Doctors, nurses and the paperwork crisis that could unite them

They don’t always get along. But they are both under siege by the bureaucracy of a failing health care system.

By and Stephen Bergman | 5 minute read | January 15, 2020

Originally published on Dec. 31, 2019, in The New York Times:

Broken, wasteful, inhuman, expensive, deadly. The problems with the American health care system, or non-system, are neither subtle nor unrecognized — especially by those of us doctors and nurses who actually provide the care. And yet we all too often feel the most helpless, seeing how much of the problem is driven by drug companies and hospital networks.

Too often, each profession sees the other as fighting separate battles, and sometimes against each other. Doctors blame nurses, and vice versa, for the failings of a system that punishes us all, and our patients.

Instead, the two of us are suggesting that nurses and doctors try something unusual. Let’s put our differences aside and work together to achieve real change, starting with a pernicious problem that drives so much of our mutual discontent: electronic health records.

The current system is pushing both doctors and nurses to the breaking point. Enough doctors in the United States commit suicide every year to fill two large medical school classes.1 A 2019 MedScape report found that 44 percent of physicians feel “burned out,” driving many to alcoholism and depression, or to leave the profession entirely.2

Nurse suicides are not systematically measured and reported, but a 2017 study in England found a suicide rate among nurses that was 23 percent above the national average.3 Half of all nurses are considering leaving the profession, according to a 2017 study by RNnetwork.4

Clinicians are notoriously overworked, but ask anyone on hospital staff, and he or she will tell you that workloads have become heavier the last several years, thanks almost entirely to the arrival of electronic health records — detailed reports about a patient’s medical history and care. Originally intended as a work-saving tool, the records have gone in the opposite direction, taking time away from patient care in the name of electronic box-checking.

A new report from the National Academy of Medicine says that on average nurses and doctors spend 50 percent of their workday treating the screen, not the patient, and that “increased documentation time” associated with electronic health records can lead to burnout. Burnout is also tied to finishing documentation at home, a necessity for many physicians, and for nurses who provide home care.5

The use of electronic health records increased significantly with the 2009 passage of the Health Information Technology for Economic and Clinical Health Act, which offered financial incentives for hospitals to adopt them. Such records promised efficiency and better teamwork, but as they increasingly serve the needs of America’s corporate, profit-motivated health care, those promises remain mostly unfulfilled.

Insurance companies and hospitals demand ever more data to make decisions about payments and billing, so clinicians have to provide much more information about each patient at each interaction. Mounting regulatory requirements that get built into these records are described as ensuring patient safety but are ultimately tied to compensation, which means money. And in a system rife with legal risks, there is a strong incentive to over-document everything.

This is why nurses and physicians must come together. We must acknowledge the harm done by these ever-increasing documentation requirements, without losing the core benefits of electronic record keeping.

One inspiration comes from a surprising place. Electronic health records are almost universally disliked, with one telling exception, those used by clinicians at the Department of Veterans Affairs. The reason: Billing concerns don’t shape the records at government-run V.A. hospitals. They document only what’s necessary to deliver better care.

Why can’t the rest of the health care system do the same? For example, some hospitals already have a periodic review of their electronic health records, paring items that do not relate directly to patients; more hospitals could do the same, and all could do it more aggressively. Another: A group of coders at Intermountain Healthcare in Utah is working on a more radical solution, called “activity-based design,” which updates records by voice, and offers helpful care algorithms to clinicians as they interact with patients.

Part of the reason for inaction is that not enough clinicians are making it loud and clear that change is necessary. Doing so requires a unified voice across our professions — and unfortunately, right now, doctors and nurses are anything but unified.

Physicians earn much more money than nurses and have a much higher status in the medical hierarchy, which can lead to resentment from nurses when that higher status is abused. The gendered history of both professions also contributes to a view of nurses as fundamentally subordinate to physicians.

Most important, the experience of nurses is often invisible to doctors, even though they typically work alongside them. There are examples of respectful working friendships on the front lines, but the legacy of hierarchy persists and keeps us from focusing on our common struggles.

Doctors would be wise to let nurses take the lead. For years, nurses have organized to improve hospital working conditions, in particular, fighting for better staffing levels. The Service Employees International Union and National Nurses United represent nurses all over the United States, and in general, are good at getting their demands met.

Doctors, on the other hand, have no similar organizations, no national unions and little experience in activism on workplace issues. Maybe it’s the myth of the single, heroic doctor that keeps them from recognizing the strength in collective efforts. Or maybe they believe their high status will protect them from the worst of the profit-focused excesses in American health care.

If so, those beliefs are collapsing, as most physicians are becoming painfully aware that no one will be spared, and that bureaucratic nightmares like electronic health records have impaired their ability to do their jobs well, much less enjoy them.

The millions of us, nurses and doctors, who directly attend to patients want the best for them, and yet are prevented from caring by profiteering and gross inefficiency. We need to restore caring to health care. For nurses, doctors, and even patients who take on this fight, the life you save may indeed be your own.

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  1. Anzia, Joan. M. July 21, 2016. It’s Time to Recognize and Prevent the Tragedy of Physician Suicide. STAT News.
  3. Windsor-Shellard, Ben. March 17, 2017. Suicide by occupation among females. Office of National Statistics.
  4. Portrait of a Modern Nurse Survey Finds Half of Nurses Consider Leaving the Profession. February 2017. RN Network.
  5. Carayon,Pascale. Cassel, Christine. October 23, 2019. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. The National Academy of Medicine.


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