Advertisement
Mayo Clinic Proceedings Home

Radical Reorientation of the US Health Care System Around Relationships

Rebalancing the Transactional Model
Open AccessPublished:October 04, 2022DOI:https://doi.org/10.1016/j.mayocp.2022.08.003
      “Dr Serra’s last urgent appointment for today just filled, but Dr Breznik can see you at 1 pm.” Same-day service. All is good, right? No. The work of managing this patient more than doubled, the patient was needlessly inconvenienced, potentially unnecessary tests were ordered, and hazards were introduced into his care. This patient has a complex medical and surgical history which Dr Serra has managed over several years. When the patient is seen, Dr Breznik labors to get modestly up to speed, applies some temporizing measures, and schedules an appointment 3 days hence with Dr Serra, who currently is standing down the hall, between seeing other patients, documenting.
      Over the past several decades, health care has increasingly been conceptualized as a series of independent encounters (ie, transactions) that can be distributed nearly randomly among health care workers: any physician can round on the patient, any clinician can be on the other side of the telemedicine screen, any resident can cover “continuity clinic.” Although this is a factor in almost all specialties, this transactional mindset that treats physicians as interchangeable parts is particularly problematic in specialties where continuity and longitudinal care play a critical role (eg, primary care disciplines, neurology, oncology, and psychiatry). We believe that this industrial-based conceptualization has been harmful to health care and has impeded progress toward quadruple-aim
      • Bodenheimer T.
      • Sinsky C.
      From triple to quadruple aim: care of the patient requires care of the provider.
      outcomes. Yet, such fragmentation of care is ubiquitous.
      We acknowledge the variety of countervailing forces that have brought us to this very transactional model, including the corporatization and commodification of health care;
      • Pellegrino E.D.
      The commodification of medical and health care: the moral consequences of a paradigm shift from a professional to a market ethic.
      • Waitzkin H.
      The commodification of health care and the search for a universal health program in the United States. Culture of Health Blog.
      • Huang E.C.-H.
      • Pu C.
      • Chou Y.-J.
      • Huang N.
      Public trust in physicians — health care commodification as a possible deteriorating factor: cross-sectional analysis of 23 countries.
      the consumer movement;
      • Topol E.J.
      The consumer movement in health care.
      , the revenue-driven focus of many delivery institutions; electronic health records designed for individual transactions more than for longitudinal care; the increasingly narrow subspecialization of many physicians; and the increasing involvement of private equity investors in health care delivery.
      • Offodile A.C.
      • Cerullo M.
      • Bindal M.
      • Rauh-Hain J.A.
      • Ho V.
      Private equity investments in health care: an overview of hospital and health system leveraged buyouts, 2003–17.
      Examples of structural pressures that deprioritize relationships abound: adoption of models where care is provided separately by inpatient and outpatient physicians without creating time or incentives for these physicians to coordinate with each other; scheduling approaches that result in a surgeon working with a different scrub team and anesthesiologist each day; transitions clinics where patients are seen after hospitalization, not by a physician who participated in their inpatient care, nor by the physician who will manage their care as an outpatient, but rather by a physician they have never seen before and will likely never see again.
      Evidence suggests that being cared for by the same physician over time — whether for a week in the hospital, a year in the ambulatory clinic, or over a lifetime across settings — is associated with a host of benefits including improved diagnostic accuracy,
      • Starfield B.
      Primary care and equity in health: the importance to effectiveness and equity of responsiveness to peoples' needs.
      care coordination, patient satisfaction, and trust
      • Pandhi N.
      • Saultz J.W.
      Patients' perceptions of interpersonal continuity of care.
      • Wasson J.H.
      • Sauvigne A.E.
      • Mogielnicki R.P.
      • et al.
      Continuity of outpatient medical care in elderly men. A randomized trial.
      • Saultz J.W.
      • Albedaiwi W.
      Interpersonal continuity of care and patient satisfaction: a critical review.
      • Day J.
      • Scammon D.L.
      • Kim J.
      • et al.
      Quality, satisfaction, and financial efficiency associated with elements of primary care practice transformation: preliminary findings.
      ; fewer emergency room visits,
      • Pourat N.
      • Davis A.C.
      • Chen X.
      • Vrungos S.
      • Kominski G.F.
      In California, primary care continuity was associated with reduced emergency department use and fewer hospitalizations.
      ,
      • Nyweide D.J.
      • Bynum J.P.W.
      Relationship between continuity of ambulatory care and risk of emergency department episodes among older adults.
      hospital admissions,
      • Pandhi N.
      • Saultz J.W.
      Patients' perceptions of interpersonal continuity of care.
      ,
      • Wasson J.H.
      • Sauvigne A.E.
      • Mogielnicki R.P.
      • et al.
      Continuity of outpatient medical care in elderly men. A randomized trial.
      ,
      • Pourat N.
      • Davis A.C.
      • Chen X.
      • Vrungos S.
      • Kominski G.F.
      In California, primary care continuity was associated with reduced emergency department use and fewer hospitalizations.
      ,
      • Barker I.
      • Steventon A.
      • Deeny S.R.
      Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data.
      • Bayliss E.A.
      • Ellis J.L.
      • Shoup J.A.
      • Zeng C.
      • McQuillan D.B.
      • Steiner J.F.
      Effect of continuity of care on hospital utilization for seniors with multiple medical conditions in an integrated health care system.
      • Bazemore A.
      • Petterson S.
      • Peterson L.E.
      • Bruno R.
      • Chung Y.
      • Phillips Jr., R.L.
      Higher primary care physician continuity is associated with lower costs and hospitalizations.
      • Tammes P.
      • Purdy S.
      • Salisbury C.
      • MacKichan F.
      • Lasserson D.
      • Morris R.W.
      Continuity of primary care and emergency hospital admissions among older patients in England.
      and readmissions
      • Goodwin J.S.
      • Lin Y.L.
      • Singh S.
      • Kuo Y.F.
      Variation in length of stay and outcomes among hospitalized patients attributable to hospitals and hospitalists.
      ,
      • Gill J.M.
      • Mainous 3rd, A.G.
      The role of provider continuity in preventing hospitalizations.
      ; and higher quality
      • Day J.
      • Scammon D.L.
      • Kim J.
      • et al.
      Quality, satisfaction, and financial efficiency associated with elements of primary care practice transformation: preliminary findings.
      ,
      • Cohen-Mekelburg S.
      • Saini S.D.
      • Krein S.L.
      • et al.
      Association of Continuity of Care With Outcomes in US Veterans With Inflammatory Bowel Disease.
      • Frandsen B.R.
      • Joynt K.E.
      • Rebitzer J.B.
      • Jha A.K.
      Care fragmentation, quality, and costs among chronically ill patients.
      • Jones P.M.
      • Cherry R.A.
      • Allen B.N.
      • et al.
      Association between handover of anesthesia care and adverse postoperative outcomes among patients undergoing major surgery.
      • Goodwin J.S.
      • Li S.
      • Hommel E.
      • Nattinger A.B.
      • Kuo Y.-F.
      • Raji M.
      Association of inpatient continuity of care with complications and length of stay among hospitalized medicare enrollees.
      • Goodwin J.S.
      • Li S.
      • Kuo Y.-F.
      Association of the work schedules of hospitalists with patient outcomes of hospitalization.
      ; lower costs
      • Day J.
      • Scammon D.L.
      • Kim J.
      • et al.
      Quality, satisfaction, and financial efficiency associated with elements of primary care practice transformation: preliminary findings.
      ,
      • Barker I.
      • Steventon A.
      • Deeny S.R.
      Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data.
      • Bayliss E.A.
      • Ellis J.L.
      • Shoup J.A.
      • Zeng C.
      • McQuillan D.B.
      • Steiner J.F.
      Effect of continuity of care on hospital utilization for seniors with multiple medical conditions in an integrated health care system.
      • Bazemore A.
      • Petterson S.
      • Peterson L.E.
      • Bruno R.
      • Chung Y.
      • Phillips Jr., R.L.
      Higher primary care physician continuity is associated with lower costs and hospitalizations.
      ,
      • Goodwin J.S.
      • Lin Y.L.
      • Singh S.
      • Kuo Y.F.
