C. Matthew Hawkins, MD

Physician burnout is receiving a substantial amount of national attention currently. There are a number of organizations that have identified this entity as an epidemic – one that threatens health care in this country. Many professionals have begun to devote their academic careers to burnout and figure out how best to mitigate it. In fact, the emotions that this topic elicits are impressive. Simply reading the comment sections following various blogs/posts addressing burnout reveal an inner-fury that is insinuating throughout the fabric of physicians from all specialties. This is indeed a problem.

There are some very smart people implementing creative solutions to this crisis. And before I continue any further – I must acknowledge that I think physician burnout is real, it is important, and we need to deal with this swiftly and effectively.

But, while it is easy to jump on the burnout bandwagon, a few hard questions should be asked and answered – before we collectively reach (perhaps overreach) for solutions to a problem we are yet to fully understand.

1. In an era of work-hour restrictions and emphasis on work-life balance, why is burnout at an all-time high NOW?

2. What are physicians who are NOT burnt-out doing differently? (Maybe they’re just emotionally numb...?)

Oft cited reasons for burnout among radiologists and other physicians are plentiful. Pain points include EMR mandates, lack of tort reform/defensive medicine, quality reporting metrics, increased individual accountability, voice-recognition software, increasingly challenging patients, health care websites, student loans, declining reimbursement, non-physician administrators, insurance companies, pre-authorization, radiology benefit managers, peer-review discoverability, driving Hondas instead of Acuras, other policies, offices without windows, bad parking, and cessation of unlimited free scrubs.

We can’t fix all of these things in health care. And yet – again – there are physicians that aren’t burning out. Why?

Now – I don’t claim to be an expert in the burnout field. I am far from it. I am classified by many as a failing work-aholic that put life out to pasture while pursuing a fairy-tale treasure at the bottom of a career-abyss. But I think one singular question may begin to at least raise attention regarding a dominant reason many of us in health care are burning out.[[{"type":"media","view_mode":"media_crop","fid":"52453","attributes":{"alt":"Physician burnout","class":"media-image media-image-right","id":"media_crop_1868704444348","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6514","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 205px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©Lightspring/Shutterstock.com","typeof":"foaf:Image"}}]]

How many of us like the people we work with?

I don’t mean “like” as in, “He is so nice!” or, “She is great to hang out with.” I’m talking about a relationship of mutual understanding and common goals. Where team members respect the skill set that each brings to the table and where each is intrinsically motivated to do a little extra to reach the level of performance that is jointly expected by all members of the team. Where accountability is considered premium. Where everyone on the team is excited about the opportunity to excel beyond the conventional bounds of health care-workflow-limiting vices. How many people work with a team like that?

High-functioning teams have a few common characteristics:

 Ability to adapt to unforeseen circumstances quickly

 Continuous learning and willingness to identify areas for improvement

We should all take a moment and reflect on these characteristics and ask ourselves whether or not our work-teams embody them. And I am not suggesting to only think about our physician teams – rather I am imploring us to reflect upon the 

 teams we work with every day. Nurses, technologists, trainees, medical assistants, ancillary staff, etc.

Now again, let’s think about physicians that 

 burning out. Are they more or less likely to be a part of high-functioning teams? Perhaps, nurturing and promoting the development of high functioning teams in health care would be a sound strategy for battling the health care burnout epidemic.

But, how much time to we actually devote in health care to building and studying high-functioning teams? I think we all agree that there are some high-functioning teams in health care. Why aren’t we studying them more? What is the highest functioning team in your department? What are they doing differently?

 regarding high-functioning teams is by Liz Ryan. And to quote her directly, “Making your team’s focus the achievement of goals and milestones imposed on them by someone high up in the chain, someone who is not part of the team and has no mission-connection to them, is the best way to stop your team’s forward motion.”

I would offer that most of our teams in health care and in radiology are charged with doing exactly what is described in the quote above. Seems like a poor strategy…

I am not here to endorse or criticize existing efforts to fight physician burnout. But I would encourage that our profession – radiology – lead the charge in creating environments that promote the development of flourishing, high-functioning teams. To trust our leaders to function autonomously and intrinsically motivate their teams, rather than menially “manage” them and “monitor” performance.

If physicians work on teams with people they like -- putting effort into work that they believe in -- they won’t burn out.

Articles

Addressing physician burnout in radiology.

Physician Burnout and High-functioning Teams

Some stories must be told. Even when they are not your own.

So here it goes. This is the story of a radiologist with a vision. Conviction. And an unwavering passion to make that vision tangible, despite institutional inertia and human blockade. His drive has cultivated a movement that will transcend our profession…if we allow it. 

