University of Wisconsin–Madison ⋅ Medical College of Wisconsin
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The Three Confounding Elements of the Triple Aim

Joseph Edward Fojtik, MD, MPH

WMJ. 2021;120(4):260-261.

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The United States health care system has been described as inefficient, delivering inconsistent levels of care and inordinately expensive; the question is not if it needs transformation but how to do so. In 2008, Donald Berwick and associates described the Triple Aim, in which improving the patient’s experience of care, improving the health of populations of patients, and reducing the per capita cost of care may lead to a high-quality health care system, facilitating this transformation.1

Several issues have since evolved, impeding the Triple Aim from attaining its goals. Although several could be cited, three are of primacy: the decline of primary care, physician burnout, and the accumulating amount of unmeaningful work for practicing physicians. These three confound the Triple Aim, act as barriers to any meaningful transformation, and need mitigation to move forward; they also may be interrelated and irreducible to the extent correcting one requires correcting all.

Primary care continues to decline.2 Despite several studies showing a strong primary care presence improves a community’s health care outcomes,3 it continues to be underfunded, challenged in recruiting medical students, and increasingly fragmented.4-6

Primary care spending, an index for primary care funding, has remained historically low in the United States at 5.5% to 7.1% and compares unfavorably with other countries.7 This may partially explain the comparatively low income of generalist specialists and why medical students choose primary care in anemic numbers.8 Medical student recruitment also is challenged by primary care’s demising prestige, which has been exacerbated by the recent political demands to expand scope of practice laws by other health care professions. Medical students may pause and consider that their education is now societally perceived to be not necessary in order to deliver presumptively equitable primary care. Primary care also has become more fragmented and difficult to manage. Generalists, increasingly electronically isolated and unaware of their patient’s location in the medical neighborhood, may believe the “chart on the rake” is quiescent when, in fact, the patient is in a nearby intensive care unit (ICU).9 Patients, encouraged to be health care consumers, seek alternative modes of care outside their generalist’s purview, circumventing and minimalizing the patient-physician relationship.10

Team-based care and patient-centered medical home initiatives, among other developments, may reverse some of these trends. More innovated interventions are needed, as the decline of primary care adversely affects the Triple Aim by limiting access to the high level of quality care it implicitly requires.

The effects of physician burnout on physicians have been described for over 2 decades,11 but only recently has its indirect sequalae on patients, populations of patients, and the cost of care been appreciated.

Patient care is directly affected by burnout. Medical errors, ICU mortality rates, and longer discharge recovery times are positively correlated with burnout and decrease the patient’s experience of care.12-14 Populations of patients are also indirectly affected. Increased physician turnover, decreased physician work effort, and productivity are positively correlated with burnout,15-17 which impedes access to care, strains local health care resources, and destabilizes remaining physicians’ patient panel sizes.18 The cost of care is also affected. Increased medical orders and referral rates19 and increased physician turnover are all positively correlated with burnout, which increases health care costs. The decreased physician work effort and productivity, equivalent to the lost productivity of 7 graduating medical school classes,20 may also transform simple, inexpensive care into delayed, expensive care.

Recent initiatives addressing burnout have been promising. Medical schools now incorporate physician burnout in their curricula, national organizations have wellness initiatives, and medical groups have initiated wellness committees with chief wellness officer positions. Although the prevalence of physician burnout has improved,21 it remains significantly entrenched in the profession. More innovations are critically needed, as physician burnout affects the Triple Aim specifically at the 3 areas it endeavors to improve.

Of the 3 confounding issues to the Triple Aim, unmeaningful work may be the least understood and its adverse effects on primary care and physician burnout most underappreciated. Any work associated with direct patient care may be meaningful. However, work not license-level appropriate nor clinically relevant to the work at hand may be perceived as unmeaningful. Unmeaningful work could be further defined as cognitive work demanded upon a physician that is not license-level appropriate, adds no value to a clinical encounter, and typically must be completed to finalize that encounter. Further work is needed to refine unmeaningful work’s definition and develop its taxonomy. Preliminary subgroups could include miscellaneous unmeaningful work units, electronic frustrations, and redundant layers of complexity.

Several examples of these subgroups could be given, but only a few will suffice to underscore unmeaningful work’s subtle pervasiveness in medicine. Unmeaningful work units include the requirement of computerized physician order entries to be completed only by physicians due to the persistent misinterpretation of regulatory statutes associated with them.22 Electronic frustrations, widespread within the now widely perceived dysfunctional electronic health record (EHR) ecosystem, include the seemingly endless EHR pop-ups intruding into a clinical encounter.23 Redundant layers of complexity are the added, unnecessary requirements health care entities compel physicians to complete to order to practice medicine within those entities and that supersede a Medical Practice Act’s requirements and include discordant continuing medical education and maintenance of certification activities.24

Unmeaningful work intrudes upon the cognitive work needed in a clinical encounter, acts as a disrupter to care, and invades the cognitive workspace needed by a physician in that encounter. Recent work evaluating cognitive load in clinical settings has been promising,25 but further work on how unmeaningful work negatively affects physician well-being is needed. A principle or overarching ethic is also wanting—one that describes the physician’s cognitive workspace utilized in a clinical setting and endeavors to safely protect it. Further studies also are needed to evaluate if protecting a physician’s cognitive workspace decreases unmeaningful work, decreases physician burnout, and affects the ongoing demise of primary care.

The dysfunctional status of the US health care system persists. Meaningful transformation remains elusive. Several factors confound the Triple Aim, and unmeaningful work is the least understood. Its presence underscores that an ethic is needed to protect physicians and their cognitive workspace within a clinical setting.

