Subscribe to The Podcast by KevinMD. Catch up on old episodes!

Join Diane Shannon, an internal medicine physician and physician coach. Explore the evolving landscape of physician autonomy and discover actionable insights on how health care professionals can regain agency and empower themselves for a more fulfilling career and life.

Diane W. Shannon is an internal medicine physician and physician coach and can be reached at her self-titled site, Diane W. Shannon.

She discusses the KevinMD article, “Physicians have no autonomy. Here’s how to change that.”

Careers by KevinMD is your gateway to health care success. We connect you with real-time, exclusive resources like job boards, news updates, and salary insights, all tailored for health care professionals. With expertise in uniting top talent and leading employers across the nation’s largest health care hiring network, we’re your partner in shaping health care’s future. Fulfill your health care journey at KevinMD.com/careers.

VISIT SPONSOR → https://kevinmd.com/careers

Discovering disability insurance? Pattern understands your concerns. Over 20,000 doctors trust us for straightforward, affordable coverage. We handle everything from quotes to paperwork. Say goodbye to insurance stress – visit Pattern today at KevinMD.com/pattern.

VISIT SPONSOR → https://kevinmd.com/pattern

SUBSCRIBE TO THE PODCAST → https://kevinmd.com/podcast

RECOMMENDED BY KEVINMD → https://kevinmd.com/recommended

GET CME FOR THIS EPISODE → https://earnc.me/ktxOPk

Powered by CMEfy.

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Diane Shannon. She’s an internal medicine physician and a physician coach. Today’s KevinMD article is titled “Physicians have no autonomy. Here’s how to change that.” Diane, welcome back to the show.

Diane W. Shannon: Thank you so much, Kevin. It’s great to be here today.

Kevin Pho: So Diane’s been on multiple times. Go to KevinMD.com/podcast; there’s a little search icon in the upper right-hand corner, and you can search for Diane’s name and prior episodes to hear her story. Today I want to talk about physician autonomy, because I do think it’s a critical issue facing all clinicians today. The article is titled “Physicians have no autonomy. Here’s how to change that.” Tell us how this article came together.

Diane W. Shannon: Mostly it’s from my experience coaching over the past five years. I coach frontline physicians, and I can tell you that the situation is pretty dire. In terms of autonomy, what I’m hearing is that it’s a huge pressure. We know from the research that one of the key drivers of professional burnout is loss of control, and we have seen that over decades, but it’s accelerated in recent times. I’m hearing over and over again about situations where physicians want to treat patients in a high-quality, safe, compassionate way, and they feel like their hands are tied and they can’t do the things they know are right, which we know leads to moral distress and moral injury. So there are all kinds of connections and reasons why we really need to look at this.

Kevin Pho: So give us some specific examples that really illustrate that loss of autonomy, because whenever we talk about moral distress, moral injury and burnout with the non-clinician population, sometimes there’s a lack of empathy, because they don’t quite know how that loss of autonomy can impact patients. From your coaching of clinicians, what are some specific examples where loss of autonomy can lead to detrimental patient care?

Diane W. Shannon: One example is when there’s a medication that you know is the number one thing you should be providing to this patient, and you can’t do it. Either it’s a prior authorization issue, or it’s just not on the formulary, or the cost to the patient would be so high that they’d be choosing between eating and taking the medication. So you know what’s best, and you can’t do it.

The other big place I see it is time, especially for primary care physicians, who have that ongoing relationship with patients. Right now, with a workforce shortage both in support staff and in clinicians, if you say, “OK, we have to deal with these two things today; we can’t deal with the other seven. You need to come back,” there’s no slot for them to fit into. So you feel like you have to do all of it, and that then extends into after-hours, doing all your notes after hours in order to do what’s best for the person right in front of you. We know that the more you work on the EHR at home, the higher your risk of burnout, and that then leads to more access problems. So I think there’s a direct connection between the physician being able to be there in the moment and do their best, and their autonomy: their ability to provide the time, the medications and the clinical decision-making that are really needed for the best patient care.

Kevin Pho: So those two scenarios you mentioned, not being able to prescribe a specific medication because of prior authorization, or not being able to address all of a patient’s issues in a single visit, how do they impact physicians emotionally?