David Larson (Stanford), through a variety of experiences during training and his early career, deduced that there had to be a better way of doing things; that our broken health care system could be fixed with a systematic approach to quality and improvement. He believed that rather than overly focusing effort and resources complying with arbitrary benchmarks and federally legislated standards, institutions could transform health care by scientifically implementing performance improvement programs that continuously evaluate quality, implement change when necessary, and monitor the effectiveness of interventions. Rather than “meeting a standard” or “aiming for compliance” – we should strive to “

This type of thinking is transcendent. Instead of telling health care workers “how” they should do something – this approach empowers teams of people to solve problems and discover improved methods to perform their craft. It promotes engagement, coaching, introspection, and willingness to tolerate failure (in light of the underlying premise of improvement). It is the antithesis of “policies” and “standards” that are often unilaterally determined yet universally enforced. This mind-set suggests that only through trial and error, iterative attempts, and systematic methods can real improvement and 

 be achieve in health care. This value is realized in both reduced cost and improved outcomes. [[{"type":"media","view_mode":"media_crop","fid":"46263","attributes":{"alt":"lesson in radiology","class":"media-image media-image-right","id":"media_crop_4637267334449","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5358","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â©CoraMax/Shutterstock.com","typeof":"foaf:Image"}}]]

The scientific field of “improvement” has transformed manufacturing and service industries. Pioneers such as Demming and Crosby serve as role models, such that this ideal of performance improvement is founded by reality – not simply wishful thinking. Isn’t it time we learn from this scientific discipline and utilize its principles to transform medicine – health care – caring for the disease(d)?

In the radiology department at Stanford, a Radiology Improvement Team has been constructed and charged with helping members of the radiology team improve and solve problems. They are not relied upon for solutions – but rather deployed to aid dedicated teams in mapping processes, identifying areas for improvement, implementing interventions, and tracking sustainability of their efforts. The improvement team empowers front-line workers to influence behavior and execution – and inspire other co-workers. They do not solve the problems. They help others do so.

The improvement team is comprised of individuals trained in quality improvement methodologies. They are not necessarily physicians, nurses, or technologists (although they can be).  Rather they are experts at change management, program implementation, and team building. When accompanied by visionary physician leadership – this team becomes remarkably influential. 

The team in Palo Alto is aligned with the leadership structure of the department, and integrated throughout the enterprise. In a very short time, their squad has successfully improved workplace satisfaction for administrative associates and reduced the amount of time it takes to transport patients to and from the radiology department. They have reduced wait times for women being screened for breast cancer and slashed time-to-treatment for patients suffering from a stroke. Wouldn’t it be nice if this could be accomplished at all institutions?  (Pause) 

Why can’t it be?  Why shouldn’t it be?

While reading this story, do not be distracted by the definition of “quality.” For “quality” is in the eye of the beholder. The beauty of this transcendent approach is that while “quality” can depend on perception, “performance” cannot. Either you are getting better, staying the same, or getting worse.  There is not poetic license in the interpretation of “performance.”

Dr. Larson and his team have demonstrated that this approach works even in complex organizations. It has redefined “quality” – such that the definition used by members of this camp refer to “quality” as “consistent excellent performance;” a definition that offers a time-frame and degree of expected performance. This counters antiquated quality-assurance workers who aimed to investigate “never-events” and audit “compliance” – rather than driving behavior change and performance improvement.

The conundrum is that “performance improvement” in radiology is not yet a discipline. There is little guidance, literature, or precedent. In comparison – in the “discipline” of interventional radiology – there is literature and a body of knowledge that can help a new leader build an interventional oncology program or thrombolysis clinical care guidelines. In contradistinction, a radiologist charged with improving performance in his/her department usually has little (if any) guidance or formal training to help build their program. While the work at Stanford is a breakthrough, they need our community’s support and resources to allow for patients outside of Silicon Valley to reap the benefits of health care entities that embrace this methodology. Does this emerging discipline need its own society? Does it need a journal for scholarly publication? Does it need a formal fellowship training program for physician leaders?

But I do know that existing leaders would be wise to acknowledge this movement, embrace it – and re-organize existing radiology leadership structures such that performance improvement teams can influence change and improve performance throughout the organization, rather than function on the periphery in isolation from operational managers and business-types. I know that peer-reviewed journals would be wise to inspect the scholarly work stemming from radiology performance teams and consider it worthy of publication and impactful. I know that a culture change such as this can only be achieved by influencing our trainees to dive headfirst into the methodologies that are scientifically proven to improve performance in our profession.

