Keywords
physician burnout - patient advocacy - insurance authorization - healthcare legislation
Recent data in a systematic JAMA review report that the prevalence of physician burnout
is over 80%.[1] While the exact percentage varied across specialties, none were immune to its effects.
It is well established that physician burnout has a significant negative impact upon
patient healthcare experiences, patient outcomes, physician health, and well-being,
including significantly higher rates of physician suicide compared with the general
population. There is growing evidence that physician burnout can be deadly for both
patients and physicians.[2]
[3]
Most of the literature on the topic of physician burnout emphasizes eliminating obvious
risk factors, such as long work hours and the negative impact of the implementation
of electronic medical records (EMR), which are often burdensome, awkward, and user-unfriendly.
Accordingly, over the past 20 years, the United States has restricted work hours for
residents and begun offering numerous mental health initiatives, such as access to
mental health providers and training on stress management techniques with some positive
impact.[4]
[5]
[6]
[7]
[8]
However, these initiatives do not address other significant and perhaps more important
causes of burnout—loss of autonomy, professional purpose, and meaning. In a broken
healthcare system, physicians often burn out because their long hours and hard work
seem powerless to make a true difference in patients' lives.[9] After all, most of us in the medical profession were motivated to become physicians
to help and to heal in some way. When we encounter, again and again, barriers to care,
such as lack of insurance coverage and other healthcare inequities that render us
ineffective and powerless to properly treat our patients, we become frustrated, anxious,
angry, depressed, and burned out.[10]
[11] In a powerful essay published in The New England Journal of Medicine, Leo Eisenstein writes that “In this link between social determinants of health and
burnout, I see a problem, but also a way forward. If individual powerlessness is the
crux of this source of burnout, then organizing toward a collective action should
be part of the solution.”[12] We propose that advocating for your patients can be a powerful solution to address
physician burnout.
But what do we mean by patient advocacy and how do we go about advocating? Don't we
advocate for our patients every day? In every encounter? We do! However, we're talking
about going beyond the prescriptions you write and the surgeries you perform. We are
talking about stepping up to use your extensive knowledge, experience, and credibility
as a physician to make significant changes to patient care outside of the individual
physician–patient encounter. This can be as simple as fighting for insurance authorization
for a medically necessary procedure for your patient, to writing an editorial for
a newspaper or a blog to raise awareness of healthcare issues, working to help pass
legislation that will improve healthcare access and equity, or even traveling to remote
areas of the globe to improve healthcare for people with very little healthcare access.[12]
[13]
[14]
Examples of Patient Advocacy
When news broke about the Flint, MI, water crisis, it was Dr. Mona Hanna-Attisha,
a pediatrician, who noted the systemically elevated lead levels in her patient's laboratory
work. Following research in both her own patients and through electronic health records,
she risked her career to reveal her findings at a public health conference prior to
it being scientifically peer-reviewed. A day after releasing her study, the city of
Flint put out a health advisory telling residents, especially children, to minimize
their exposure to Flint tap water. While she initially faced backlash from the state
of Michigan Health Department, Dr. Hanna-Attisha's findings were later confirmed by
The Detroit Free Press where she was recognized publicly by Governor Snyder for her
work.[15]
Similarly, physicians worked tirelessly with numerous other stake holders to pass
through Congress the recently passed law known as H.R. 1318 or The Preventing Maternal
Deaths Act of 2018. In an effort to reduce the excessively high and rising maternal
mortality rate in the United States, the law establishes a platform and allocates
millions of dollars for collecting and analyzing data on maternal death. While much
more work needs to be done, this is a critical step forward in the public health effort
to save postpartum mothers' lives.[16]
[17]
Yet, patient advocacy does not always have to take place on such a large scale. In
fact, most often, it takes place in small moments between the doctor and patient.
For many like myself, it has required that I get involved and actively take part in
fighting for insurance coverage for my patients. This means I have had to learn a
lot about insurance: deductibles, coinsurance, and prior authorizations, as well as
the structure of different types of insurance plans and how to properly use CPT and
ICD10 coding to not only receive reimbursement but also to allow the patients maximum
access to their benefits.
Last year, one of my patients almost died of a ruptured ectopic pregnancy. She had
insurance coverage for in vitro fertilization (IVF), but she still had one tube open;
her policy required her to have six failed intrauterine insemination (IUI) cycles
with exogenous hormone medication to access her IVF benefits. Given the significant
risks and costs of recurrent ectopic, and the significant costs and reduced efficacy
of medicated IUI cycles and then paying for the IVF anyway, the insurance company
could reduce patient stress, patient risk, and potentially their own costs by going
straight to IVF with single embryo transfer.[18]
[19]
[20] I filed an appeal which was denied, so I filed a second appeal. Sometimes this does
not work, but this extra effort often results in a successful appeal. No matter the
outcome, the patients always appreciate the efforts on their behalf, and that alone
can be gratifying for their physicians. In addition, our billing staff has now learned
that they also have a voice and can advocate for patients. Having a billing staff
who advocates for patient access has made a traditionally adversarial relationship
between the patient and the biller into a positive one that benefits the staff, the
patients, and the physicians. This culture change alone is a significant part of why
I look forward coming to work each day and goes a long way to reducing burnout for
me.