      Variation in length of stay and outcomes among hospitalized patients attributable to hospitals and hospitalists.
      ,
      • Frandsen B.R.
      • Joynt K.E.
      • Rebitzer J.B.
      • Jha A.K.
      Care fragmentation, quality, and costs among chronically ill patients.
      ,
      • Raddish M.
      • Horn S.D.
      • Sharkey P.D.
      Continuity of care: is it cost effective?.
      • Burge F.
      • Lawson B.
      • Johnston G.
      Family physician continuity of care and emergency department use in end-of-life cancer care.
      • Mosquera R.A.
      • Avritscher E.B.C.
      • Pedroza C.
      • et al.
      Hospital consultation from outpatient clinicians for medically complex children: a randomized clinical trial.
      • Romano M.J.
      • Segal J.B.
      • Pollack C.E.
      The association between continuity of care and the overuse of medical procedures.
      • Sabety A.H.
      • Jena A.B.
      • Barnett M.L.
      Changes in health care use and outcomes after turnover in primary care.
      • Sinsky C.A.
      • Shanafelt T.D.
      • Dyrbye L.N.
      • Sabety A.H.
      • Carlasare L.E.
      • West C.P.
      Health care expenditures attributable to primary care physician overall and burnout-related turnover: a cross-sectional analysis.
      • Hussey P.S.
      • Schneider E.C.
      • Rudin R.S.
      • Fox D.S.
      • Lai J.
      • Pollack C.E.
      Continuity and the costs of care for chronic disease.
      • Henry T.L.
      • Petterson S.
      • Phillips R.S.
      • Phillips R.L.
      • Bazemore A.
      Comparing comprehensiveness in primary care specialties and their effects on healthcare costs and hospitalizations in medicare beneficiaries.
      • Bazemore A.
      • Petterson S.
      • Peterson L.E.
      • Phillips R.L.
      More comprehensive care among family physicians is associated with lower costs and fewer hospitalizations.
      • Starfield B.
      • Shi L.
      • Macinko J.
      Contribution of primary care to health systems and health.
      • Weiss L.J.
      • Blustein J.
      Faithful patients: the effect of long-term physician-patient relationships on the costs and use of health care by older Americans.
      ; and reduced mortality.
      • Barker I.
      • Steventon A.
      • Deeny S.R.
      Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data.
      ,
      • Goodwin J.S.
      • Li S.
      • Hommel E.
      • Nattinger A.B.
      • Kuo Y.-F.
      • Raji M.
      Association of inpatient continuity of care with complications and length of stay among hospitalized medicare enrollees.
      • Goodwin J.S.
      • Li S.
      • Kuo Y.-F.
      Association of the work schedules of hospitalists with patient outcomes of hospitalization.
      • Raddish M.
      • Horn S.D.
      • Sharkey P.D.
      Continuity of care: is it cost effective?.
      • Burge F.
      • Lawson B.
      • Johnston G.
      Family physician continuity of care and emergency department use in end-of-life cancer care.
      • Mosquera R.A.
      • Avritscher E.B.C.
      • Pedroza C.
      • et al.
      Hospital consultation from outpatient clinicians for medically complex children: a randomized clinical trial.
      • Romano M.J.
      • Segal J.B.
      • Pollack C.E.
      The association between continuity of care and the overuse of medical procedures.
      • Sabety A.H.
      • Jena A.B.
      • Barnett M.L.
      Changes in health care use and outcomes after turnover in primary care.
      • Sinsky C.A.
      • Shanafelt T.D.
      • Dyrbye L.N.
      • Sabety A.H.
      • Carlasare L.E.
      • West C.P.
      Health care expenditures attributable to primary care physician overall and burnout-related turnover: a cross-sectional analysis.
      • Hussey P.S.
      • Schneider E.C.
      • Rudin R.S.
      • Fox D.S.
      • Lai J.
      • Pollack C.E.
      Continuity and the costs of care for chronic disease.
      • Henry T.L.
      • Petterson S.
      • Phillips R.S.
      • Phillips R.L.
      • Bazemore A.
      Comparing comprehensiveness in primary care specialties and their effects on healthcare costs and hospitalizations in medicare beneficiaries.
      • Bazemore A.
      • Petterson S.
      • Peterson L.E.
      • Phillips R.L.
      More comprehensive care among family physicians is associated with lower costs and fewer hospitalizations.
      • Starfield B.
      • Shi L.
      • Macinko J.
      Contribution of primary care to health systems and health.
      ,
      • Shin D.W.
      • Cho J.
      • Yang H.K.
      • et al.
      Impact of continuity of care on mortality and health care costs: a nationwide cohort study in Korea.
      • Wolinsky F.D.
      • Bentler S.E.
      • Liu L.
      • et al.
      Continuity of care with a primary care physician and mortality in older adults.
      • Chan K.S.
      • Wan E.Y.
      • Chin W.Y.
      • et al.
      Effects of continuity of care on health outcomes among patients with diabetes mellitus and/or hypertension: a systematic review.
      Stable team composition also contributes to positive outcomes for patients and clinicians.
      • Ilbawi N.M.
      • Kamieniarz M.
      • Datta A.
      • Ewigman B.
      Reinventing the medical assistant staffing model at no cost in a large medical group.
      • Mundt M.P.
      • Gilchrist V.J.
      • Fleming M.F.
      • Zakletskaia L.I.
      • Tuan W.-J.
      • Beasley J.W.
      Effects of primary care team social networks on quality of care and costs for patients with cardiovascular disease.
      • Mundt M.P.
      • Zakletskaia L.I.
      Professional communication networks and job satisfaction in primary care clinics.
      • He W.
      • Ni S.
      • Chen G.
      • Jiang X.
      • Zheng B.
      The composition of surgical teams in the operating room and its impact on surgical team performance in China.
      • Helfrich C.D.
      • Simonetti J.A.
      • Clinton W.L.
      • et al.
      The association of team-specific workload and staffing with odds of burnout among VA primary care team members.
      • Hysong S.J.
      • Amspoker A.B.
      • Hughes A.M.
      • et al.
      Impact of team configuration and team stability on primary care quality.
      • Sinsky C.A.
      • Sinsky T.A.
      • Althaus D.
      • Tranel J.
      • Thiltgen M.
      “Core teams”: nurse-physician partnerships provide patient-centered care at an Iowa practice.
      • Sinsky C.
      Improvement happens: an interview with Christine Sinsky, MD. Interview by Richard L. Kravitz.
      How would health care differ if the infrastructures, policies, and technologies upon which care delivery is based were reoriented to prioritize relationships at every level? Not just on the surface, such as turning the monitor so the patient can watch the clinician type, nor a romanticized “Marcus Welby” notion from the past, but deep within the structures, processes, and assumptions of modern health care. This vision, informed by one of the author’s 3 decades of experience in a setting that prioritized relationships,
      • Sinsky C.A.
      • Sinsky T.A.
      • Althaus D.
      • Tranel J.
      • Thiltgen M.
      “Core teams”: nurse-physician partnerships provide patient-centered care at an Iowa practice.
      ,
      • Sinsky C.
      Improvement happens: an interview with Christine Sinsky, MD. Interview by Richard L. Kravitz.
      goes beyond relationship-centered care, which focuses on what the physician as an individual actor should do to maintain relationships
      • Nundy S.
      • Oswald J.
      Relationship-centered care: a new paradigm for population health management.
      • Suchman A.L.
      A new theoretical foundation for relationship-centered care. Complex responsive processes of relating.
      • Tresolini C.P.
      Health Professions Education and Relationship-centered Care: Report. Pew Health Professions Commission.
      and extends to whether the health system itself is constructed to appropriately value clinician-patient and clinician-clinician relationships.
      We believe that intentionally reshaping operations, culture, technology, and financial incentives to prioritize relationships will benefit patients, the health care workers and delivery systems that serve them, the payers who share in the costs of their care, and other stakeholders who care about quality, equity, and access.
      So, how can system transformation centered on relationships be accomplished? In this commentary we present three foundational actions that must be advanced to reorient the care delivery system: structurally prioritize continuity of relationships, make room for relationships by removing sludge
      • Sunstein C.R.
      Sludge Audits. Harvard Public Law Working Paper No 19-21.
      from the system, and realign reimbursement and incentives at the delivery-system level (Figure). We present examples of implementation strategies and tactics in each of these three domains to guide organizational leaders, policy makers, technology vendors, and other interested stakeholders.
      Figure thumbnail gr1
      FigureReorientation of the US health care system around relationships. EHR, electronic health record.

