The volume of alerts and texts overshadows important information that requires action. One-half of such alerts have little clinical significance or could be handled by other team members 80% of the text in the alerts is unnecessary. 11 Between 20, primary care physicians at a Veterans Affairs facility spent 49 minutes per day responding to inbox-type alerts in addition to documentation of care provided. 10 Even when in the exam room with patients, primary care physicians spend from 25% to 50% of the time attending to the computer. 9 Physicians spend more time on non–face-to-face activities (eg, letters, in-box management, and medication refills) than with patients. 8 Forty-three percent of physicians surveyed in 2014 reported spending over 30% of their day on administrative tasks. In a 2011 national survey, 87% of physicians named the leading cause of work-related stress and burnout as paperwork and administration, with 63% indicating that stress is increasing. “I am no longer a physician but the data manager, data entry clerk and steno girl… I became a doctor to take care of patients. “I can’t tell you how defeated I feel…The feeling of being punished for delivering good care is nerve-racking.” “I hate being a doctor…I can’t wait to get out.”
“The joy of practicing medicine is gone.” We have heard physicians making such statements as: 7 Physician dissatisfaction, therefore, is an early warning sign of a health care system creating barriers to high-quality practice.
TRIPLE AND QUADRUPLE AIM DRIVER
5, 7 According to a recent RAND Corporation survey, the principal driver of physician satisfaction is the ability to provide quality care.
TRIPLE AND QUADRUPLE AIM PROFESSIONAL
6 Professional burnout is characterized by loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment and is associated with early retirement, alcohol use, and suicidal ideation. 5 In a 2014 survey, 68% of family physicians and 73% of general internists would not choose the same specialty if they could start their careers anew. Widespread across specialties, burnout is especially prevalent among emergency department physicians, general internists, neurologists, and family physicians. The wide gap between societal expectations and professional reality has set the stage for 46% of US physicians to experience symptoms of burnout. In visiting primary care practices around the country, 2 the authors have repeatedly heard statements such as, “We have adopted the Triple Aim as our framework, but the stressful work life of our clinicians and staff impacts our ability to achieve the 3 aims.” These sentiments made us wonder, might there be a fourth aim-improving the work life of health care clinicians and staff-that, like the patient experience and cost reduction aims, must be achieved in order to succeed in improving population health? Should the Triple Aim become the Quadruple Aim? 1 The primary Triple Aim goal is to improve the health of the population, with 2 secondary goals-improving patient experience and reducing costs-contributing to the achievement of the primary goal. The Triple Aim is an approach to optimizing health system performance, proposing that health care institutions simultaneously pursue 3 dimensions of performance: improving the health of populations, enhancing the patient experience of care, and reducing the per capita cost of health care. Since Don Berwick and colleagues introduced the Triple Aim into the health care lexicon, this concept has spread to all corners of the health care system.
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