This is only the beginning. A birthing. Thank goodness someone started it.

The start of something great in radiology.

The Discipline of Performance Improvement in Radiology

Developing a new CPT code is hard. And as the number of minimally-invasive therapeutic options available to interventional radiologists continues to multiply, despite clear proof of improved efficacy (in the setting of improved technical capabilities of physicians), the challenges for crafting codes that accurately capture the degree of physician work, and practice expense associated with these procedures is becoming increasingly complex.

But why is it hard? Can’t you just apply for a new code once a new technology is developed and start getting paid? 

Understanding the code development process- and using percutaneous ablation procedures as a case example- might help to elucidate some of the challenges.

There are a few basic requirements to understand up front: 1) A certain amount of literature is required to get a Category I (Cat1) CPT code. Without it, no code. No code = no payment. 2) The procedure must be performed by many physicians across the United States. 3) The procedure must be performed at a reasonable frequency within the patient population for which it was intended.

If a procedure does not meet the criteria for a Cat1 code, it may be eligible for a category III code, which can be helpful for tracking the frequency with which the procedure is being performed, despite not being reimbursed.

Currently, some of the existing Cat1 percutaneous ablation codes include RF and cryoablation in the liver, kidney, and bone. There is a Cat1 percutaneous RF ablation code for pulmonary tumors, as well. What is conspicuously missing is percutaneous pulmonary cryoablation, which is being performed across the United States. And despite coding guidance clarifying that microwave ablation is part of the RF spectrum and should be reported with radiofrequency ablation codes, some payers are not paying for microwave ablation as there are no microwave-specific ablation codes. Lastly – irreversible electroporation is a novel ablation technique with a growing of body of literature supporting its use in certain scenarios. The bottom line is that there are a number of established and budding ablative technologies that are not being (or going to be) reimbursed in the current coding milieu.[[{"type":"media","view_mode":"media_crop","fid":"42421","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_9450852386728","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4588","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"C. Matthew Hawkins, MD","typeof":"foaf:Image"}}]]

So, should our specialty societies just apply for new Cat1 codes for all of these ablation techniques in the organs in which they are being used? Should we get a liver microwave ablation code, a pulmonary cryoablation code, and a pulmonary microwave ablation code? Sounds great, right? Then everyone that is performing these procedures might get reimbursed appropriately for the work being done and the equipment being used. Physicians would be happy, hospitals would be happy, and vendors can begin to reap their return on investment.

But, chew on this possibility for a minute. Let’s say we craft and propose a Cat1 CPT code for pulmonary cryoablation – which, for all intents and purposes seems appropriate based on the frequency of use and supporting literature. And let’s assume that the code is approved by the AMA’s CPT Editorial Panel.

Once approved, a new code must then be surveyed by the specialty societies in order to assess the amount of work involved in performing a procedure, as compared to existing CPT codes. The results of these surveys inform the RUC, which then submits recommendations to CMS about what the valuation of the code should be. But, precedent exists from the RUC (who determines relative value for all CPT codes) to ask that when a new code is introduced, that the 

 of codes be resurveyed and revalued. And let’s not forget that by “revalue” – the RUC and CMS actually mean “devalue”.   

So in the instance of pulmonary cryoablation, what is considered the 

? Should only pulmonary RF ablation be resurveyed? That seems most sensible. Or should all percutaneous ablation codes be resurveyed? Remember, this is not the choice of our specialty societies. If all percutaneous ablation codes are resurveyed – it is exceedingly unlikely that current reimbursement will be preserved. And if imaging guidance is currently not bundled into the CPT code – you can bet the ranch that after resurveying and revaluing, it will be bundled. While it is likely that a Cat1 CPT code for pulmonary cryoablation can be attained – is it worth the risk of potentially decreasing valuation for existing CPT codes? Furthermore – will re-valuation appropriately account for the variation in practice expense associated with the different ablation technologies? Will what be lost be gained with new codes? Is the data that currently exists accurate enough to answer these questions?

The challenge is real, but not insurmountable. All is not lost. This scenario simply accentuates the necessity for accurate coding (so that coding data can be mined) and population of data registries (so that clinical outcomes can be tracked). Accurate claims and outcomes data allow our specialty societies the ability to study how often procedures for which an existing Cat1 code exists are performed, how often they are performed in hospitals versus outpatient facilities, and what the economic impact of “re-valuation” might be for the family – should a new Cat1 code be introduced.

If you haven’t audited the accuracy of your practices’ coding efforts – audit it. Make sure it is accurate. If you haven’t yet planned to enroll in the ACR’s IR registry – please register. Report your outcomes and resource utilization. Our specialty needs accurate data in order to make informed decisions about these complex scenarios.

