Spring 2023 (Volume 33, Number 1)
Balancing Burnout, Burden Reduction
and Appropriateness
By Philip A. Baer, MDCM, FRCPC, FACR
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Scenes from my office recently: A patient of mine is
transitioning to another rheumatologist closer to
where she lives. She said she would miss me, particularly
because of my help in obtaining WheelTrans for
her (a mobility service for those with disabilities). Could
I do one last thing for her, and fill out her disability tax
credit (DTC) form? Unfortunately, the answer had to be
no, as the criteria for the DTC are more stringent than for
mobility assistance.
The next patient arrived with a bright red envelope
perched on the seat of her walker. Given we were meeting
in January, that could have been a card for our office for
New Year or Lunar New Year. But it was not. Instead, I was
presented with a form from a small country thousands of
kilometers away, asking me to stipulate that my patient
was still alive. Reminiscent of old Canadian passport applications,
only certain professionals could be trusted as
guarantors. Now there are a lot of fraudulent supercentenarians
apparently,1 but my patient was only in her 70s.
I laughed when I saw that both a signature and an office
stamp were required; yes, I have one of those from
30 years ago, but most doctors probably don’t anymore.
Rheumatology used to be called “The Happiest Specialty.”
2 Now studies say we have high levels of burnout,
even surveys conducted at the Maui winter rheumatology
conference!3 My inbox and medical social media feeds are
deluged with links to articles on burnout, burden, and
forms. Reading it all is dangerous to one’s mental health.
As a result, our Editorial Board decided that the Journal of
the Canadian Rheumatology Association (CRAJ) theme issue on the topic
should focus on wellness rather than burnout, to put
a more positive spin on the issue.
Everyone seems to agree burnout relates to systemic
issues. So, we are now engaged in burden reduction. The
Medical Post mentioned a burden reduction committee
in British Columbia, and Doctors Nova Scotia made the
news with their survey on how much time doctors spend
on administrative tasks. Even the Canadian Federation
of Independent Business (CFIB) has taken up our cause,
given the importance of health care to businesses, and
the fact that most medical practices are small businesses.
One appeal of larger corporate and investor-run medical
clinics is their claim to handle the business side, leaving
doctors free to concentrate on medical practice. Of course,
the forms burden still falls on physicians. At the Ontario
Medical Association (OMA), we have a Forms Committee
taking up the challenge, with our own Dr. Jane Purvis
highly engaged as a member.
The other side of the burden coin is the issue of appropriateness.
We are all familiar with inappropriate test
ordering of ANAsa, RFsb, anti-CCPsc, ENAsd, and imaging
such as knee MRIse when plain X-rays have already demonstrated
osteoarthritis (OA). Choosing Wisely Canada
is working on the matter, but based on the referrals
that come through my office, they have a lot of work to
do to achieve their goals. Our standard provincial lab requisition
has tried a different approach, with some tests
moving from ordering by ticking a box to having to write
or type out the lab test name to order it. That apparently
works for tests such as TSHf and ferritin. For a couple of
tests, namely PSAg and Vitamin D levels, there are tick
boxes to designate the test as appropriate and government
paid, or as uninsured and billed to the patient.
Speaking of MRIs, a recent blog by Dr. Sohail Gandhi,
ex-OMA President, mentioned that to order an MRI as a
GP (general practitioner), he had to fill out an MRI appropriateness
form in addition to the MRI requisition.4 He
didn’t seem to mind, but that is the battleground between
burden and appropriateness that we are all facing.
Other examples of that battle: sending me a referral
note with the one word “arthritis?” reduces burden on the
referring doctor, but increases the triage burden on the
consultant. Sending a hundred pages of duplicated lab
results with the referral might also reduce the burden on
the GP (“just fax them the whole chart”), but the burden
at our end is no less. And what about one of my most
common referral sources who doesn’t know how to attach
documents to their referral letter? We have become
experts at merging various categories of imaging tests and
lab results into a single document as a result.
The latest office skirmish in the war on burden: I saw
a patient a few months ago for knee OA. Injections were
given, and I told the GP that the patient could be referred
to an orthopedic regional assessment clinic (RAC)
if knee replacement surgery was desired in future. The
RAC requires a specific referral form (burden). Recently,
I received a document from the regional home care
service with an updated knee X-ray, my last note, and a
blank RAC referral form. The implication was clear: the
GP had made a referral, but the key form had not been completed. My choices: fax the document back to the GP
or to home care, stating that the GP needs to complete
the form (burden reduction for me, burden increase for
GP). Or, since it is a mutual patient, and I had suggested
the orthopedic referral, and I have completed the RAC
form many times, and it autopopulates much of the required
info from my electronic medical record (EMR), I
could take care of it myself and feel I had done my good
deed for the day. So, I completed the form and sent it to
the proper place. But I also noticed that the patient must
bring a CDh of their knee X-ray to the appointment (burden
and cost to patient). So, I closed the loop by calling
the patient. Much to my surprise, she told me she already
had an appointment at the RAC next week! Conclusion 1:
The GP must have completed the proper referral form
eventually. Very unclear why I would then be sent a blank
referral form. Conclusion 2: calling our current state of
affairs a healthcare “system” is laughable.
Philip A. Baer, MDCM, FRCPC, FACR
Editor-in-chief, CRAJ
Scarborough, Ontario
Glossary:
aANA: antinuclear antibody
bRF: rheumatoid factor
canti-CCP: anti-cyclic citrullinated peptide
dENA: extractable nuclear antigens
eMRI: magnetic resonance imaging
fTSH: thyroid-stimulating hormone
gPSA: prostate-specific antigen
hCD: compact disc
References:
1. Newman SJ, Supercentenarian and remarkable age records exhibit patterns indicative of clerical
errors and pension fraud. bioRxiv preprint doi: https://doi.org/10.1101/704080.
2. O’Dell J. The Happiest Specialty: Rheumatology Is #1! The Rheumatologist. Available at https://www.the-rheumatologist.org/article/the-happiest-specialty-rheumatology-is-1. Accessed
March 1, 2023.
3. Tiwari V, Kavanaugh A, Martin G, Bergman M. High Burden of Burnout on Rheumatology Practitioners.
J Rheumatol. 2020: 47(12):1831-1834. doi: https://doi.org/10.3899/jrheum.191110.
4. Gandhi S. Moving Procedures to IHFs is a Step in the Right Direction (January 17, 2023 entry).
Avaialble at https://justanoldcountrydoctor.com. Accessed March 1, 2023.
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