. Allison Kempe: Primary care practitioners are so overstretched that it's rather
impractical , and they also require a level of technical expertise that
sometimes they don't have .

Margaret Flinter : Dr. Allison Kempe condu cted a study on what would help to generate
better compliance with required vaccinations. S he found that when parents
receive timely reminders from their state and local health departments ,
p arents were much more likely to get the vaccinations and boosters for the ir

20190617Chaoui

children that they needed .

Dr. Allison Kempe : W hat our study did w as to centralize those efforts , so it didn't take
away from the primary care providers, but it helped them to do the reminder
recall for their practices centrally using a State Re gistry .

Margaret Flinter: Dr. Kempe says he r research shows that when a reminder message
can be generated for an entire population across communities , i t takes the
onus and the burden off of the primary care and pediatric practices .

Dr. Allison Kempe : Abou t 19% of children who are not up - to - date became up - to - date ,
versus about 13% in the practice - based recall state. So which , on a
population level within six months it’s really very powerful .

Margaret Flinter: And the s tudy also suggest s that there is a cost savings with a
centralized state or county run database and reminder system.

Dr. Allison Kempe : I can tell you that there have been some studies in recent years ,
showing outbreaks related to a lack of immunizations. One case of influenza e
haemophilus , men ingitis can cost tens of thousands of dollars .

Margaret Flinter : A state health department driven vaccination program that assist
private practices in vaccine compliance for the ir patient population ,
improving vaccination rates of young and vulnerable chil dren , n ow that's a
bright idea .

[Musi c ]

Mark Masselli: You have been listening to Conversations on Healthcare.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Peace and health.

Moderator: Conversations on Healthcare is recorded at WESU at Wesle yan University,
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