Avoiding Stressors & Provider Burnout in the Wound Clinic

  Stress is a natural response to any difficult situation. Healthcare providers are often more tuned in to their patients’ stress levels than their own. It’s fair to assume that at some time in our professional lives, all healthcare providers have experienced “burnout” as a result of chronic stress based on patients’ conditions and difficulties that may cause clinicians to perform poorly or even leave their chosen profession. Employee wellness programs can help to prevent these stressors from leading to burnout and promote an overall healthier environment in the clinic so that we may be able to better take care of our more acutely ill patients and ourselves, but sometimes a needed personal “break” may be justified.

  There are times when this is a temporary release after a particularly trying week or day. These temporary stressful situations are usually assuaged by a short vacation, a relaxing weekend, a venting session with a friend or colleague, or even a trip to the gym. Short periods of discontent with our professional or personal lives are normal emotions that can actually help to strengthen us as individuals by establishing boundaries between our lives and our work. However, when this stress lasts for longer periods of time and becomes chronic, a true “burnout syndrome” is realized and is evident through signs of physical and emotional exhaustion, cynicism and emotional detachment, or feelings of ineffectiveness and lack of accomplishment. Sherrie Bourg Carter, Psy.D, describes the signs of physical and emotional exhaustion specifically being chronic fatigue, insomnia, forgetfulness/impaired concentration and attention, increased illness, loss of appetite, anxiety, depression, and various physical symptoms including palpitations, chest pain, and headaches.¹ She further characterized signs of cynicism and detachment as loss of enjoyment, pessimism, and isolation, with signs of ineffectiveness and lack of accomplishment being feelings of apathy and hopelessness, increased irritability, lack of productivity, and poor performance. These very signs can be found in any stressful profession. In healthcare, however, a clinician experiencing this burnout syndrome potentially can have a very negative effect on the healing of patients.

  A 2012 article by the New York Times described physicians who are living with burnout as being less empathetic and more likely to treat patients like diagnoses or objects while being more prone to errors.² This is not limited to physicians but all clinicians in healthcare as we continue to assess and treat a more critically ill population with multiple comorbidities and greater healthcare needs. When looking specifically at those who practice in an outpatient wound clinic, several specialty-specific stressors can be identified that can lead to practitioner burnout. These include:
    drug-seeking patients;
    the need to increase volume to make budget;
    pressure from administration on volume growth;
    increased competition;
    financial constraints including staff productivity, supplies, and healing modalities;
    reimbursement changes;
    threat of audit;
    the “authorization maze”;
    increasing numbers of patients not eligible for certain services depending on insurance;
    changes in services provided by insurance carriers year to year;
    recalcitrant or “rebound” patient;
    overbearing families; and/or
    patients who use the wound center as a primary provider.

  What follows is a summary of each stressor and advice to help providers identify where there feelings of burnout may stem from and how to appropriately avoid or manage their negative emotions.

Drug-Seeking Patients

  Wound care patients often report pain at different times, whether in the clinic for a debridement or with the use of compression. Many times, patients report a constant pain with the affected extremity. It is incumbent on the physician to determine the cause of the pain and the most efficacious way to treat it. Long gone are the days of simply writing a prescription to alleviate pain or placate the patient. Nationwide narcotic prescription-filling laws have taken effect to help prohibit the abuse of these medications by patients and prescribing physicians. These laws mandate when a prescription may be filled, how often, what must be documented on the prescription, and the additional record keeping that must be done both by the prescribing facility and the pharmacy. With this increased responsibility on the prescriber, judicious use of narcotics is needed as well as appropriate diagnosis of pain etiology and the consideration of other pain-modulating treatments. Wound patients can present with complaints of wound pain as well as neuropathic pain and pain associated with arterial insufficiency and edema. The treatment must address the cause. Stress lies in wanting to adequately care for the patient’s pain while protecting patients from addiction and/or abuse of medications. Many times, these patients come in only when they need a refill or are constantly calling the clinic for medications, leaving the clinician frustrated and feeling detached. As healthcare providers, we must realize that we can best help patients who want to actively participate in their own healthcare. Practitioners should council patients on alternative pain-relief methods and involve the patient’s primary provider as well as family in this process. At that point, separating ourselves from feelings of guilt is a bit easier. Recognize the patient’s pain, but determine the best way to treat the underlying problem.

