A System to Identify Overworked Doctors: Is it Possible?

Doctors spend roughly around 34 hours working with patients per week or around 22 minutes per encounter. Too often, they go very long hours without breaks, while still being held to the best standards. Doctors cannot possibly be expected to provide patient care to their full potential when they are overworked. Failures in doctor performance are not rare, but they pose a threat to patient safety and well-being. Some failures may be caused by short-term stressors, such as being overworked or emotionally distraught, while others may be a result of more severe problems, such as mental or physical illness.

A recent survey conducted on 500 healthcare professionals found that over 40% took on more patients than they could handle. Moreover, 25% of the doctors said that their excessive workload prevented them from being able to clearly discuss medication and treatment options with their patients. This, in turn, led over 22% of the doctors to order unnecessary tests because they did not have enough time to properly examine their patients’ medical charts. “If a hospitalist is short on time and a patient is having chest pains, for example, the doctor may be more likely to order additional tests, prescribe aspirin and call a cardiologist, all because there isn't adequate time to immediately and fully evaluate the patient,” said Dr. Henry Michtalik, an assistant professor of medicine at the Johns Hopkins University School of Medicine.

Unfortunately, very few medical practices and hospitals respond to such failures in a timely and efficient manner. The failure to ensure patient safety and well-being is a breach in healthcare’s responsibility to the public. A major reason why these healthcare organizations lack proper responses to performance failures is because they do not have the adequate systems to monitor doctor performance and to identify shortcomings. Currently, research shows that a majority of medical errors are attributable to a lack of functional systems or just faulty systems that lead careful healthcare professionals to make errors. In order to identify and develop safer systems, medical practices and hospitals require better performance measures and expansions of current external programs. This is a task that requires effort on a national level for the purpose of implementing safer practices and helping doctors who are overworked.

First and foremost, it is necessary to identify a few key terms that represent professional competence. Such terms include knowledge, communication, technical skills, medical reasoning, values, passion, emotions, and daily reflections in practice. Failure to adhere to any one of these factors can redirect a doctor’s attention from a patient, thereby leading to a lack in clinical judgement and performance.

Secondly, it is important to identify underlying causes that threaten doctor performance and patient safety. Such causes include mental or physical illness, substance abuse or dependence, cognitive impairment or failure to maintain/acquire much-needed knowledge and skills. Stressors that contribute to such causes include overwork, a dysfunctional workplace, pressure from the supervisor, difficulty balancing personal and professional life, and anxiety. Within medical practices and hospitals, a ‘normal’ amount of stress is to be expected when working in a fast-paced clinical environment. However, when stress starts to build up, such as from being overworked, it can lead to more severe problems. “Physicians need to be trained to understand their limits. They need to learn how to care for patients in circumstances of fatigue, because they themselves will function in clinical practice after graduation in circumstances where they are fatigued,” said Thomas Nasca, CEO at ACGME.

Thirdly, it is necessary to identify the extent of the problem within the workplace because every medical practice and hospital is different. When factors and causes are taken into consideration, it has been estimated that at some point in their careers, one third of all doctors will experience a period that will affect their ability to practice medicine safely. Therefore, ensuring high standards of professionalism is the greatest obligation that healthcare organizations have to the general public.

Neither doctors nor medical practices and hospitals have been able to properly implement systems to identify overworked doctors or to address performance problems. In fact, very few organizations monitor doctor performance or have programs to identify potential problems. Why is this so? A healthcare organization cannot implement systems to identify overworked doctors if doctors are reluctant to confront behavioral or competence problems, which a majority of them are. Consequently, departments often lack the training and skills necessary for monitoring doctors whose performances are slipping. In more severe cases, disciplinary action may be met with lawsuits or countercharges. In a worst-case scenario, every individual involved is potentially at risk.

To date, there are a few national or state regulations on competence or rather, measures for monitoring performance. State medical boards tend to discipline doctors after the fact or once malpractice settlements are being reviewed. Therefore, the responsibility is quite clear: to identify overworked and burned out doctors early on and to address the problems in a timely manner. To do so, better measures and programs are required to identify doctors who are in need of help and to provide help to those in need.

A model monitoring system would be one that is routine and proactive. It would merely focus on clinical and behavioral performance, taking into account 3 factors: objectiveness, fairness, and responsiveness. Evaluations would be made based on data gathered in accordance with performance regulations (objectiveness); evaluations would be open and unbiased in accordance with labor regulations (fairness); and problems would be treated with feedback, internal counseling, referral programs, or further assessment (responsiveness). Still, a national effort is required to accomplish 3 main objectives:

• To develop guidelines for yearly data-based assessment on doctor performance and to implement them among healthcare organizations.
• To implement better behavioral and performance measures.
• To develop more local and national centers for assessment and remedial therapy of doctors with performance failures.

As to whether a system can be implemented to identify overworked doctors, the answer derives from the ability to manage all underlying causes of poor performance: behavioral problems, substance abuse, mental or physical illness, etc. Programs should be personalized in an effort to enable the professional to use his or her strengths to the best of their ability. In turn, the demonstration of a professional’s competence, in compliance with national standardized guidelines, could please certification and state renewal license requirements. Failure to demonstrate professional competence by refusing to accept monitoring, treatment, or any necessary measures of practice must result in a referral to the state medical board.

An effective system for identifying overworked doctors and managing performance issues is built on objectively defining proper performance, monitoring performance of staff members on a regular basis, and responding to any performance failures/problems in a prompt, fair, and constructive manner. The long-term objective of such a system would enable doctors to continue to practice medicine both safely and effectively, all the while ensuring patient safety and well-being. If the system works properly, it could pinpoint doctors who perform poorly, doctors who are burned out, or doctors who are overworked, before more severe consequences arise. “Personally speaking, every day at the hospital is challenging. I have to see a lot of patients, and most are extremely sick. I am usually pressed for time, but I try to do my best. Patient care remains a priority, but I also have to abide by hospital rules in terms of timely admissions and discharge in an attempt to appease the hospital administrators. I try my best to balance patient care with the bureaucratic side of hospital medicine. We all took the oath to do no harm and serve as patient advocates. Ultimately, we are doing the best we can for our patients despite the overwhelming hospital expectations and demands. I hope there is a positive change soon when it comes to improving patient safety measures, but I also hope that the people involved in making that change understand the physician’s challenges,” wrote Neha Sharma, a hospitalist.