      Prioritize Continuity of Relationships

      What if clinical care was restructured around relationships? Such a framework must attend to multiple relationships: physician-patient; physician–team members; team member–team member (such as nurse-scheduler); clinician-colleagues, and also relationships and communication channels between institutions, such as between a hospital and an ambulatory clinic. Although the patient example used in the introduction highlighted the ambulatory environment, continuity is also important in the inpatient setting. For example, the Cleveland Clinic Department of Infectious Disease has pioneered a “one-attending” policy where hospitalized patients are followed by the same consultant until discharge even if new attendings rotate on service. Much clinical knowledge is housed in the relationship, and this continuity throughout the course of the hospitalization allows that deeper knowledge to inform the care. To avoid unrealistic work expectations, this model requires adapting ambulatory clinic hours to accommodate this tail of hospital rounding responsibilities, yet, as one physician reflects, “for those who find joy and meaning in developing meaningful relationships with patients and their families, it can be deeply fulfilling” (personal communication, Susan Rehm, MD, June 8, 2022).
      Systems that promote continuity must also be balanced with mechanisms of cross coverage to permit physicians time to recharge. For example, some physicians pair with another physician and design complementary office and vacation schedules. When a physician is unable to provide continuity for their patients, a back-up level of continuity occurs with their partner. Given their close working relationship, the partnering physicians can share knowledge with each other about their patients. These partnering physicians also benefit from the stronger collegial bond in caring for patients as a team and providing coverage that allows each to have meaningful time away.
      Continuity is more efficient for the system, decreasing the total volume of work. It takes less time and fewer resources to evaluate a patient the physician knows well; the diagnostic workup can be more targeted, and the therapies more easily aligned with the patient’s preferences and other conditions. As the Cleveland Clinic infectious disease physician notes: “One could also argue that it reduces burnout among the group as a whole. Picking up a patient who has been in the hospital for a long time is akin to doing a brand new consult, and every patient I follow on the tail is one that my partner doesn’t need to pick up.” Points of discontinuity throughout the health care system increase the total volume of work and thus decrease the total system capacity.
      Similarly, in the opening vignette, the deferral of an established patient of Dr Serra to Dr Breznik increased the total work for the physicians and staff of the unit. One appointment rather than two, along with fewer tests and referrals to resolve an issue reduces the total volume of work for the reception, rooming, billing, information technology, and other staff. It also increases the total amount of clinical resources available to the wider patient population. Future research could explore the impact of continuity and relationships on overall workload and rates of professional satisfaction and burnout.
      An interruption in a patient’s primary care relationship, such as when a primary care physician leaves their organization, is associated with higher costs and worse outcomes.
      • Sabety A.H.
      • Jena A.B.
      • Barnett M.L.
      Changes in health care use and outcomes after turnover in primary care.
      Based on analysis of Medicare claims, we have recently shown that loss of continuity due to primary care physician turnover results in nearly $1 billion in excess health care expenditures in the US each year
      • Sinsky C.A.
      • Shanafelt T.D.
      • Dyrbye L.N.
      • Sabety A.H.
      • Carlasare L.E.
      • West C.P.
      Health care expenditures attributable to primary care physician overall and burnout-related turnover: a cross-sectional analysis.
      independent of the costs to recruit and replace the physician.
      • Han S.
      • Shanafelt T.D.
      • Sinsky C.A.
      • et al.
      Estimating the attributable cost of physician burnout in the united statescost of physician burnout.
      ,
      • Shanafelt T.
      • Goh J.
      • Sinsky C.
      The business case for investing in physician well-being.
      That estimate does not take into account the costs of loss of continuity in subspecialty care.
      Relationships between team members are also critical. Staff members are also often treated as interchangeable cogs in the machine of the clinic, operating room, or hospital ward. Yet stability is a prerequisite to developing trust, reliance, mutual emotional support, and optimized workflows within care teams.
      • Ilbawi N.M.
      • Kamieniarz M.
      • Datta A.
      • Ewigman B.
      Reinventing the medical assistant staffing model at no cost in a large medical group.
      ,
      • He W.
      • Ni S.
      • Chen G.
      • Jiang X.
      • Zheng B.
      The composition of surgical teams in the operating room and its impact on surgical team performance in China.
      ,
      • Hysong S.J.
      • Amspoker A.B.
      • Hughes A.M.
      • et al.
      Impact of team configuration and team stability on primary care quality.
      ,
      • Willard-Grace R.
      • Hessler D.
      • Rogers E.
      • Dube K.
      • Bodenheimer T.
      • Grumbach K.
      Team structure and culture are associated with lower burnout in primary care.
      • Kurmann A.
      • Keller S.
      • Tschan-Semmer F.
      • et al.
      Impact of team familiarity in the operating room on surgical complications.
      • Mundt M.P.
      • Gilchrist V.J.
      • Fleming M.F.
      • Zakletskaia L.I.
      • Tuan W.J.
      • Beasley J.W.
      Effects of primary care team social networks on quality of care and costs for patients with cardiovascular disease.
      Ilbawi et al
      • Ilbawi N.M.
      • Kamieniarz M.
      • Datta A.
      • Ewigman B.
      Reinventing the medical assistant staffing model at no cost in a large medical group.
      found that matching medical assistants with family physicians in stable pairings resulted in improvements in quality indicators for chronic illness care and screening; increased productivity (an 11% increase in relative value units generated per physician); and improved physician control over their work environment and satisfaction. A stable team also fosters trust between the care team and the patient. A patient who has a relationship not just with her physician but with the nurse, medical assistant, and scheduler has many more familiar faces to call on for support. In turn, a care team member who has a relationship with a patient is more likely to know and respond to the patient’s unique needs.
      One straightforward approach to support relationships is to schedule return visits for patients at the conclusion of each visit,
      • Sinsky C.A.
      • Sinsky T.A.
      • Rajcevich E.
      Putting pre-visit planning into practice.
      ,
      • Sinsky C.
      Pre-Visit Planning. American Medical Association Steps Forward online resources.
      including relevant pre-visit testing,
      • Sinsky C.
      Pre-Visit Laboratory Testing. American Medical Association Steps Forward online resources.
      rather than simply stating “come back and see me in a year” or, perhaps even more commonly, not addressing the next appointment at all. This simple act tells the patient “We have a relationship, we want to see you again, and we will plan ahead to make that visit most meaningful.” In addition, patients can be advised to “start with us first” for any problem that arises between scheduled appointments. A simple introduction to the people and processes of the practice
      • Sinsky C.
      Introduction to Our Practice Sinsky Healthcare Innovations.
      can go a long way toward enabling patients to reach out to their personal physician when new concerns develop.
      One of the most fragile points of disjuncture within the health care system occurs at hospital discharge. In a health care system radically reoriented around relationships, the patient would not be discharged with advice to “call your doctor and make a follow-up appointment” with the attendant risk of not being able to arrange the appointment or being seen by a physician who does not have information about the recent hospitalization. Instead, the patient would leave the hospital with actual appointments (date, time, and location) for all of the follow-up required to safely continue her care. Systems would be built to communicate with the ambulatory clinic to arrange these appointments. Discharging physicians would identify the appropriate labs to be done before the follow-up appointment. Clear, concise, and actionable discharge summaries would be available at the time of the follow-up appointment making clear the key findings and changes made. If the discharging and receiving physicians are not the same physician, systems in the best of models would be built to support a conversation between the two physicians for the safest and most satisfying handoff.
      Provision of continuity cannot rely solely on individual physicians’ professionalism. Physicians’ ability to provide continuity must be supported by the design of the systems in which they practice. Staffing models, communication channels, and scheduling systems must all support the physician in providing continuity without sacrificing their own well-being. Table 1
      • Sinsky C.A.
      • Bodenheimer T.
      Powering-up primary care teams: advanced team care with in-room support.
      • Smith P.C.
      • Lyon C.
      • English A.F.
      • Conry C.
      Practice transformation under the University of Colorado’s primary care redesign model.
      • Shaw J.G.
      • Winget M.
      • Brown-Johnson C.
      • et al.
      Primary care 2.0: a prospective evaluation of a novel model of advanced team care with expanded medical assistant support.
      • Jerzak J.
      Radical redesign: the power of team-based care.
      • Sinsky C.A.
      • Willard-Grace R.
      • Schutzbank A.M.
      • Sinsky T.A.
      • Margolius D.
      • Bodenheimer T.
      In search of joy in practice: a report of 23 high-functioning primary care practices.
      • Chung M.K.
      Tuning up your patient schedule.
      • Stevens J.P.
      • Nyweide D.J.
      • Maresh S.
      • Hatfield L.A.
      • Howell M.D.
      • Landon B.E.
      Comparison of hospital resource use and outcomes among hospitalists, primary care physicians, and other generalists.
      • Meltzer D.O.
      • Ruhnke G.W.
      Redesigning care for patients at increased hospitalization risk: the Comprehensive Care Physician model.
      • West C.P.
      • Dyrbye L.N.
      • Rabatin J.T.
      • et al.
      Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.
      • Swensen S.
      LISTEN-SORT-EMPOWER. AMA Steps Forward. Published June 25, 2020.
      • Swensen S.
      • Shanafelt T.D.
      Cultivating Leadership. AMA Steps Forward.
      • DeChant P.
      Building Bridges Between Practicing Physicians and Administrators. AMA Steps Forward.
      provides additional examples of strategies and tactics practices or health systems can use to improve continuity and support relationships.
      Table 1Operational, Technological, and Cultural Strategies and Tactics to Improve Continuity and Support Relationships
      StrategyTactical examples
      Operations
       Maximize team stabilityTeam members need an ongoing relationship with each other to build the trust necessary for continuous improvement, appropriate delegation, and to complement and support each other’s unique strengths. Prioritizing the stability of the team within hiring and scheduling decisions will create the highest functioning teams.

      Ex: The same nurses and/or medical assistants are paired with the same physician for each clinic session.
      • Ilbawi N.M.
      • Kamieniarz M.
      • Datta A.
      • Ewigman B.
      Reinventing the medical assistant staffing model at no cost in a large medical group.


      Ex: The same team of OR staff routinely work with the same surgeon.
       Optimize team size and skill levelFully staffed teams have better outcomes.
      • Helfrich C.D.
      • Simonetti J.A.
      • Clinton W.L.
      • et al.
      The association of team-specific workload and staffing with odds of burnout among VA primary care team members.
      Teams composed of members with higher training (ie, RNs) can delegate more of the tasks to nonphysician members.

      Ex: In advanced models of team-based care,
      • Sinsky C.A.
      • Bodenheimer T.
      Powering-up primary care teams: advanced team care with in-room support.
      a nurse or medical assistant forms an independent relationship with patients as they perform agenda setting, medication reconciliation, self-management support, and, in some models, also assist with real-time documentation and order entry.
      • Sinsky C.A.
      • Bodenheimer T.
      Powering-up primary care teams: advanced team care with in-room support.
      • Smith P.C.
      • Lyon C.
      • English A.F.
      • Conry C.
      Practice transformation under the University of Colorado’s primary care redesign model.
      • Shaw J.G.
      • Winget M.
      • Brown-Johnson C.
      • et al.
      Primary care 2.0: a prospective evaluation of a novel model of advanced team care with expanded medical assistant support.
      Therefore, the physician is able to provide undivided attention to his patient, focusing on medical decision making and relationship building.