Volume Growth

  Over the past several years, we have seen reimbursement become more strict for the hospital-based outpatient wound clinic (HOPD) in addition to the physician provider. This often translates into less revenue for the hospital. The HOPD must be able to maintain a profit while providing quality patient care in order to “keep the lights on and the doors open.” To accomplish this, clinics are often asked to increase the number of patients they see, the number of times they see the patient, and/or the number of procedures performed. This in itself can be stressful to the staff member who knows how many patients can effectively be treated on a given day with a certain number of staff members as well as the physician who wants to develop the plan of care based on patient need, not clinic numbers. We must find a balance in volume and quality. The clinic goal should always be to provide the best care available to the patient population in need. This will ensure patient satisfaction and prevent clinicians from feeling as though they are working on an assembly line.

Improving Patient Care

  When volume increases in a clinic, time spent with each patient and the quality of care for that patient may be compromised. Staff members may also be “spread thin” among a greater number of patients, limiting personalized time that they are able to devote to patients, who may in turn feel neglected and may not be as likely to report all changes that they have noted since their last visit. As a result, clinicians may become less personable with the patient from visit to visit, less tuned in to small changes in the patient’s healing trajectory, and less attentive to the family members or caregiver. Some staff duties may also be relegated to staff members with less experience, thus impacting care quality. Staff members may feel inadequate in the care they provided and not gain the rewarding feeling of having intimately assisted the patient in the healing process. It’s imperative for the clinician to recognize time constraints and to help educate patients on these. On reminder calls about upcoming appointments, patients can be asked to write down all questions, concerns, and new medications. This helps to streamline the visit process and decreases the stress on both patients and the clinicians.

Increased Competition

  As our population ages and the number of patients living with a metabolic syndrome and vascular disease increases, the need for specialized wound care continues to rise. Wound clinics are becoming the norm now versus wound treatment in a physician’s office. The 2014 Association for the Advancement of Wound Care (AAWC) Clinic Directory contains the contact information on 900 wound clinics in the US. There are more that aren’t listed, as well as physician offices, outpatient rehab facilities, and physical therapy clinics that offer wound management services. Patients require services that are reimbursable and the number of facilities that specialize in caring for this population has mushroomed. There are often more than one or even several clinics in one town or city that are all vying for the same wound care market. In addition to competition from other facilities or clinics, there can be competition among the practitioners in the facility. There may be several professions employed by the clinic that through individual practice acts are capable of providing the same services, treatments, or modalities. Everyone’s skill set and scope of practice should be examined, and then paired with a practice pattern that will best suit the patient from a healing and financial standpoint. With competition comes pressure on the clinic manager/coordinator to gain a larger portion of the market for profitability.

Financial Constraints

  Providing healthcare costs money. Productivity factors are the mantra of any financial officer of a facility. Are we being as productive as possible in the shortest amount of time possible while rendering treatment to our patients? Are we efficient in the care that we give? Are we utilizing cost-effective supplies and treatments? Money can be made in the wound clinic as well, and it is the hope of every hospital administration that more is made than spent so that the doors can remain open and services provided. To obtain the greatest profit, every penny spent must be accounted for, including what is spent on disposable supplies, staffing hours, and the treatment modalities utilized. Typically, the clinician just wants to know if he or she is giving the best care possible for the greatest healing outcome without worrying about cost. This is no longer feasible. We must maintain reasonable costs to continue to provide the care to the greatest number of patients possible. Staff members and physicians need to understand that the healthcare we provide must be a value to the patient and the facility.