Diane W. Shannon: Oh my gosh. I think it comes back, over and over again, to why we came into medicine. All of us want to alleviate suffering; that’s why we’re here. If we didn’t, we would have gone into something else. And here we are, with a person in front of us, and we can’t do that. Talk about stress levels, and also just the wearing away of the meaning of why we do what we do. A lot of the physicians I coach will say, “Well, I can put up with this; maybe it’s a little bit of extra drudgery, the scut work. But if I don’t see the difference I’m making, if I can’t make a difference, if I can’t do what I’m here to do, why am I here?” It really wears away at the energy and the bandwidth you have to show up every day. I have learned that one of the key quotes, like a red signal for burnout, is “I dread going to work.” Dread. How long can you make yourself do something when you’re dreading it, and how can you do it at your best? You can’t.

Kevin Pho: Now, you’ve been coaching physicians for a while. Are these stories of physicians losing autonomy more frequent now than they had been in the past? And are the themes you mentioned, whether it’s prior authorization, not enough time or the EHR, universal across outpatient and inpatient physicians, primary care physicians and specialists? Are they cutting across all specialties?

Diane W. Shannon: In primary care, it’s often about the time to develop those relationships and to have the access that those repeated visits need. In the ED, it may be that there’s such a backlog of admissions that we’re having to hold patients and can’t do the work we need to do. There’s also, in a way, the lack of relationships, or the degrading of relationships, between the ED docs and some of the specialists, just because everyone is so busy, and that makes it that much harder to get those consults and have them happen quickly. Everybody is stretched so thin right now.

Kevin Pho: So let’s say a physician comes to you with that exact scenario, encountering moral distress or burnout because of the inability to provide optimal patient care. Take us into one of your coaching sessions. What kind of direction, advice or guidance would you give that particular physician?

Diane W. Shannon: Well, I separate training from coaching, and in my coaching, I would talk about what matters to them, and also go through their day and look at literally what it looks like: Where are the places where they have some control, and where could they make a different choice? When you think about the commonalities among those of us who end up in medicine, we do have some traits in common, for example perfectionism, people pleasing or a lack of confidence. Those tend to come up, and they can get in your way. So it’s about being aware: Where is my perfectionism leading me down a rabbit hole, where I’m wasting energy, and where is it actually clinically necessary that this be perfect? That’s an example of raising awareness and helping the person plan a little experiment, just slightly outside their comfort zone, to try something different and see what happens.

One of the biggest places I’ve seen this have an impact is with the EHR and work outside of work. Two things I would share: One is looking at pre-charting, especially for folks who have ongoing relationships, in primary care and other specialties. How are you doing it, and when do you have focused time to do it? The other is trying to finish the note before the next patient. Even if it’s not 100 percent done before the next patient, even if you’re getting from 0 percent to 25, that’s that much less you have to do at the end of the day. Then we talk through what you might do to make that happen, to be able to finish the note in between.

Kevin Pho: For those physicians who say they’re unable to do that, what are the typical barriers that prevent them?

Diane W. Shannon: I think one of them is this: There you are, trying to get your note done, and you are interrupted every 30 seconds. So one piece that can help is to think upstream. Is there a way of batching those interruptions? Speak with your MA or your nurse and say, “I’m going to check in with you halfway through the morning. If you could batch any non-urgent messages for me, we can talk at that point.” Then you’ll have fewer interruptions when you’re sitting down trying to get that done.

I think the other part is really looking at the guilt feelings that come up when you imagine the next patient waiting for you. There’s a trade-off. You don’t want them waiting too long, but on some level, are you going to accommodate to the extent that at the end of the day you have no charts done and it’s all on your own time? So where is that balance?

Kevin Pho: So it sounds like these are all examples where physicians have to take a proactive approach, that prerogative, to reclaim some of the autonomy that’s been taken away from them, because if they don’t do any of the things you describe, more and more autonomy will be taken away and they may spiral further into burnout. So it’s really up to the clinician to speak up, and whether it’s batching interruptions or pre-charting, they have to take a proactive approach to protect themselves against burnout. Am I reading that correctly?

Diane W. Shannon: Absolutely. And I think one of the tricky places is that when this starts to happen, you feel more and more like you have no choices. It’s about turning that around and saying, “Wait a second. Where in my environment do I have a choice?” and just trying one small change. That small change can then help you get the energy to do more. The way I think about one-on-one coaching is that by helping a single clinician have the bandwidth to begin looking at the practice inefficiencies or the organizational inefficiencies, there’s a spillover effect that can improve things for everyone and make everyone’s experience better. But if all clinicians are just trying to get through the day and don’t have the bandwidth to raise their heads and look at anything or take the prerogative, then it is going to continue to get worse.