      Ex: A hospital nurse, pharmacist, physician, and, in some cases, also a documentarian round together, contributing their unique domain knowledge, operationalizing care decisions in real time, and thus maximizing the undivided attention the physician can provide the patient and family.
       Design physical space to support relationshipsConnecting care teams by physical colocation
      • Jerzak J.
      Radical redesign: the power of team-based care.
      ,
      • Sinsky C.A.
      • Willard-Grace R.
      • Schutzbank A.M.
      • Sinsky T.A.
      • Margolius D.
      • Bodenheimer T.
      In search of joy in practice: a report of 23 high-functioning primary care practices.
      allows for the quick communication and small, frequent readjustments required for a day to go smoothly.

      Ex: Co-location of reception staff with the clinical team allows joint problem solving to serve the needs of the patient and accommodate urgent requests. Schedulers who are a part of a specific care team know their patients and their team’s work style.
       Design the schedule to support relationshipsA well-designed and managed schedule is key to efficient practice, access, and continuity. It is often beneficial to provide the physician and team a degree of autonomy and control over the nature of the schedule. In some settings, this may include setting appointment duration and/or start/stop times for the clinic day.

      Ex: Scheduling patients on a wave allows more flexibility to meet the inherent unpredictability of patient needs.
      • Chung M.K.
      Tuning up your patient schedule.


      Ex: Include a buffer time in each day where the patient care can expand as needed.

      Ex: Avoid setting the expectation that patients should be immediately roomed upon arrival. Instead set a standard for maximum waiting time that realistically accommodates the unpredictable needs of a population of patients.
       Maximize inpatient continuityContinuity, even within a single site of care, such as the inpatient setting, improves care.
      • Goodwin J.S.
      • Li S.
      • Kuo Y.-F.
      Association of the work schedules of hospitalists with patient outcomes of hospitalization.


      Ex: A hospitalist continues to manage the patient when they are moved from one unit to another (ie, from the medical unit to a surgical unit).

      Ex: If multiple hospitalists are admitting, a hospitalist who previously cared for a given patient preferentially readmits the patient.

      Ex: A subspecialty attending continues to follow their patient through to discharge even if the attending is no longer on service.
       Enhance inpatient-outpatient continuityRecognize the importance of enhanced inpatient-outpatient continuity

      Ex: Support and recognize the value of the primary physician caring for their patients across inpatient and outpatient settings for those who are able to do so.
      • Stevens J.P.
      • Nyweide D.J.
      • Maresh S.
      • Hatfield L.A.
      • Howell M.D.
      • Landon B.E.
      Comparison of hospital resource use and outcomes among hospitalists, primary care physicians, and other generalists.
      In such “comprehensivist models,” the patient’s personal physician in that specialty (eg, primary care, neurology, cardiology, or oncology) manages their patients’ care across both ambulatory and hospital settings.
      • Meltzer D.O.
      • Ruhnke G.W.
      Redesigning care for patients at increased hospitalization risk: the Comprehensive Care Physician model.


      Ex: When the discharging and receiving physicians are not the same physician, create and support systems that foster conversation and coordination between the two physicians for the safest and most satisfying handoff.

      Ex: Rather than develop a stand-alone post-discharge clinic, patients are scheduled to see their personal physician in the appropriate specialty for hospital follow-up. For this to happen, the hospital discharging unit takes responsibility for setting up the follow-up appointment with pertinent previsit laboratory testing, and the receiving physician’s practice takes responsibility for the efficiency and schedule flexibility required to see patients within the requested time frame.
      Technology
       Design EHRs for relationshipsEHRs designed to support relationships will facilitate rapid situational awareness of the patients’ social and medical context.

      Ex: A thumbnail photo of the patient is on every screen, providing a visual cue to assist in recall of the patient.

      Ex: The EHR includes a list of the patient’s “social vitals” (ie, their support people, hobbies, or job).
       Design EHRs to reduce cognitive loadEHRs must also include human factors designed to reduce the cognitive load associated with the interacting with the EHR.

      Ex: The EHR includes a concise display of past history, medications, results, etc without the clutter of lower priority information, such as the detailed chemical names of medications or the units of measure of labs that are always resulted with standard units. (Hovering technology could make such lower priority information available in the rare instances when it is pertinent.)
      Culture
       Support team communicationStructurally supporting communication among the clinical team will enhance performance.

      Ex: Daily team huddles (ie, 5-min stand-up meetings to share unique information for the day)

      Ex: Periodic team meetings (ie, 30- to 60-min step-aside meetings to optimize workflows) can improve communication, trust, and operations.

      Ex: Meeting practices that begin with an informal check-in or time for personal sharing can build trust and relationship among the team.
       Support professional collegialityStructurally supporting communication and relationships among professional colleagues will enhance care and professional satisfaction.

      Ex: A system that fosters relationships between inpatient and outpatient teams and between physicians of multiple specialties smooths care transitions, reduces redundant testing, and reduces professional isolation.

      Ex: Clinical spaces built with shared breakrooms, and organizational support for collegial dinners.
      • West C.P.
      • Dyrbye L.N.
      • Rabatin J.T.
      • et al.
      Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.


      Ex: Programs that support relationship-building among leaders and building bridges between leaders and the clinical faculty, including listening sessions.
      • Swensen S.
      LISTEN-SORT-EMPOWER. AMA Steps Forward. Published June 25, 2020.
      • Swensen S.
      • Shanafelt T.D.
      Cultivating Leadership. AMA Steps Forward.
      • DeChant P.
      Building Bridges Between Practicing Physicians and Administrators. AMA Steps Forward.


      Ex: One model that structurally supports cross-specialty communication is to administratively nest subsets of interacting specialties together (eg, a “pod” of 20 primary care physicians, 4 cardiologists, 2 pulmonologists, 2 endocrinologists, etc) in which consultations and referrals are shared. This clustering can occur through collocated physical or virtual pods. It is easier to pick up the phone or walk down the hall to discuss the nuances of a patient’s care with a colleague you know and trust, which may decrease the need for referrals, ensure appropriate testing is in place when a referral is necessary, and improve efficiency through direct, in-person communication rather than assuming a distant, unknown colleague will understand all by reading the EHR.
      EHR, electronic health record; Ex, example; OR, operating room; RN, registered nurse.