The power of this kind of advocacy—just one patient at a time in your office with
the insurance company—seems small but can have much larger benefits for you and your
patients. We have spoken about this with other patients, with our staff, and with
the public through blogs and social media. These stories have power and hope. The
positive energy this generates with your patients should not be taken lightly. When
your patient knows that she is not alone, that you stand with her in her struggle
to access proper care in a broken healthcare system, you give her hope and positivity.
We all know that one of the biggest barriers to success with fertility treatment in
this country is the dropout rate, and that patient dropout is often due to the loss
of hope.[21] This “one case at a time” advocacy tells your patient that she is worth fighting
for, that you believe she has a chance to succeed with treatment, and that you believe
helping her get the treatment she needs is worth your time and effort.
One of our patients felt so empowered by our advocacy in helping her to access her
insurance benefits, that she was inspired to join with her wife and another lesbian
couple to sue NJ State for discrimination under the NJ State Family Building Mandate.[22] Her lawsuit raised awareness and inspired action on the part of the NJ legislature.
The 2001 law written for “husbands and wives” that had infertility was wonderful in
terms of providing access to IVF and infertility treatment but was full of discrimination
and bias and needed to be updated. In 2017, the new NJ Mandate was signed into law
removing the biases and many of the barriers against LGBTQ people and single people
who wanted and needed to use IVF to build their families. My patient told me later
that our attitude toward her care, that our belief that she deserved access to care,
and our willingness to fight for her individual access, gave her the hope and resolve
to proceed and improve access for people like her across an entire state. She and
her wife were just trying to have a baby, but they truly changed the world. NJ state
is a leader in access to infertility treatment for all, including the LGBTQ community,
but advocates across the country are using the successes in NJ to inform their advocacy
work in other states and at the federal level.[23]
Other examples of physician advocacy that are occurring across the nation include
the work being done by medical students and physicians at the Medical College of Wisconsin
to identify and address needs of homeless pregnant women in their community. They
found that more information and education was welcomed by this population and identified
many areas of need that could improve health and outcomes in these moms and babies.[24] This study will launch future initiatives beneficial not only to the pregnant women
in the homeless shelter but also to medical student education and medical student
gratification with their education. Key areas identified by medical student––run focus
groups were as follows: the need and desire for more pregnancy-related information
and education, wanting to take a Lamaze class but not being able to afford it; logistics
of getting to prenatal appointments, not having a mode of transportation, and needing
help in understanding what happens during a pregnancy and during prenatal appointments
as well as during labor and delivery. From these data, easily identified solutions
could be as simple as providing buses or volunteer transport services or developing
educational programs in homeless shelters and recruiting health advocates for women
by accompanying them to prenatal appointments. By identifying the needs of our shared
communities, we can better advocate for our patient's well-being and better serve
public health crisis.
Yet another example of physician advocacy leading to legislation that is making a
real difference in patients' lives is the recent passage of new mandates in Connecticut,
Rhode Island, and New Jersey providing for coverage for fertility preservation for
cancer patients or other patients facing medical conditions that may render them infertile.[25] Getting involved in these types of efforts for reproductive endocrinologists is
as easy and accessible as signing up for the Resolve.org email list, which keeps their
recipients up to date on multiple local and national opportunities for advocacy: some
of them simple, like donating money to Resolve.org to support their patient education
and their legislative efforts to improve reproductive healthcare access, or emailing
a Senator; some of them are more involved such as going to DC to speak with Congressional
representatives during the annual Resolve/American Society for Reproductive Medicine
(ASRM) Advocacy Day each year in May, or testifying about oncofertility in front of
a state legislative committee. Working with an organization such as Resolve, ASRM,
the American College of Obstetricians and Gynecologists (ACOG), or the American Medical
Association (AMA) can help physicians to become more effective advocates, since these
organizations already have a tremendous amount of knowledge about things like the
legislative process and physicians can contribute in their areas of strength—medical
knowledge and patient experience.