Kevin Pho: Now, give us an example, or a success story, of a physician who came to you with this exact scenario, whom you coached to reclaim small moments of autonomy. Can you share a success story?

Diane W. Shannon: A physician came to me who was a primary care internist working 0.6 FTE, so three days in the clinic, and yet she was working every single day. She came and said, “I just want one day off. I just want one day away from the monotony of doing notes every day.” She had three small children and a spouse, and yet her weekends and her evenings were taken up with this. So she took on some of these specific small tasks. The changes she started with were pre-charting and trying to finish before the next patient, and she came back two weeks later and said, “I had a Saturday off.” Then she kept at it and kept adding little tweaks to how she was working: the flow of patients through the clinic, when she would do the charting and the phone calls, and all the tasks that go along with that. She got to the point where she had 80 percent of her charts done by the end of the day, so there wasn’t that much to do before she left, and she then had the whole weekend off. She said, “It’s been 14 years. Why didn’t I try this sooner?” It made a huge difference in her experience at work and also at home. And she said, “I realize now I was getting kind of bored, because I was doing charting every day, and now I can put my focus back on the clinical work, which I really love.”

Kevin Pho: Now, in your experience, how difficult is it for physicians to change their mindset into that success story?

Diane W. Shannon: Gosh, well, let me put it this way. A lot of times physicians come to me and they’re like, “I cannot do this anymore. Something has to change.” For many of them, we’re able to tweak where they are, the decisions they’re making and where they set boundaries, and they can stay where they are, find a way to make it work and have a sustainable, satisfying career. Some choose to leave their organization, and some, and I would say this is rare, choose to leave medicine entirely, or leave clinical practice entirely. My wish is that more physicians would seek help earlier, because that’s the point where you can go from good to great, instead of, “I am falling apart. My life isn’t working. I can’t do this, and now I’m desperate.” I can help you at that point, but it would be a lot more fun, easier and more productive to start earlier.

Kevin Pho: Now, these are great examples of fixing things on an individual level, but that doesn’t take away from the fact that, on a more macro level, more and more autonomy is being taken away from physicians. Is there anything physicians can do on a more global, macro level to reclaim some of that autonomy for the profession?

Diane W. Shannon: I think that comes from joining together. No one person can make those systemic changes, but together, when people have the bandwidth and are being proactive in looking at where we need to make changes, they can. One example I would bring up is the noncompete agreement. So many of the physicians I work with find, if they even think of moving to a different organization, that they’ve got a yearlong noncompete, and if they’re in an urban area, it may cover every other place they could work without moving. One individual is probably not going to be able to negotiate that out of a contract with a large health system, but if a number of physicians banded together as a group, or a professional organization worked on it, that could be changed. That’s another example of where physicians’ autonomy has been constricted: your autonomy to choose to leave where you are and go work somewhere else that may have a better culture, better benefits or just a better work life. So that’s an example of where, by banding together, maybe we could get that changed.

Kevin Pho: We’re talking to Diane Shannon. She’s an internal medicine physician and physician coach. Today’s KevinMD article is titled “Physicians have no autonomy. Here’s how to change that.” Diane, one of the things you said earlier is that you want physicians to seek help at an earlier stage, rather than letting things get so dire that they’re thinking of leaving their jobs or leaving medicine completely. What do you mean by that? Do you mean coaching? What other resources can physicians turn to when you tell them to get help earlier?

Diane W. Shannon: Well, I think there are always mental health professionals. That is a place to start, and it works very well in parallel with coaching. Not everyone needs it, but that’s definitely something I want to mention, and especially for physicians who are at risk, take a step to get help early. Coaching is another example, either individual or group. And I think also reaching out to peers and mentors, just to let people know you’re struggling. That can be a very hard thing to do, but even starting those conversations begins to rebuild the camaraderie that we have also lost over the past years, as we’ve become busier and there are fewer opportunities to meet in person. So I think that’s a really important piece: looking for where I can find that connection, both in person and online.

Kevin Pho: And my final question, Diane: Tell us some of the take-home messages that you want to leave with the KevinMD audience.

Diane W. Shannon: I think one that I’ve said before is that we’re human. Somehow we get this message that we’re not human, that we can withstand anything and keep going. I myself have found that this is not true, and it’s not true for any of us. We deserve to have lives at work.

Kevin Pho: Diane, thank you again for coming on the show and sharing your perspective.

Diane W. Shannon: Thank you so much, Kevin.