  The clinic manager or director should have a firm grasp on reimbursement changes as they relate to services and supplies. If changes occur, alternative products should be examined for clinical effectiveness. Each patient’s situation must be evaluated for what is most cost effective for the patient and those who render care — be it the wound clinic, home health agency, or other facility. If a treatment modality has little or no reimbursement, though it may be the most clinically effective, the treatment more than likely won’t be adhered to, subsequently eliminating the clinical efficacy. Stay abreast of local coverage determinations (LCDs) and product alternatives.

Reimbursement Changes

  Even prior to the implementation of the Affordable Care Act, healthcare in general has experienced frequent, almost constant, reimbursement changes, more specifically related to wound treatment services. There are Medicare changes and LCDs issued on at least an annual basis. Private insurers may change services, medications, and/or products covered from year to year. There may be different levels of care reimbursed under the same carrier depending on the group or individual plan being used by the patient. All of this can be confusing and frustrating to the clinician. In the recent past we have seen an increase in bundled procedures in the HOPD, which has consequently decreased the amount of reimbursement we garner from the same services that were offered just one year ago. Productivity levels and calculations change based on this, and the clinic that does not have a reimbursement champion who is able to stay abreast of these situations may appear as though it is not performing at the level it previously has. Pressure from administrative-level partners could then fall on clinic staff.

Threat of Audits

  Anyone working in a healthcare setting is going to be subjected to an audit or survey at some point, whether voluntary (eg, Joint Commission) or involuntary (eg, American Health Care Association, Centers for Medicare & Medicaid Services). Any audit will be stressful no matter how prepared one is, mostly due to an unpredictable nature of the process involved, whether being surveyed by members of a hospital or a corporation’s internal team as a tracer, mock survey (or whatever the terminology may be), or by an outside agency. Part of the stress is the fact that different members of the survey team may come from varied backgrounds, have diverse opinions and interpretations of the survey criteria, and be focused on different aspects of clinic operations. One may focus on clinical tasks such as hand hygiene and dressing techniques where another may be more consumed with charts and have little time observing the actual clinic. The key to doing well in an audit of any type is consistency in staff education, awareness of hospital policy, and procedures and techniques in care that follow a reasonable standard of care and are grounded in evidence-based theory. Many clinicians are not comfortable providing constructive suggestions to co-workers or executing activities that change behavior. Unfortunately, however, they often will talk to others about faults that they may perceive, resulting in the enabling of techniques and behaviors that may not only be detrimental to patient care, but certainly may not pass muster with an outside observer — the result being citations that could have been avoided. This is where the role of a clinical coordinator is so critical to act as an educator and behavioral-change agent to assure consistent best practices within the center.

  The wound clinic staff must stay abreast of annual reimbursement changes and be certain that interpretation of the coding and billing of procedures and services are accurate and appropriate. This applies not only to the HOPD itself but the providers practicing within. Detailed, accurate documentation is key to success during an audit. Pressure placed on providers to perform some level or number of debridements or patients placed in hyperbaric chambers is fraught with risk if an audit should occur. Equally, providers consistently documenting the performance of high levels of debridements on patients week after week are putting themselves and the center at risk. There must be communication between the providers and the center as it relates to the charges being generated with the end result of accurate and honest accounting for what was provided for the patient.

The Authorization Maze

  There seems to be an ever-increasing number of patients who are under insurance plans that require prior authorization for specialty services such as wound care. It is not so simple to just follow an LCD as guidance for coverage because submission of documentation as to the need is increasingly becoming the norm for much of what we do, not just for procedures but for the basic visit to the center. This has become a large part of doing business, but has resulted in a significant time and personnel burden for many centers. Not only are there different insurance plans, but differing levels of coverage within any one plan as well. Having someone in the role of securing these authorizations is critical. Not only does one become skilled at this work, he/she also develops relationships with authorization representatives at the primary physician’s office, which can certainly facilitate expedited receipt in many cases. Beyond basic authorizations looms the need to assure coverage for many of the advanced biologicals and devices used in wound care today. Many companies have specific hotlines and departments to assist with this, and taking advantage of this opportunity can save a tremendous amount of time and potential risk of denial after the fact. This does require providing protected patient information, so knowledge and adherence to the hospital’s policy on utilization of these services is highly recommended.

