Stopping burnout at the source: Delegating administrative burden

I was drowning in a sea of administrative requirements. With the advent of the electronic health record at my health system, I moved much more slowly through patient visits and spent much of my time staring at the screen rather than making eye contact with my patients.

I poured more and more of my days (and my evenings) into tasks that did not require years of medical school and residency training. Like all too many other family physicians, I was burning out.

My longtime nurse felt similarly worn out and when she turned in her resignation, it was the last straw — I knew I needed to figure out a better way of practicing medicine.

What I wanted was an experience more like a surgeon, who walks into the operating room with the patient prepared, the equipment ready, and the nurses available. That vision inspired me to tinker, experiment, and innovate to create a comprehensive primary care workflow that would allow me to focus just on the tasks that required my MD designation.

Equipping, empowering, and expanding my clinical support staff not only freed me up from administrative tasks that I should have delegated years earlier, it also allowed me to improve care and increase patient access. I was enjoying medicine again and was going home at night with my charts 100% current.

My patients were delighted to find that they could now make same-day appointments for acute conditions rather than seeing a stranger at an urgent care center. System leadership at Riverside Health System in Newport News, Virginia, was delighted to see my financial profile flip from losing six figures per year to the most productive practice in the network.

In the ensuing years, the Team Care Medicine Model has been endorsed by the American Medical Association, the American Board of Internal Medicine, the American Academy of Family Physicians, and other health care leaders across the United States. The TCM Model reflects a handful of basic insights but, like individual steps in a dance, putting them all together in a cohesive, organic sequence takes good coaching and intentional practice. To be clear, it is not a set of tips and techniques to be selected à la carte based on personal preference.

The transformation starts with a major shift in mentality for the physician. Though medical schools rarely include the management training coursework included in an MBA program, physicians must embrace the reality that they manage a team. Their role can and should be less like the star player that needs the ball in their hands all the time and more like the team captain that raises the performance of the entire team through coaching and leadership on and off the court.

In the TCM Model, the clinical staff (registered nurses, medical assistants, etc.) take on a role called the Team Care Assistant. They execute six discrete steps in the patient visit. Crucially, the physician is only present for two of them. Much of the administrative work is performed at the beginning and the end of the visit, and is performed by the TCA rather than the physician.

When the physician is present, the TCA summarizes the preliminary medical information that has already been collected, in much of the same way that a medical student presents the patient’s case to the attending physician. Then the TCA scribes the very concise examination by the physician, freeing up the physician to hone in on the diagnosis and prescription without even touching the keyboard.

Because they operate extensively without the physician in the room, each TCA offers dramatically more leverage to the physician’s time than a scribe. Indeed, a high functioning TCM physician can be supported by up to four TCAs at the same time, while an individual physician never needs more than one scribe.

In recent years, the TCM Model has been adopted by a range of practices from coast to coast, including small federally qualified health centers and large integrated delivery networks. Physicians have learned to coach, to lead, and to delegate in the exam room; they’re reporting restored joy in medicine as they engage the patient rather than the computer screen and then go home on time with all their charts current. With improved clinic access, patients are delighted to get same day acute appointments with their own physician rather than an urgent care center. Executives are pleased by a strong ROI as the increase in visit volumes easily covers the conversion costs, not to mention the improved morale and retention of the physicians. This is just the beginning and I’m delighted that relief from administrative burden is beginning to restore primary care nationwide.

This article is reprinted with permission from The Ohio Academy of Family Physicians, Winter 2018 edition.