      Make Room for Relationships by Removing Sludge From the System

      What gets in the way of continuity? In large part, as in the opening vignette, the administrative work or “sludge” of health care has reduced the capacity of physicians to see their own patients when a need arises. We believe that much of this sludge can and should be removed from the system, freeing physicians and their teams to focus more completely on their patients. In the current practice model, many physicians spend more time documenting care than delivering care.
      • Sinsky C.
      • Colligan L.
      • Li L.
      • et al.
      Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties.
      • Arndt B.G.
      • Beasley J.W.
      • Watkinson M.D.
      • et al.
      Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations.
      • Young R.A.
      • Burge S.K.
      • Kumar K.A.
      • Wilson J.M.
      • Ortiz D.F.
      A time-motion study of primary care physicians' work in the electronic health record era.
      Nurses spend hours on the phone on prescription refills that could be re-engineered out of the practice.
      • Sinsky C.A.
      • Willard-Grace R.
      • Schutzbank A.M.
      • Sinsky T.A.
      • Margolius D.
      • Bodenheimer T.
      In search of joy in practice: a report of 23 high-functioning primary care practices.
      ,
      • Sinsky C.
      Annual Prescription Renewal. AMA Steps Forward.
      ,
      • Sinsky T.A.
      • Sinsky C.A.
      A streamlined approach to prescription management.
      Medical assistants have a large number of low-value templated tasks to complete during the patient rooming process.
      • Simon J.
      • Panzer J.
      • Adetoro E.
      • et al.
      Frequency of administration of standardized screening questions in federally qualified health centers.
      The inbox is Sisyphean — many physicians feel that the inbox work is never done.
      • Adler-Milstein J.
      • Zhao W.
      • Willard-Grace R.
      • Knox M.
      • Grumbach K.
      Electronic health records and burnout: Time spent on the electronic health record after hours and message volume associated with exhaustion but not with cynicism among primary care clinicians.
      • Holmgren A.J.
      • Downing N.L.
      • Tang M.
      • Sharp C.
      • Longhurst C.
      • Huckman R.S.
      Assessing the impact of the COVID-19 pandemic on clinician ambulatory electronic health record use.
      • Hilliard R.W.
      • Haskell J.
      • Gardner R.L.
      Are specific elements of electronic health record use associated with clinician burnout more than others? J Am Med Inform Assoc.
      • Akbar F.
      • Mark G.
      • Warton E.M.
      • et al.
      Physicians’ electronic inbox work patterns and factors associated with high inbox work duration.
      • Tai-Seale M.
      • Dillon E.C.
      • Yang Y.
      • et al.
      Physicians' well-being linked to in-basket messages generated by algorithms in electronic health records.
      • Rittenberg E.
      • Liebman J.B.
      • Rexrode K.M.
      Primary care physician gender and electronic health record workload.
      • Yan Q.
      • Jiang Z.
      • Harbin Z.
      • Tolbert P.H.
      • Davies M.G.
      Exploring the relationship between electronic health records and provider burnout: a systematic review.
      • McMahon Jr., L.F.
      • Rize K.
      • Irby-Johnson N.
      • Chopra V.
      Designed to fail? The future of primary care.
      • Lieu T.A.
      • Warton E.M.
      • East J.A.
      • et al.
      Evaluation of attention switching and duration of electronic inbox work among primary care physicians.
      • Akbar F.
      • Mark G.
      • Prausnitz S.
      • et al.
      Physician stress during electronic health record inbox work: in situ measurement with wearable sensors.
      A substantial portion of the physician workday is spent on low-value activities that do not directly benefit the patient, such as entering orders for low-risk interventions such as influenza vaccinations, oximetry measurements, and fingerstick glucose readings; processing prescription renewal requests that could be re-engineered out of the practice; performing password revalidation before entering a nonscheduled medication, and meeting insurance providers’ requirements for prior authorizations that could be either streamlined or eliminated.
      For physicians, the meaningful “solution shop” work, defined as the management of unstructured problems, and which in medicine consists of complex medical decision making and relationship building, is often pushed to the margins by the mandatory “production line” work of compliance, attestation, and performance measurement.
      • Sinsky C.A.
      • Panzer J.
      The solution shop and the production line — the case for a frameshift for physician practices.
      These inefficiencies and this misdirected use of time form the tip of the iceberg of the largely invisible, and mostly avoidable, operational waste clogging up the US health care system. Much of the waste can be avoided by considering the impact of each proposed policy change on the workload and ability of the care team to provide continuity, which in turn will impact the patient experience. Much of the existing waste can and should be redesigned out of the practice.
      • Sinsky C.A.
      • Willard-Grace R.
      • Schutzbank A.M.
      • Sinsky T.A.
      • Margolius D.
      • Bodenheimer T.
      In search of joy in practice: a report of 23 high-functioning primary care practices.
      Additional administrative burdens can be removed by de-implementing outdated or non–evidence-based policies.
      • Ashton M.
      Getting rid of stupid stuff.
      • Association A.M.
      Deimplementation Check List. AMA Steps Forward.
      • Sinsky C.
      • Linzer M.
      Practice and policy reset post–COVID-19: reversion, transition, or transformation?.
      Removing waste and freeing practices of these administrative tasks will allow physicians to more consistently see their own patients, and begin a virtuous cycle of value, efficiency, and satisfaction based on continuity and relationship.
      Atrius Health reduced the inbox volume for their physicians by 25% by eliminating and automating select message types. Examples include turning off notification of tests results ordered by physicians in other specialties, automating routine labs and prescription renewals for patients, and converting admission/discharge/transfer notifications to a dashboard. They also eliminated 1500 clicks per physician per day by partnering information technology experts with clinical teams in optimization sprints (personal communication, April 11, 2022, Steve Strongwater, MD, CEO, Atrius Health). The time saved by eliminating this type of waste can and should be reinvested in relationships and reducing after-hours work (aka, “pajama time”). Kaiser-Permanente of Southern California removed the requirement for password revalidation for most orders, impacting 1.5 billion orders per week (personal communication, April 26, 2022, Dawn Clark, MD, Chief Wellness Officer). Table 2
      • Sinsky C.A.
      • Shanafelt T.D.
      • Dyrbye L.N.
      • Sabety A.H.
      • Carlasare L.E.
      • West C.P.
      Health care expenditures attributable to primary care physician overall and burnout-related turnover: a cross-sectional analysis.
      ,
      • Han S.
      • Shanafelt T.D.
      • Sinsky C.A.
      • et al.
      Estimating the attributable cost of physician burnout in the united statescost of physician burnout.
      ,
      • Shanafelt T.
      • Goh J.
      • Sinsky C.
      The business case for investing in physician well-being.
      ,
      • DeChant P.
      Building Bridges Between Practicing Physicians and Administrators. AMA Steps Forward.
      ,
      • Ashton M.
      Getting rid of stupid stuff.
      • Association A.M.
      Deimplementation Check List. AMA Steps Forward.
      • Sinsky C.
      • Linzer M.
      Practice and policy reset post–COVID-19: reversion, transition, or transformation?.
      AMA. Debunking Regulatory Myths.
      • Sinsky C.A.
      • Privitera M.R.
      Creating a “manageable cockpit” for clinicians: a shared responsibility.
      • Ashton M.
      Getting Rid of Stupid Stuff. American Medical Association Steps Forward online resources..
      provides additional examples of strategies and tactics practices can use to remove sludge and waste in an effort to support relationships.
      Table 2Operational, Technological and Cultural Strategies and Tactics to Reduce Sludge and Waste That Present Barriers to Relationships
      StrategyTactical Examples
      Operations
       Reduce unnecessary workRemoving unnecessary work creates time to devote to deepening relationships. Ex: The Getting Rid of Stupid Stuff
      • Ashton M.
      Getting rid of stupid stuff.
      toolkit provides a guide for organizational leaders in removing unnecessary sludge from their operations.

      Ex: Inbox. Organizations can turn off automatic notifications about test results not ordered by the particular physician, reducing both inbox overwhelm and also the hazards associated with ambiguity about who is responsible for responding to the result.

      Ex: Signatures. Requirements for signatures for low-risk activities, such as ear wash, fingerstick glucose, and for services that would not require an order in another setting, such as an influenza vaccination, should be removed.

      Ex: De-implement outdated policies. A De-implementation Checklist,
      • Association A.M.
      Deimplementation Check List. AMA Steps Forward.
      developed by the American Medical Association and reviewed by the Joint Commission, provides specific suggestions to minimize alerts, reduce inbox volume, decrease note bloat, and improve efficiency.

      Ex: Avoid over-interpretation of accreditation standards and state or federal policies. The Debunking Regulatory Myths
      AMA. Debunking Regulatory Myths.
      initiative prevents over-interpretation of state or federal regulations.
      Technology
       Reduce the workload of visit note documentation and reviewThe time required for visit note documentation and chart review can be reduced by improved staffing, processes, and technology.

      Ex: Dictation to a human transcriptionist who over-edits speech-to-text output results in better notes and more efficient use of physician time than requiring the physician to manually type the note or to themselves edit the speech-to-text output.

      Ex: Concise, customized notes that communicate clear clinical information make less work for everyone. In place of heavily templated notes, which risk reducing patient interactions to a litany of close-ended questions, technology, regulatory and payment structures could promote the open-ended, conversational style of history-taking that elicits a full, coherent story.
       Streamline log-in and log-out processesThe administrative and security processes involved in accessing the EHR costs time and cognitive focus. Reducing this burden can improve the work environment.

      Ex: Log-ins can be simplified, using RFID proximity identification or bio identification (ie, fingerprint or facial recognition).

      Ex: Intervals between auto-logouts can be extended, with the interval adjusted according to the location of the workstation.
      Culture
       Governance structuresChanging the nature of the administrator-physician relationship so that both groups share accountability for common goals can result in better outcomes and job satisfaction.
      • DeChant P.
      Building Bridges Between Practicing Physicians and Administrators. AMA Steps Forward.
      ,
      • Sinsky C.A.
      • Privitera M.R.
      Creating a “manageable cockpit” for clinicians: a shared responsibility.


      Ex: The impact of new policies on physician workload, and thus on access and continuity, can be calculated before implementation, and the high cost of clinician burnout and turnover
      • Sinsky C.A.
      • Shanafelt T.D.
      • Dyrbye L.N.
      • Sabety A.H.
      • Carlasare L.E.
      • West C.P.
      Health care expenditures attributable to primary care physician overall and burnout-related turnover: a cross-sectional analysis.
      ,
      • Han S.
      • Shanafelt T.D.
      • Sinsky C.A.
      • et al.
      Estimating the attributable cost of physician burnout in the united statescost of physician burnout.
      ,
      • Shanafelt T.
      • Goh J.
      • Sinsky C.
      The business case for investing in physician well-being.
      can be treated with the urgency its financial and cultural impact deserve.
      EHR, electronic health record; Ex, example; RFID, radio frequency identification.