“Rebound” Patients

  No matter how busy a center is, how great outcomes are, or how thorough patient education is, wound centers are going to have their “frequent fliers.” But providing clear education is not a fail-safe measure to improving patient adherence. Sadly, patients are going to have recurrent wounds. Unless they are blatantly demonstrating risky behavior, the reality is that the folks under our care have comorbid conditions that lead to wounds. Of course, teaching until they understand that healing requires lifestyle changes such as nutrition, weight loss, and smoking cessation coupled with offloading, use of compression, and avoidance of skin injury will go a long way toward reducing the number and frequency of recurrences. Additionally, encouraging patients to return at the first sign of a wound forming can enable early intervention and possibly mitigate the severity of the wound.

  Recalcitrance is another story. An online medical dictionary defines recalcitrance as a condition in which someone stubbornly resists treatment. Frequent re-evaluation of the treatment plan and moving to advanced or active treatments are the obvious steps toward managing the nonhealing wound. One reality is that some wounds, despite our best efforts, are simply not going to heal and placement on palliative care is appropriate. Palliative care, however, should not be a place to put patients simply to “improve numbers.” If a patient is making slow, albeit steady, movement toward healing, that is not necessarily a palliative care patient.

  Many clinics ask patients to sign a “care contract.” The patient is shown the plan of care and asked to agree that he/she will adhere to the best of their ability, attend scheduled appointments, and actively participate in their healthcare. This includes maintaining offloading techniques, compression, and glycemic control. If, as outlined in the contract, patients fail to participate fully in their care, they’re asked to leave the practice. This process should be vetted by a risk-management manager and approved by administration.

Overbearing Family Members

  Patients who live with chronic wounds are also “chronic patients.” Because they usually have comorbid conditions requiring monitoring and management, it is important for these individuals to have a provider outside of the clinic who can oversee their general health needs. There is no question that being the family member, spouse, or significant other of a person living with a chronic wound can bring significant stress into the relationship. Chronic patients often need someone else to be the primary breadwinner, the source of transportation, the dressing changer, and the “rock” on whom the patient leans. They may be forced to balance work with the needs of the patient, having to take time off and causing worry about their own repercussions to assisting the patient. This source of stress, though born out of love, can bring out the best or, unfortunately, the worst in some. Not wanting to take hurt feelings out on the patient, they may project their frustrations toward healthcare staff. This can manifest itself in anger, demands, questioning of what is or is not being done to get the wound healed, or in more of an emotional sense with tears and expression of fear of what the future may hold. This can make many providers very uncomfortable and feel ill equipped to deal with these challenges amid a busy clinic. To the extent possible, simply providing a listening ear and showing compassion, understanding, and acceptance of one’s feelings can go a long way. Suggestions and referrals for counseling, if appropriate, may help. On the other hand, if it becomes a true behavior problem in the clinic, enlisting help from the clinic manager or director may be required.

Patients With No Primary Provider

  Some patients will enter the wound clinic for a variety of reasons without being under the care of a primary provider and seek assistance for general medical needs. This is clearly problematic for a variety of reasons, the obvious one being the liability of taking responsibility for the total care of a patient. A refill on routine medications while the patient is seeking a primary provider that’s clearly documented may be appropriate on a one-time basis, but a firm stance must be taken and documented so that the patient understands this cannot become routine. Most patients need to consult their list of providers included in their insurance plan, however, having a list of options for patients that includes local primary providers, clinics, health departments, and other community services may be helpful to provide options for these needy patients.

  Dot Weir and Valerie Sullivan are members of the TWC editorial board.

References

1. Carter SB. In: High-octane women: How superachievers can avoid burnout. Prometheus Books. 2011.

2. Chen PW. The widespread problem of doctor burnout. New York Times. 2012. Accessed online at https://well.blogs.nytimes.com/2012/08/23/the-widespread-problem-of-doctor-burnout.