The budget.
A seemingly benign exercise designed to help create a financial roadmap for the upcoming fiscal year, the annual budget process is now being used as a tool to nudge physicians to see more patients and do more procedures. RVU benchmarks have long been used to benchmark physician productivity. Now, C-suite finance executives have introduced a new way to poke and prod already productive physicians and departments to do more.
Our community hospital GI department sits within a larger academic health system and is largely made up of employed physicians. Our endoscopic procedural numbers have steadily risen year over year since elective procedures returned after the COVID-19 pandemic. We are full-time clinicians with fully packed schedules. Many established providers will double book clinic slots and squeeze in outpatient procedures given the otherwise lengthy wait times.
Our practice has added physicians and physician extenders to help manage the increased volume. Not satisfied with this steady, organic growth, our administrators decided to affix a 10% increase in procedural volume to the budget for this fiscal year. How do you increase volume 10% when utilization rates are already well above 90%?
A recent change in our EMR’s scheduling procedure robbed physicians of even more autonomy. We were no longer able to manipulate case times. I, for one, noticed my colonoscopy time slots shrinking from 45 minutes to 34 minutes per case. This AI-generated change would allow schedulers to squeeze in an extra case or two every day. What the computer algorithm could not take into account, however, was the time needed to complete post-procedure tasks, including procedure documentation, discharge orders, and relaying findings to patients and families. Further, physicians often use time in between procedures to answer portal messages and answer calls from hospitalists regarding inpatients.
The most recent nudge came when management asked why several physicians were starting cases at 8:30 a.m. instead of 7:30 a.m. This “lost” hour, they said, could be a reason we were falling behind budget.
Why should already productive physicians who provide high-quality care (our adenoma detection rates are two times the national benchmark) change their practices to try and meet arbitrary benchmarks? Should we potentially sacrifice colonoscopy quality by doing more procedures in the same amount of time? Should we ask physicians to shirk their morning family responsibilities to do an extra procedure? What if a physician wanted time to take a morning walk, attend an exercise class, or start their day with a cup of coffee and the newspaper?
The counter argument is, of course, that these ever-increasing demands from administration are part of the cost of doing business for employed physicians. Want autonomy? Stay in private practice.
This is a fair point, but surely there is a world in which the interests of health systems and physicians can align. To start with, physician productivity benchmarks must be established with physician input. Asking an endoscopist whose utilization rate is in the mid-90% range to do 10% more cases in the coming year is unreasonable.
Allowing AI algorithms to determine case length without regard for the time necessary to adequately communicate with patients and family members before and after the procedure is self-defeating. These same administrators will hammer the importance of patient satisfaction surveys, results that are largely based on how well physicians communicate with patients. In the end, setting unreasonable productivity goals yields burnt out physicians and unsatisfied patients.
Physicians understand productivity. We are programmed from our days in medical school to see the extra patient, scrub into the extra surgical case. Administrators take advantage of our desire to please, our grind mentality, by moving our productivity goalposts year after year. Monthly volume dashboards sent to physicians often hide year-over-year growth numbers, instead choosing to highlight deficiencies compared to fiscal year budget estimates.
Junior physicians are more likely to yield to the unreasonable demands for increased year-over-year productivity, fearing reputational damage if they do not meet benchmarks. It is the job of more senior physician leaders to provide the push back, to help balance institutional demands with physician wellness while emphasizing care quality and patient satisfaction.
The fascinating thing about productivity expectations and budgets, especially in large health systems, is that no one really knows where the numbers come from. Middle managers are quick to crack the whip but are rarely in the know on how the expected numbers came to be. Those cultivating these unreasonable expectations often have little clinical experience or knowledge of the inner workings of physician scheduling.
In the end, unreasonable budgetary expectations can be grouped with other institutional efforts which sap physician autonomy and lead to overworked, unhappy physicians. Administrators, let alone AI-powered algorithms, do not consider the physical and cognitive toll of performing more and more procedures. How do we account for the inevitable complicated procedure that sets your schedule back 30 minutes, or the extra time needed to utilize the translator line in the recovery room to explain procedural results to a non-English speaking patient?
The best administrators will seek physician input before setting productivity benchmarks. Only by understanding the true demands on physician time can reasonable productivity benchmarks be created. Physician buy-in aligns hospital and physician interests. As physicians, we must continue to advocate — for our patients and for ourselves — by pushing back when productivity demands threaten care quality and physician well-being.
How do you push back when efficiency threatens patient care? Share in the comments.
Anish A. Sheth, MD, is chief of gastroenterology at Penn Medicine Princeton Health and is the author of several books on gut health including the best-seller, "What's Your Poo Telling You?" He is a mid-career physician who loves practicing medicine and is looking for ways to keep the fire burning!
Illustration by Diana Connolly