      Realign Reimbursement and Incentives

      The current design of health care reimbursement and incentives has systematically undermined relationships: urgent care centers, pharmacies, and retail clinics skim off lower-acuity, higher revenue care; and physician practices spend substantial resources supporting the profit-generating capacity of commercial entities, including pharmacy benefits managers, commercial pharmacies, durable medical equipment suppliers, and insurance providers.
      • Casalino L.P.
      • Nicholson S.
      • Gans D.N.
      • et al.
      What does it cost physician practices to interact with health insurance plans?.
      As one example, in 2009, Casalino et al
      • Casalino L.P.
      • Nicholson S.
      • Gans D.N.
      • et al.
      What does it cost physician practices to interact with health insurance plans?.
      estimated that physician practices annually spend $23-$31 billion interacting with insurance plans.
      In another example, a Chair of Medicine is under pressure to increase access within her department for new patients, who generate downstream revenue through subspecialty care and procedures that contribute to the financial stability of the organization. Therefore, new patient appointments are prioritized in physicians’ schedules. The result is overpaneled practices and a moral dilemma for physicians: see their established patients needing care as overbooked appointments, work longer hours and compromise personal and family well-being, or tell their established patients they are unable to be seen or must be managed by portal or seen by a substitute.
      Fee-for-service (FFS) payment models are often blamed for suboptimal outcomes within the US health care system.
      • Guterman S.
      Wielding the Carrot and the Stick: How to Move the U.S. Health Care System Away from Fee-for-Service Payment. Commonwealth Fund Blog.
      ,
      • Schroeder S.A.
      • Frist W.
      Phasing out fee-for-service payment.
      Fee-for-service can discourage continuity by incentivizing organizations to fill physicians’ schedules far in advance, effectively resulting in practices that are overpaneled for their supporting resources,
      • Sinsky C.A.
      • Brown M.T.
      Optimal panel size: are we asking the right question?.
      leaving little room for short-term access for urgent needs and for hospital follow-up. On the other hand, FFS payment, when coupled with control over one’s practice environment (eg, team size, structure, and skill level; number of exam rooms; and scheduling template) can also incentivize practice efficiency, although physicians in large organizations are rarely afforded such control.
      A payment model that promotes relationships would financially incentivize continuity between a patient and a physician. Practices would be meaningfully reimbursed for coordination that occurs outside of a visit, whether two physicians conferring about a shared ambulatory patient or a hospital-based physician consulting with an outpatient colleague on hospital admission and again at discharge. Payment approaches that require documentation of ever-thinner slices of physician activity will quickly reach a point of diminishing returns where the work of justifying the service requires as much time as the delivering the actual service. Table 3
      • Sinsky C.
      Pre-Visit Laboratory Testing. American Medical Association Steps Forward online resources.
      ,
      • Sinsky T.A.
      • Sinsky C.A.
      A streamlined approach to prescription management.
      ,
      • Sinsky C.A.
      Improving office practice: working smarter, not harder.
      addresses financial strategies that individual physicians, health systems, and policy makers can consider as means of supporting a health care system reoriented around relationships.
      Table 3Financial Strategies and Tactics to Structurally Support Relationships
      StrategyTactical Examples
      Adopt an owner’s mindset in practicePhysicians in practice can adopt an owner’s mindset, whether they are employed by a health system or own their own practice, and thus strive to maximize their efficiency in how they spend their time and generate revenue.

      Ex: Hiring sufficient staff (in some settings this may be 2 clinical assistants per physician) to develop the capacity to offer same-day access for urgent and semi-urgent visits.

      Ex: Attending to the fundamentals of practice workflows,
      • Sinsky C.A.
      Improving office practice: working smarter, not harder.
      such as incorporating the annual wellness visit into the rooming process for an evaluation and management visit; routinely prescribing 90 days plus 4 refills for stable medications
      • Sinsky T.A.
      • Sinsky C.A.
      A streamlined approach to prescription management.
      ; and performing previsit laboratory testing.
      • Sinsky C.
      Pre-Visit Laboratory Testing. American Medical Association Steps Forward online resources.


      Ex: Being willing to see one’s own patients who call in on an urgent basis, recognizing that doing so improves patient care, increases patient loyalty, and increases revenues generated.
      Align payment to support relationshipsPayment systems can contribute to the sludge in health care that is a barrier to relationships and, on the other hand, can also fund the mechanisms that support relationships.

      Ex: Payers can simplify or eliminate prior authorization requirements or pay physicians for providing this service.

      Ex: Payers can provide funding for virtual consultations that support integrated care, including payment for physicians to discuss with colleagues the care of mutual patients.

      Ex: Delivery systems can more equitably distribute operating dollars to the clinical units that generate downstream revenue for the organization.
      Ex, example.
      The National Institutes of Health and private industry invest $130 billion annually researching disease-specific treatments,
      • Office C.B.
      Research and Development in the Pharmaceutical Industry.
      whereas the Agency for Healthcare Research and Quality receives less than 1% of this amount ($500 million) to conduct research designed to optimize delivery models that determine whether or not those treatment advances are appropriately deployed and safely delivered to patients in day-to-day practice.
      • Meyers D.
      The FY 2022 President’s Budget Request for AHRQ: Building Back Better.
      Increased funding for research addressing care delivery, including the role of continuity, will help shape a health care system that delivers more value, and could include: (1) optimizing care team size, structure, and skill level to fully leverage the skills of physicians and other clinicians, as is done in advanced models of team-based care with in-room support
      • Sinsky C.A.
      • Bodenheimer T.
      Powering-up primary care teams: advanced team care with in-room support.
      ; (2) reducing the cognitive workload and time-costs of interacting with electronic health records and other technologies
      • Johnson K.B.
      • Stead W.W.
      Making electronic health records both SAFER and SMARTER.
      ; (3) improving information flow and workflow within and across health care settings; and (4) analyzing the value of comprehensiveness, continuity, and cohesion.

      Barriers to Reorientation of the US Health Care System Around Relationships

      One of the biggest barriers to reorientation around relationships is simply recognizing the degree to which our current system has become conceptualized as a series of transactions. The power of relationships rests in our collective blind spot. Another important barrier is the difficulty physicians and leaders may have imagining a care model and health system that they have not yet experienced. Some physicians are overpaneled for their resources and percent full time equivalent, which can be a structural barrier to continuity and relationship. This is a particularly acute problem for physicians who reduce their clinical effort, often in an attempt to deal with work overload, without reducing the size of their patient panel. A final important barrier is a belief that the current constraints in health care cannot be changed. If only the physician can enter orders, if staffing is limited to half or one minimally trained clinical assistant per physician, if compliance concerns always trump the feasibility of the work, and if no systems are built to increase the ease of communication between individuals and between institutions, then substantive change is limited. But we have experienced and thus believe that a radical reorientation of the infrastructures, priorities, and practices of health care around relationships is possible and will be of benefit to patients, physicians, and payors.

      Opening Vignette Revisited

      “Dr Serra and the care team can see you for an urgent visit today.” The receptionist, co-located with the clinical team, was able to check with the staff to offer a same-day appointment. Dr Serra is able to make the needed minor adjustment to address the patient’s new symptoms. Because Dr Serra knows the patient well, this adjustment is made without unnecessary imaging and laboratories. A team member aids in real-time documentation and order entry, freeing Dr Serra to engage without distraction. The team now consists of Dr Serra and the same two clinical assistants (medical assistants or nurses) each day. This stable and upskilled team is able to perform much of the “production line” work for the practice, freeing up Dr Serra to both have greater capacity to see his own patients and greater focus on their concerns during the encounter. Because of the important contributions of team members, the encounter required a total of 10 minutes of Dr Serra’s time. The patient was grateful to be seen quickly and felt reassured by Dr Serra, whom they trust. Drs Serra and Breznik and their team members all went home on time.

      Conclusion

      The transactional conceptualization of health care has been at odds with the fundamental relational nature of the work, to the detriment of health care costs, quality, and satisfaction.
      In recommending a radical restructuring around relationships, we call for a fundamental shift in the mindset and actions of a diverse set of stakeholders. No physician, leader, payor, or policy maker can single-handedly facilitate this shift. Yet we believe that a collective commitment by all stakeholders to examine every decision in light of its impact on relationships will result in better outcomes for patients, clinicians, and the health care delivery system.

      Potential Competing Interests

      Dr Sinsky is employed by the American Medical Association. Dr Shanafelt is a co-inventor of the Well-being Index instruments (Physician Well-being Index, Nurse Well-being Index, Medical Student Well-being Index, and the Well-being Index) and of the Participatory Management Leadership Index. Mayo Clinic holds the copyright for these instruments and has licensed them for use outside of Mayo Clinic. Mayo Clinic pays Dr Shanafelt a portion of any royalties received. None of these instruments were used in the present manuscript. The remaining authors report no potential competing interests.

      Acknowledgments

      The authors thank Drs Mark Linzer, Pat Lee, Jeff Panzer, Kevin Hopkins, and Thomas Sinsky for their review of earlier versions of this manuscript. The opinions expressed in this article are those of the authors and should not be interpreted as American Medical Association policy.