Another form of advocacy is medical mission work. In New Jersey, the Robert Wood Johnson
Barnabas Health Care System (RWJBH)—the largest hospital system in New Jersey—has
implemented programs aimed at improving global health, supporting graduate medical
education, and addressing physician burnout by creating easily accessible ways for
all physicians and employees in the system to support multiple medical missions throughout
the world—from simple things like pretax payroll deductions to traveling the globe
on sophisticated medical missions aimed at creating better systems for healthcare
around the world. One recent mission sent a team of gynecologists to Peru to train
dozens of Peruvian nurses to see and treat cervical dysplasia and cancer using low-tech,
low-cost methods like acetic acid cervical wash, visualization of acetowhite areas,
and then providing same-day cryo of the cervix. Dr. Sadural is the Director of Global
Health for the RWJBH system and this project collaborates with the Peruvian government
to help eradicate cervical cancer in Peru, which has one of the highest rates of cervical
cancer deaths in the Americas. The nurses trained in this low-tech, see-and-treat
protocol will be traveling by equipped vans throughout remote areas of Peru with no
previous access to routine gynecologic care. As Dr. Sadural states, “The RWJ Barnabas
Health Office of Global Health is developing a systemwide volunteer program for clinicians
to combat burnout. In addition to the primary benefit gained by underserved communities
globally, we posit that volunteering combats physician burnout through social camaraderie,
connection to intrinsic motivators and purpose, a shift from administrative burdens
to “pure” medicine and creative problem-solving, all of which can be energizing.”[26]
The Benefits of Patient Advocacy: Raising the Bar for Healthcare and Reducing Physician
Burnout
Overall, it is true that public aid, policy, or reform would seldom be possible without
the voices of physicians in the community speaking out and being heard. Whether it
is health insurance reform, the opioid epidemic, or even climate change, physicians
have a voice that can make a positive difference in policy. In an opinion piece published
in The Inquirer by the University of Pennsylvania School of Medicine, it was explained that, “Central
to our work is the belief that human health is inextricably linked to the conditions
in which we live, learn, work, and play…. Understanding the social drivers of health
and illness is not peripheral or tangential to health. It is key to diagnosing and
meeting a patient's fundamental needs and to restoring health.”[27] Health determines our social well-being and vice versa. Because this is true, social
disparities and inequities are inherently a part of our job as healthcare providers
in caring for the health of both our individual patients and our global society.
Organizations such as Resolve (https://resolve.org/) and the ASRM (https://www.asrm.org/) are advocating daily for better patient care and equitable access to care at the
state and national legislative and public awareness levels. Getting involved with
organizations such as these can be an easy and effective way to advocate for our patients.
Other articles in this monograph detail the work already done to successfully improve
access to assisted reproduction and fertility preservation for our patients who serve
in the military.
Patient advocacy outside of the traditional doctor–patient relationship can be unfamiliar
for many physicians because it is not part of our formal medical training. However,
successful advocacy utilizes the skills, knowledge, and experience you already have
as a physician. Having a medical degree and real patient care experience allows you
to speak eloquently, powerfully, and authentically to an insurance company or a Senator
or Congressional Committee about medical issues ([Table 1]). Physicians who have done this, who have advocated for better healthcare, have
made a difference for others and for themselves.[28]
Table 1
Four advocacy skills attributes physicians already possess
|
Medical expertise
|
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Credibility
|
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Communication skills
|
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Real-life patient care experience
|
Being a doctor today is difficult. Working under the tremendous burdens of a broken
healthcare system day after day creates a high risk for burnout. The consequences
of burnout can be deadly for both physicians and their patients. The things you do
every day, when directed toward even small efforts of advocacy, can make large differences
for your patients and yourself. Through patient advocacy, we can prioritize the doctor–patient
relationship again. As healthcare professionals, we are poised to make great change,
scientifically and socially. However, if we choose not to act as advocates then change
will never come and the status quo will remain the same—a broken healthcare system.
Physicians can be of tremendous benefit to advocacy efforts. That is the purpose of
this essay—to recruit valuable people to this effort. We want to make the case that
advocacy benefits not only society and your patients but also you personally ([Table 2]). Advocacy directly addresses some of the most powerful causes for physician burnout—the
loss of autonomy, purpose, and meaning in medicine. The skills you already possess
as a physician can make you a powerful and effective patient advocate. The process
of advocating for individual patients or larger groups or policy changes can connect
you with patients and colleagues in meaningful and gratifying ways. Connecting with
other advocates can be fun, energizing, and empowering, which, in turn, can reduce
physician burnout. Thank you for taking out the time to read this article, we hope
that you will help us promote physician advocacy as a solution to physician burnout.
Table 2
Ten ways advocacy addresses physician burnout
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Improves physician autonomy
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Improves physician–patient relationships
|
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Provides opportunities to connect, collaborate, and network
|
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Provides an opportunity to be an agent for change
|
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Can improve patient optimism, hope, and compliance
|
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Can be an opportunity for marketing
|
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Can introduce diversity, enjoyment, and interest into your normal routine
|
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Can be a morale builder for your staff
|
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Can improve healthcare
|
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Provides opportunities to make a positive impact at a global level
|
