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How the EHR Rollout Fueled Physician Burnout
How the EHR Rollout Fueled Physician Burnout
What happens when an industry is forced to become pioneers overnight? We were told it was progress. We felt like we were failing.
What happens when an industry is forced to become pioneers overnight? We were told it was progress. We felt like we were failing.
During my residency the hospital I trained at did not have computerized records except for labs. All imaging was printed to film; all charting was still handwritten. This is the era where you went down to radiology to ask for films each morning at 4 am on the neurosurgery rotation in order to get all of the head CTs hung for morning rounds. If you were doing chart review for research you had to request and wait for all of the paper charts to be brought in from long-term storage. Humans transcribed notes that I dictated. I would go down to medical records to sign charts. The information available was more limited, which led to different expectations for what you should know about a patient.
The Broken Promise:
The Broken Promise:
Then the electronic health record arrived. We were told it would Save Time! Save Money! Improve Patient Outcomes! After a few hours of training we were set loose using a whole new system to care for patients without any real idea of how to use it.
It was easy to articulate the potential benefits. A system that allows multiple users to simultaneously access a complete patient record is a huge benefit. Additional safety improvements result from standardized order entry, drug and allergy checks, and legibility. Efficiencies can be gained from decision-support, reduction in duplication of testing, and patient access to the records.
However, at implementation, these tools were not truly ready for prime time. This is not surprising. An immense, industry-wide overhaul like this will require multiple iterations before reaching the “promised land”. The reality is that early EHR systems were not optimized for users. On top of their normal cognitive load for patient care, physicians also had to manage the complexity of the interface, data overload, excessive alerts, and new sources of duties which are often uncompensated (“pajama time”).
The Pioneer Penalty: Why Unready Tech Triggers Burnout
The Pioneer Penalty: Why Unready Tech Triggers Burnout
Over a period of 10-15 years, the day-to-day details of the job of practicing medicine fundamentally changed. Many people are familiar with the graph for technology adoption. Only about 16% of people fall into the Innovator and Early Adopter groups. Being a pioneer is challenging and requires immense effort and commitment. By their very definition, pioneers are willing to be on the leading edge of the curve - they have a higher tolerance for uncertainty and change. When people are forced to adopt new technology ahead of their personal adoption curve, they feel cognitive dissonance, anxiety and frustration, perceived loss of control, and a sense of isolation.
Being shoehorned into becoming digital pioneers without the advertised time savings and improvements in patient care leads to reduced engagement, cynicism and depersonalization, and decreased job satisfaction - all significant risk factors for burnout.
Unhelpful Advice: The Lie of Resilience and Systemic Gaslighting
Unhelpful Advice: The Lie of Resilience and Systemic Gaslighting
The response from many administrators, IT, and the EHR vendors often felt like gaslighting. An idealized fictional workflow would be shown as the standard, ignoring the reality that the implemented instance of the EHR didn’t have all of that functionality yet or that the user didn’t have the training to take advantage of it. Physicians were left wondering what they were doing wrong while simultaneously without the resources or pathway to improve.
When physicians expressed frustration, they were made to feel that they were the problem. It was a crisis of both identity and competence. In response, administrators offered mandatory presentations on preventing burn-out, which primarily advocated for physicians to be more resilient and practice more self-care.
Having progressed through the gauntlet of medical school and residency, physicians are uniquely resilient so this advice was unhelpful at best and victim-blaming at worst. There was limited acknowledgement that the bulk of the problem resided with the system, implementation, and expectations, which were largely outside of the physicians’ control.
Name It to Tame It
Name It to Tame It
I am aware that I’m not offering a solution here. The electronic health record tidal wave has already crashed over the entire health care system. What I’m offering here is an explanation for the damage this has caused to health care providers.
My hope is that by giving physicians insight that they may have been hijacked into a pioneer role, they will be better able to respond to their reactions. “Name it to Tame it.” While I am intimately familiar with how this occurred in healthcare, this is happening in many industries. In what specific way have you felt "shoehorned" into a pioneer role? Naming the source of the frustration is the first step toward taming it.
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