      Supplemental Online Material

      References

        • Bodenheimer T.
        • Sinsky C.
        From triple to quadruple aim: care of the patient requires care of the provider.
        Ann Fam Med. 2014; 12: 573-576
        • Pellegrino E.D.
        The commodification of medical and health care: the moral consequences of a paradigm shift from a professional to a market ethic.
        J Med Philos. 1999; 24: 243-266
        • Waitzkin H.
        The commodification of health care and the search for a universal health program in the United States. Culture of Health Blog.
        https://www.rwjf.org/en/blog/2012/10/the_commodification.html
        Date: October 11, 2012
        Date accessed: March 10, 2022
        • Huang E.C.-H.
        • Pu C.
        • Chou Y.-J.
        • Huang N.
        Public trust in physicians — health care commodification as a possible deteriorating factor: cross-sectional analysis of 23 countries.
        Inquiry. 2018; 550046958018759174
        • Topol E.J.
        The consumer movement in health care.
        Pharos Alpha Omega Alpha Honor Med Soc. 2010; 73: 34-35
        • Compton J.
        The Consumerism Movement In Healthcare: How It's Making A Difference.
        Forbes. 2018; 13
        • Offodile A.C.
        • Cerullo M.
        • Bindal M.
        • Rauh-Hain J.A.
        • Ho V.
        Private equity investments in health care: an overview of hospital and health system leveraged buyouts, 2003–17.
        Health Aff (Millwood). 2021; 40: 719-726
        • Starfield B.
        Primary care and equity in health: the importance to effectiveness and equity of responsiveness to peoples' needs.
        Humanity & Society. 2009; 33: 56-73
        • Pandhi N.
        • Saultz J.W.
        Patients' perceptions of interpersonal continuity of care.
        J Am Board Fam Med. 2006; 19: 390-397
        • Wasson J.H.
        • Sauvigne A.E.
        • Mogielnicki R.P.
        • et al.
        Continuity of outpatient medical care in elderly men. A randomized trial.
        JAMA. 1984; 252: 2413-2417
        • Saultz J.W.
        • Albedaiwi W.
        Interpersonal continuity of care and patient satisfaction: a critical review.
        Ann Fam Med. 2004; 2: 445-451
        • Day J.
        • Scammon D.L.
        • Kim J.
        • et al.
        Quality, satisfaction, and financial efficiency associated with elements of primary care practice transformation: preliminary findings.
        Ann Fam Med. 2013; 11: S50-S59
        • Pourat N.
        • Davis A.C.
        • Chen X.
        • Vrungos S.
        • Kominski G.F.
        In California, primary care continuity was associated with reduced emergency department use and fewer hospitalizations.
        Health Aff (Millwood). 2015; 34: 1113-1120
        • Nyweide D.J.
        • Bynum J.P.W.
        Relationship between continuity of ambulatory care and risk of emergency department episodes among older adults.
        Ann Emerg Med. 2017; 69: 407-415.e403
        • Barker I.
        • Steventon A.
        • Deeny S.R.
        Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data.
        BMJ. 2017; 356: j84
        • Bayliss E.A.
        • Ellis J.L.
        • Shoup J.A.
        • Zeng C.
        • McQuillan D.B.
        • Steiner J.F.
        Effect of continuity of care on hospital utilization for seniors with multiple medical conditions in an integrated health care system.
        Ann Fam Med. 2015; 13: 123-129
        • Bazemore A.
        • Petterson S.
        • Peterson L.E.
        • Bruno R.
        • Chung Y.
        • Phillips Jr., R.L.
        Higher primary care physician continuity is associated with lower costs and hospitalizations.
        Ann Fam Med. 2018; 16: 492-497
        • Tammes P.
        • Purdy S.
        • Salisbury C.
        • MacKichan F.
        • Lasserson D.
        • Morris R.W.
        Continuity of primary care and emergency hospital admissions among older patients in England.
        Ann Fam Med. 2017; 15: 515-522
        • Goodwin J.S.
        • Lin Y.L.
        • Singh S.
        • Kuo Y.F.
        Variation in length of stay and outcomes among hospitalized patients attributable to hospitals and hospitalists.
        J Gen Intern Med. 2013; 28: 370-376
        • Gill J.M.
        • Mainous 3rd, A.G.
        The role of provider continuity in preventing hospitalizations.
        Arch Fam Med. 1998; 7: 352-357
        • Cohen-Mekelburg S.
        • Saini S.D.
        • Krein S.L.
        • et al.
        Association of Continuity of Care With Outcomes in US Veterans With Inflammatory Bowel Disease.
        JAMA Netw Open. 2020; 3e2015899
        • Frandsen B.R.
        • Joynt K.E.
        • Rebitzer J.B.
        • Jha A.K.
        Care fragmentation, quality, and costs among chronically ill patients.
        Am J Manag Care. 2015; 21: 355-362
        • Jones P.M.
        • Cherry R.A.
        • Allen B.N.
        • et al.
        Association between handover of anesthesia care and adverse postoperative outcomes among patients undergoing major surgery.
        JAMA. 2018; 319: 143-153
        • Goodwin J.S.
        • Li S.
        • Hommel E.
        • Nattinger A.B.
        • Kuo Y.-F.
        • Raji M.
        Association of inpatient continuity of care with complications and length of stay among hospitalized medicare enrollees.
        JAMA Netw Open. 2021; 4e2120622
        • Goodwin J.S.
        • Li S.
        • Kuo Y.-F.
        Association of the work schedules of hospitalists with patient outcomes of hospitalization.
        JAMA Intern Med. 2020; 180: 215-222
        • Raddish M.
        • Horn S.D.
        • Sharkey P.D.
        Continuity of care: is it cost effective?.
        Am J Manag Care. 1999; 5: 727-734
        • Burge F.
        • Lawson B.
        • Johnston G.
        Family physician continuity of care and emergency department use in end-of-life cancer care.
        Med Care. 2003; 41: 992-1001
        • Mosquera R.A.
        • Avritscher E.B.C.
        • Pedroza C.
        • et al.
        Hospital consultation from outpatient clinicians for medically complex children: a randomized clinical trial.
        JAMA Pediatr. 2020; 175e205026
        • Romano M.J.
        • Segal J.B.
        • Pollack C.E.
        The association between continuity of care and the overuse of medical procedures.
        JAMA Intern Med. 2015; 175: 1148-1154
        • Sabety A.H.
        • Jena A.B.
        • Barnett M.L.
        Changes in health care use and outcomes after turnover in primary care.
        JAMA Intern Med. 2021; 181: 186-194
        • Sinsky C.A.
        • Shanafelt T.D.
        • Dyrbye L.N.
        • Sabety A.H.
        • Carlasare L.E.
        • West C.P.
        Health care expenditures attributable to primary care physician overall and burnout-related turnover: a cross-sectional analysis.
        Mayo Clinic Proc. 2022; 97: 693-702
        • Hussey P.S.
        • Schneider E.C.
        • Rudin R.S.
        • Fox D.S.
        • Lai J.
        • Pollack C.E.
        Continuity and the costs of care for chronic disease.
        JAMA Intern Med. 2014; 174: 742-748
        • Henry T.L.
        • Petterson S.
        • Phillips R.S.
        • Phillips R.L.
        • Bazemore A.
        Comparing comprehensiveness in primary care specialties and their effects on healthcare costs and hospitalizations in medicare beneficiaries.
        J Gen Intern Med. 2019; 34: 2708-2710
        • Bazemore A.
        • Petterson S.
        • Peterson L.E.
        • Phillips R.L.
        More comprehensive care among family physicians is associated with lower costs and fewer hospitalizations.
        Ann Fam Med. 2015; 13: 206-213
        • Starfield B.
        • Shi L.
        • Macinko J.
        Contribution of primary care to health systems and health.
        Milbank Q. 2005; 83: 457-502
        • Weiss L.J.
        • Blustein J.
        Faithful patients: the effect of long-term physician-patient relationships on the costs and use of health care by older Americans.
        Am J Public Health. 1996; 86: 1742-1747
        • Shin D.W.
        • Cho J.
        • Yang H.K.
        • et al.
        Impact of continuity of care on mortality and health care costs: a nationwide cohort study in Korea.
        Ann Fam Med. 2014; 12: 534-541
        • Wolinsky F.D.
        • Bentler S.E.
        • Liu L.
        • et al.
        Continuity of care with a primary care physician and mortality in older adults.
        J Gerontol A Biol Sci Med Sci. 2010; 65: 421-428
        • Chan K.S.
        • Wan E.Y.
        • Chin W.Y.
        • et al.
        Effects of continuity of care on health outcomes among patients with diabetes mellitus and/or hypertension: a systematic review.
        BMC Fam Pract. 2021; 22: 145
        • Ilbawi N.M.
        • Kamieniarz M.
        • Datta A.
        • Ewigman B.
        Reinventing the medical assistant staffing model at no cost in a large medical group.
        Ann Fam Med. 2020; 18: 180
        • Mundt M.P.
        • Gilchrist V.J.
        • Fleming M.F.
        • Zakletskaia L.I.
        • Tuan W.-J.
        • Beasley J.W.
        Effects of primary care team social networks on quality of care and costs for patients with cardiovascular disease.
        Ann Fam Med. 2015; 13: 139-148
        • Mundt M.P.
        • Zakletskaia L.I.
        Professional communication networks and job satisfaction in primary care clinics.
        Ann Fam Med. 2019; 17: 428-435
        • He W.
        • Ni S.
        • Chen G.
        • Jiang X.
        • Zheng B.
        The composition of surgical teams in the operating room and its impact on surgical team performance in China.
        Surg Endosc. 2014; 28: 1473-1478
        • Helfrich C.D.
        • Simonetti J.A.
        • Clinton W.L.
        • et al.
        The association of team-specific workload and staffing with odds of burnout among VA primary care team members.
        J Gen Intern Med. 2017; 32: 760-766
        • Hysong S.J.
        • Amspoker A.B.
        • Hughes A.M.
        • et al.
        Impact of team configuration and team stability on primary care quality.
        Implement Sci. 2019; 14: 22
        • Sinsky C.A.
        • Sinsky T.A.
        • Althaus D.
        • Tranel J.
        • Thiltgen M.
        “Core teams”: nurse-physician partnerships provide patient-centered care at an Iowa practice.
