Dr. Vik Mali recalls a conversation with a hospital-employed surgeon who wasn’t able to practice during the height of the pandemic. “‘I haven't had a summer vacation in how long, you know?’ he said, half-jokingly,” explained Mali. “He was still employed and paid, but couldn’t see patients. But doctors who were independent still had no revenue and had overhead to maintain.”

As an independent pediatrician, Mali — who reduced his own salary significantly before the federal government’s Paycheck Protection Program kicked in — is not alone in thinking that COVID-19 could add more fuel to the fire of consolidation in U.S. healthcare.

The fiscal responsibilities of practicing compounded by the pressure of delivering high-quality patient care contribute to feelings frustration, according to 46 percent of physicians who reported feeling burned out a few times a month or more in athenahealth’s Physician Sentiment Index. The survey, conducted between Oct. 13, 2020, and Dec. 23, 2020, found that among 799 physicians who used a variety of EHR vendors, technological and organizational changes — such as mergers and acquisitions — are among the biggest stressors.

Major changes contribute to feelings of burnout

In the past 24 months, at least one major organizational change, such as changes in technology platforms, staff layoffs, temporary furloughs, and/or mergers and acquisitions, was experienced by more than half of the respondents’ organizations.

Twelve percent of physicians surveyed were impacted by a merger or acquisition. Those respondents were less likely to recommend their organization to friends or family members and reported feeling less safe and supported by their organizations. 

A proactive versus reactive strategy has helped Upperline Health flourish as the national network of foot and ankle practices continues to grow, says director of strategic operations Mary Hayes.

“You have to anticipate where the pitfalls will be,” she said, explaining that each group that is onboarded benefits from the insights gleaned from managing other Upperline practices. “Proactive practice assessments mean I can look at their clinical functions, scheduling, billing and coding, HR, all of the big processes, so we can pay extra attention to training where it is needed the most,” said Hayes. Those assessments also include learning current medical supply workflows and determining anticipated demand, all of which was essential to making employees feel safe during the pandemic.

The most difficult part of managing an acquisition, however, can be less concrete than a numbers readout. “(Changing) culture might be even more challenging,” said Hayes. “Going from a small practice where you’ve always done things your own way, to a corporate structure can be stressful.” Upperline has met that challenge during the pandemic with weekly virtual team huddles, “town hall”-style meetings, and by forming committees of providers and experienced staff to help establish new policies so everyone feels that their voice is heard.” Mali hosts daily check-ins with his team.

Regulatory measures are among the biggest stressors

Part of Upperline’s corporate structure is adherence to evolving regulatory measures, which two-thirds of respondents say is a consistent challenge. 

Sixty-two percent of physicians agree that their organization is well positioned for value-based care, but physicians who reported that their practice takes on a substantial amount of financial risk for its patient population rated their experiences more negatively across a range of survey categories. They also scored higher on the Maslach Burnout Inventory (MBI) Scale, the most commonly used tool in medicine to measure feelings of exhaustion and overextension.

Hayes said she remembers the days — and nights — researching and printing stacks of paper records to participate in quality programs. Today, with her EHR’s dashboard capabilities, she can easily monitor performance across her entire organization and take that stress off the plate of physicians so they can focus on practicing. “We are made up of many groups, including some smaller groups that historically haven’t had the bandwidth to deal with the requirements of quality programs,” she said. “Some have never even submitted before.”

For Mali, there’s also safety in numbers of a different sort. He’s on the board of directors for United Physicians, a group of about 1,700 independent physicians in Southeast Michigan. The organization pools its resources to “divide and conquer” for insurance contracting, and collectively gauges its local patient population for risk-based contracts. Adding some peace of mind into a pack mentality that allows members to stay independent is the group’s arrangement to set aside “rainy day” resources. “That allows us to bank money in case our risk-based contracts go south,” he said.

Furloughs and layoffs affect satisfaction

Despite reduced patient volume across United Physicians primary care practices during the pandemic — 24,000 in 2020 as compared to 33,000 in a typical year — Mali did not have to lay off or furlough staff at his own practice due to attrition.

But his experience was not universal. The athenahealth index found that 33 percent of respondents underwent at least one of the two (layoff or furlough) in the previous two years. Not surprisingly, physicians who faced those challenges reported more frequent feelings of burnout, callousness, and isolation.

And although some respondents report that technology can be a source of friction, for Upperline, innovative technology helped them avoid pandemic-related staff reductions. “Telehealth was the solution for a lot of our doctors,” Hayes said about COVID-19. “It was a real possibility that people would be laid off. So being handed something that offered an opportunity to continue working was a good solution.”

Hurdles may be in implementing tools, not necessarily the tools themselves

For professionals in any career, changes are bound to create challenges. But when physicians’ organizations go through technological transitions, it can have lasting effects on their perceptions of their ability to perform their jobs well — which in turn, can contribute to feelings of burnout.

Twenty-three percent of physicians went through a major technological transition in the past 24 months, such as implementing a new EHR system. These physicians were far more frustrated with their EHR than others, and were less likely to feel that technology helps them deliver high-quality care.

At Upperline Health, it’s just as much about the tools at their disposal as the training behind them. Hayes said using athenaOne, a solution that’s “easy to scale,” has been impactful as the business grows. But keeping in mind the human element — the fact that their choice of technology is simple to train on — has been essential, she said. Having one streamlined suite of clinical and financial record-keeping tools has also made Upperline more deft and eliminated the need for multiple logins and duplication of entering records into multiple systems.

Mali said he’s not surprised by physicians’ sentiments surrounding innovation and that it’s sometimes their own high standards that can create stress.

“The technology doesn't spook me — it’s a tool. I think it’s expectations that I bring upon myself,” he said.