REFERENCES

  1. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769. doi:10.1377/hlthaff.27.3.759
  2. Petterson S, McNellis R, Klink K, Meyers D, Bazemore A. The state of primary care in the United States: a chartbook of facts and statistics. Robert Graham Center; 2018. Accessed May 22, 2021. https://www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/PrimaryCareChartbook.pdf
  3. Phillips Jr RL, Bazemore AW. Primary care and why it matters for US health system reform. Health Aff (Millwood). 2010;29(5):806-810. doi:10.1377/hlthaff.2010.0020
  4. Reid R, Damberg C, Friedberg MW. Primary care spending in the fee-for-service Medicare population. JAMA Intern Med.
  5. Kost A, Bentley A, Phillips J, Kelly C, Prunuske J, Morley CP. Graduating medical student perspectives on factors influencing specialty choice an AAFP National Survey. Fam Med. 2019;51(2):129-136. doi:10.22454/FamMed.2019.136973
  6. Wagner EH, Sandhu N, Coleman K, Phillips KE, Sugarman JR. Improving care coordination in primary care. Med Care. 2014;52(11 Suppl) 4):S33-38. doi:10.1097/mlr.0000000000000197
  7. Koller CF, Khullar D. Primary care spending rate—a lever for encouraging investment in primary care. New Engl J Med. 2017;377(18):1709-1711. doi:10.1056/nejmp1709538
  8. National Resident Matching Program. Results and Data: 2018. National Resident Matching Program; 2018. Accessed June 8, 2021. http://www.nrmp.org/wp-content/uploads/2018/04/Main-Match-Result-and-Data-2018.pdf.
  9. Jones CD, Vu MB, O’Donnell CM, Anderson ME, Patel S, Wald HL, Coleman EA, DeWalt DA. A failure to communicate: a qualitative exploration of care coordination between hospitalists and primary care providers around patient hospitalizations. J Gen Intern Med. 2015;30(4):417-424. doi:10.1007/s11606-014-3056-x
  10. Reid RO, Ashwood JS, Friedberg MW, Weber ES, Setodji CM, Mehrotra A. Retail clinic visits and receipt of primary care. J Gen Intern Med. 2013;28(4):504-512. doi:10.1007/s11606-012-2243-x
  11. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med. 2018;283(6):516-529. doi:10.1111/joim.12752
  12. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000. doi:10.1097/SLA.0b013e3181bfdab3
  13. Welp A, Meier LL, Manser T. Emotional exhaustion and workload predict clinician-rated and objective patient safety. Front Psychol. 2015;5:1573. doi:10.3389/fpsyg.2014.01573
  14. Halbesleben JR, Rathert C. Linking physician burnout and patient outcomes: exploring the dyadic relationship between physicians and patients. Health Care Manage Rev. 2008;33(1):29-39. doi:10.1097/01.HMR.0000304493.87898.72
  15. Willard-Grace R, Knox M, Huang B, Hammer H, Kivlahan C, Grumbach K. Burnout and health care workforce turnover. Ann Fam Med. 2019;17(1):36-41. doi:10.1370/afm.2338
  16. Shanafelt TD, Mungo M, Schmitgen J, et al. Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clin Proc. 2016;91(4):422-431. doi:10.1016/j.mayocp.2016.02.001
  17. Dewa CS, Loong D, Bonato S, Thanh NX, Jacobs P. How does burnout affect physician productivity? A systematic literature review. BMC Health Serv Res. 2014;14(1):325. doi:10.1186/1472-6963-14-325
  18. Brown S, Gunderman RB. Viewpoint: enhancing the professional fulfillment of physicians. Acad Med. 2006;81(6):577-582. doi:10.1097/01.acm.0000225224.27776.0d
  19. Kushnir T, Greenberg D, Madjar N, Hadari I, Yermiahu Y, Bachner YG. Is burnout associated with referral rates among primary care physicians in community clinics? Fam Pract. 2014;31(1):44-50. doi:10.1093/fampra/cmt060
  20. Shanafelt TD, Dyrbye LN, West CP, Sinsky CA. Potential impact of burnout on the US physician workforce. Mayo Clin Proc. 2016;91(11):1667-1668. doi:10.1016/j.mayocp.2016.08.016
  21. Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clin Proc. 2019;94(9):1681-1694.
  22. CPOE: Is order entry a physician-only EHR task? American Medical Association. Accessed March 18, 2021. https://www.ama-assn.org/practice-management/medicare-medicaid/cpoe-order-entry-physician-only-ehr-task
  23. McCoy AB, Thomas EJ, Krousel-Wood M, Sittig DF. Clinical decision support alert appropriateness: a review and proposal for improvement. Ochsner J. 2014;14(2):195-202.
  24. Shanafelt TD, Dyrbye LN, West CP. Addressing physician burnout: the way forward. JAMA. 2017;317(9):901-902. doi:10.1001/jama.2017.0076
  25. Harry E, Sinsky C, Dyrbye LN, et al. Physician task load and the risk of burnout among US physicians in a national survey. Jt Comm J Qual Patient Saf. 2021;47(2):76-85. doi.org/10.1016/j.jcjq.2020.09.011

Author Affiliations: Illinois Department of Financial and Professional Regulation, Chicago, Illinois (Fojtik).
Corresponding Author: Joseph Edward Fojtik, MD, MPH, FACP, Illinois Department of Financial and Professional Regulation, 500 W Monroe St, Ste 500, Chicago, IL 60661; email joseph.fojtik@illinois.gov; ORCID ID 0000-0002-8403-7155.
Acknowledgement: The views put forth are solely of the author and do not represent the Illinois Department of Financial and Professional Regulation.
Financial Disclosures: None declared.
Funding/Support: None declared.

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