        Health Aff (Millwood). 2010; 29: 966-968
        • Sinsky C.
        Improvement happens: an interview with Christine Sinsky, MD. Interview by Richard L. Kravitz.
        J Gen Intern Med. 2010; 25: 474-477
        • Nundy S.
        • Oswald J.
        Relationship-centered care: a new paradigm for population health management.
        Healthc (Amst). 2014; 2: 216-219
        • Suchman A.L.
        A new theoretical foundation for relationship-centered care. Complex responsive processes of relating.
        J Gen Intern Med. 2006; 21: S40-S44
        • Tresolini C.P.
        Health Professions Education and Relationship-centered Care: Report. Pew Health Professions Commission.
        UCSF Center for the Health Professions, 1994
        • Sunstein C.R.
        Sludge Audits. Harvard Public Law Working Paper No 19-21.
        • Han S.
        • Shanafelt T.D.
        • Sinsky C.A.
        • et al.
        Estimating the attributable cost of physician burnout in the united statescost of physician burnout.
        Ann Intern Med. 2019; 170: 784-790
        • Shanafelt T.
        • Goh J.
        • Sinsky C.
        The business case for investing in physician well-being.
        JAMA Intern Med. 2017; 177: 1826-1832
        • Willard-Grace R.
        • Hessler D.
        • Rogers E.
        • Dube K.
        • Bodenheimer T.
        • Grumbach K.
        Team structure and culture are associated with lower burnout in primary care.
        J Am Board Fam Med. 2014; 27: 229-238
        • Kurmann A.
        • Keller S.
        • Tschan-Semmer F.
        • et al.
        Impact of team familiarity in the operating room on surgical complications.
        World J Surg. 2014; 38: 3047-3052
        • Mundt M.P.
        • Gilchrist V.J.
        • Fleming M.F.
        • Zakletskaia L.I.
        • Tuan W.J.
        • Beasley J.W.
        Effects of primary care team social networks on quality of care and costs for patients with cardiovascular disease.
        Ann Fam Med. 2015; 13: 139-148
        • Sinsky C.A.
        • Sinsky T.A.
        • Rajcevich E.
        Putting pre-visit planning into practice.
        Fam Pract Manag. 2015; 22: 34-38
        • Sinsky C.
        Pre-Visit Planning. American Medical Association Steps Forward online resources.
        • Sinsky C.
        Pre-Visit Laboratory Testing. American Medical Association Steps Forward online resources.
        • Sinsky C.
        Introduction to Our Practice Sinsky Healthcare Innovations.
        • Sinsky C.A.
        • Bodenheimer T.
        Powering-up primary care teams: advanced team care with in-room support.
        Ann Fam Med. 2019; 17: 367-371
        • Smith P.C.
        • Lyon C.
        • English A.F.
        • Conry C.
        Practice transformation under the University of Colorado’s primary care redesign model.
        Ann Fam Med. 2019; 17: S24-S32
        • Shaw J.G.
        • Winget M.
        • Brown-Johnson C.
        • et al.
        Primary care 2.0: a prospective evaluation of a novel model of advanced team care with expanded medical assistant support.
        The Ann Fam Med. 2021; 19: 411-418
        • Jerzak J.
        Radical redesign: the power of team-based care.
        Ann Fam Med. 2017; 15: 281
        • Sinsky C.A.
        • Willard-Grace R.
        • Schutzbank A.M.
        • Sinsky T.A.
        • Margolius D.
        • Bodenheimer T.
        In search of joy in practice: a report of 23 high-functioning primary care practices.
        Ann Fam Med. 2013; 11: 272-278
        • Chung M.K.
        Tuning up your patient schedule.
        Fam Pract Manag. 2002; 9: 41-45
        • Stevens J.P.
        • Nyweide D.J.
        • Maresh S.
        • Hatfield L.A.
        • Howell M.D.
        • Landon B.E.
        Comparison of hospital resource use and outcomes among hospitalists, primary care physicians, and other generalists.
        JAMA Intern Med. 2017; 177: 1781-1787
        • Meltzer D.O.
        • Ruhnke G.W.
        Redesigning care for patients at increased hospitalization risk: the Comprehensive Care Physician model.
        Health Aff (Millwood). 2014; 33: 770-777
        • West C.P.
        • Dyrbye L.N.
        • Rabatin J.T.
        • et al.
        Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.
        JAMA Intern Med. 2014; 174: 527-533
        • Swensen S.
        LISTEN-SORT-EMPOWER. AMA Steps Forward. Published June 25, 2020.
        • Swensen S.
        • Shanafelt T.D.
        Cultivating Leadership. AMA Steps Forward.
        • DeChant P.
        Building Bridges Between Practicing Physicians and Administrators. AMA Steps Forward.
        https://edhub.ama-assn.org/steps-forward/module/2780305
        Date: 2021
        Date accessed: July 10, 2021
        • Sinsky C.
        • Colligan L.
        • Li L.
        • et al.
        Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties.
        Ann Intern Med. 2016; 165: 753-760
        • Arndt B.G.
        • Beasley J.W.
        • Watkinson M.D.
        • et al.
        Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations.
        Ann Fam Med. 2017; 15: 419-426
        • Young R.A.
        • Burge S.K.
        • Kumar K.A.
        • Wilson J.M.
        • Ortiz D.F.
        A time-motion study of primary care physicians' work in the electronic health record era.
        Fam Med. 2018; 50: 91-99
        • Sinsky C.
        Annual Prescription Renewal. AMA Steps Forward.
        • Sinsky T.A.
        • Sinsky C.A.
        A streamlined approach to prescription management.
        Fam Pract Manag. 2012; 19: 11-13
        • Simon J.
        • Panzer J.
        • Adetoro E.
        • et al.
        Frequency of administration of standardized screening questions in federally qualified health centers.
        JAMA Intern Med. 2021; 181: 1253-1255
        • Adler-Milstein J.
        • Zhao W.
        • Willard-Grace R.
        • Knox M.
        • Grumbach K.
        Electronic health records and burnout: Time spent on the electronic health record after hours and message volume associated with exhaustion but not with cynicism among primary care clinicians.
        J Am Med Infrom Assoc. 2020; 27: 531-538
        • Holmgren A.J.
        • Downing N.L.
        • Tang M.
        • Sharp C.
        • Longhurst C.
        • Huckman R.S.
        Assessing the impact of the COVID-19 pandemic on clinician ambulatory electronic health record use.
        J Am Med Inform Assoc. 2022; 29: 453-460
        • Hilliard R.W.
        • Haskell J.
        • Gardner R.L.
        Are specific elements of electronic health record use associated with clinician burnout more than others? J Am Med Inform Assoc.
        • Akbar F.
        • Mark G.
        • Warton E.M.
        • et al.
        Physicians’ electronic inbox work patterns and factors associated with high inbox work duration.
        J Am Med Inform Assoc. 2021; 28: 923-930
        • Tai-Seale M.
        • Dillon E.C.
        • Yang Y.
        • et al.
        Physicians' well-being linked to in-basket messages generated by algorithms in electronic health records.
        Health Aff (Millwood). 2019; 38: 1073-1078
        • Rittenberg E.
        • Liebman J.B.
        • Rexrode K.M.
        Primary care physician gender and electronic health record workload.
        J Gen Intern Med. 2022;
        https://doi.org/10.1007/s11606-021-07298-z
        Date: 2021
        Date accessed: March 16, 2021
        • Yan Q.
        • Jiang Z.
        • Harbin Z.
        • Tolbert P.H.
        • Davies M.G.
        Exploring the relationship between electronic health records and provider burnout: a systematic review.
        J Am Med Infrom Assoc. 2021; 28: 1009-1021
        • McMahon Jr., L.F.
        • Rize K.
        • Irby-Johnson N.
        • Chopra V.
        Designed to fail? The future of primary care.
        J Gen Intern Med. 2021; 36: 515-517
        • Lieu T.A.
        • Warton E.M.
        • East J.A.
        • et al.
        Evaluation of attention switching and duration of electronic inbox work among primary care physicians.
        JAMA Netw Open. 2021; 4e2031856
        • Akbar F.
        • Mark G.
        • Prausnitz S.
        • et al.
        Physician stress during electronic health record inbox work: in situ measurement with wearable sensors.
        JMIR Med Inform. 2021; 9e24014
        • Sinsky C.A.
        • Panzer J.
        The solution shop and the production line — the case for a frameshift for physician practices.
        N Engl J Med. 2022; 386: 2452-2453
        • Ashton M.
        Getting rid of stupid stuff.
        N Engl J Med. 2018; 379: 1789-1791
        • Association A.M.
        Deimplementation Check List. AMA Steps Forward.
        • Sinsky C.
        • Linzer M.
        Practice and policy reset post–COVID-19: reversion, transition, or transformation?.
        Health Aff (Millwood). 2020; 39: 1405-1411
      1. AMA. Debunking Regulatory Myths.
        • Sinsky C.A.
        • Privitera M.R.
        Creating a “manageable cockpit” for clinicians: a shared responsibility.
        JAMA Intern Med. 2018; 178: 741-742
        • Ashton M.
        Getting Rid of Stupid Stuff. American Medical Association Steps Forward online resources..
        • Casalino L.P.
        • Nicholson S.
        • Gans D.N.
        • et al.
        What does it cost physician practices to interact with health insurance plans?.
        Health Aff (Millwood). 2009; 28: w533-w543
        • Guterman S.
        Wielding the Carrot and the Stick: How to Move the U.S. Health Care System Away from Fee-for-Service Payment. Commonwealth Fund Blog.
        • Schroeder S.A.
        • Frist W.
        Phasing out fee-for-service payment.
        N Engl J Med. 2013; 368: 2029-2032
        • Sinsky C.A.
        • Brown M.T.
        Optimal panel size: are we asking the right question?.
        Ann Intern Med. 2020; 172: 201-217
        • Sinsky C.A.
        Improving office practice: working smarter, not harder.
        Fam Pract Manag. 2006; 13: 28-34
        • National Institutes of Health OoB
        FY 2022 President’s Budget.
        • Office C.B.
        Research and Development in the Pharmaceutical Industry.
        • Meyers D.
        The FY 2022 President’s Budget Request for AHRQ: Building Back Better.
        • Johnson K.B.
        • Stead W.W.
        Making electronic health records both SAFER and SMARTER.
        JAMA. 2022; 328: 523-524