These types of practice management issues – that impact the collective diagnostic and interventional radiology communities – will continue to be of heightened importance as we move into the era of mixed alternative payment models and incentive payments systems.

Is it worth re-valuing if it de-values other procedures in radiology?

Re-valuation: Examining the Economic Impact of New CPT Codes

Is your radiology group stagnant? Has it been slogging along – providing adequate service that lacks differentiating features? What about apathetic? Or inertia-ridden? Are these adjectives synonymous with your group?  Perhaps there is a better way to frame the question. 

It is very hard for people and organizations to admit to being average. And average is a dangerous place to be.

We have heard and read the tales of radiology groups that have fundamentally restructured how they function and provide service. Strategies of co-management, value quantification, and noninterpretive value measurement have been successfully implemented by multiple radiology groups with tremendous success. These groups have restored relationships with hospital administrators and are now excelling. These are valuable stories.

Will other groups follow their lead?  Or will they wait until their jobs are threatened by the hospital? Or when an RFP is sent out by the health system? And even if they were to implement change – what would be the first step? What will be the strategy?

If you and your group are struggling to formulate a cogent strategy - try this. Imagine a radiology group that could move into the region tomorrow and destroy your practice. What would it look like? What weaknesses of your group might this new business exploit to capture their target audience? It is a beneficial exercise because it often illuminates the most glaring shortcomings of an existing practice.

Do you think they would build a business centered on volume – continuously aiming to have every radiologist read 22,000 RVUs annually? Would they consider themselves technologically advanced because they have PACS and voice recognition software? Would they sell themselves to hospitals by emphasizing their ludicrously fast turn-around-time?

Unlikely. Your group already has those bases covered. This new group – “Modern Radiology” – is going to target your weaknesses.


“Modern” will offer convenience. Patients will be able to schedule imaging tests online with online registration and payment systems. Their results will be available quickly – and they’ll receive a text message to let them know when their report has been posted online. The report will be downloadable as a PDF so that they can easily share with other physicians. Patients will also get a copy of their images before they leave their appointment.

See – convenience is more than valet parking. Think about how we interact with the airline and banking industries. That is how patients want to interact with health care. “Modern” plans to exploit this need with readily available software solutions.


“Modern” recognizes that there is an enormous amount of time that each of us spends each day doing activities that do not require our level of training and expertise. Spending time on these menial tasks negatively impacts the value we can provide for our hospitals and referring physicians. They will exploit this by becoming an early adopter of artificial intelligence in radiology and employ Watson for chest X-rays, musculoskeletal radiographs, and screening mammograms. They have plans, when the technology is ready, to use artificial intelligence for trauma CTs and cancer follow-up cross sectional imaging. This allows “Modern” radiologists to spend time analyzing the perplexing cases and consult on the phone and in-person with referring docs and patients. The visibility of a “Modern” radiologist is exponentially greater than an “average” radiologist, consequently. 


In a similar move, “Modern” plans to supplement its interventional radiologists with advanced practice providers (when appropriate) to perform some central venous access procedures, percutaneous biopsies, paracenteses, and thoracenteses. APPs will also make “Modern’s” E&M coding revenue more robust – a revenue source that your average radiology group is not tapping into. Consequently, “Modern’s” interventional radiologists spend more time consulting with referring physicians, performing complex procedures, and providing clinical care.


The leadership at “Modern” sees an opportunity to negotiate directly with payers to develop some alternative payment models (APMs). They first plan to build a bundled APM for breast imaging, and then plan to roll out a similar program for patients with uterine fibroids. Leadership knows this will require data to design. Costs associated with providing care for these patients must be known. Volume trends are necessary. Money saved should be calculated. And data-driven risk-sharing will be required.  “Modern’s” leadership knows that a robust data collection and analysis system will be needed for this sector of their strategy. Thus, they plan to invest a substantial portion of their budget on software tools and an informatics team charged with becoming a data/analytics leader in the radiology space. 

You get the picture.  By highlighting weaknesses – existing groups can begin to see, with greater clarity, the areas to which energy should be channeled. Do this exercise with your group leadership and build a vision for where you want to take your practice. We can all see it coming.  “Modern Radiology” is moving to a town near you soon. Don’t be left behind when they finally arrive.

Be prepared for your biggest radiology competition.

C. Matthew Hawkins, MD

Articles

Physician Burnout and High-functioning Teams

The Discipline of Performance Improvement in Radiology

Re-valuation: Examining the Economic Impact of New CPT Codes

Know Thy Competition