When Bill Clinton ran for president in 1992, his political strategist, James Carville, hung a sign at campaign headquarters to keep the operation on message. The central reminder was that it’s “the economy, stupid.” In less flowery language, Mr. Carville emphasized that a bad economy was going to move voters; everything else might be important, but not essential.
I’ll admit that running for president is complicated, but I will also posit that running a primary care office ain’t a walk in the park, either. Large healthcare systems often see pediatrics, internal medicine, and family medicine clinics as loss leaders (i.e., you’re not going to make a ton of money on primary care, but you need them to feed patients into your specialty clinics and hospitals). Indeed, Walmart admitted a few months ago that they couldn’t figure out how to profitably run their health systems. They used fancier words (“We determined that there is not a sustainable business model for us to continue”), but the meaning is the same.
On top of trying to keep a primary care clinic solvent, healthcare systems executives are also dealing with an epidemic of clinician burnout. Doctors and nurses are especially hard hit, reporting high anxiety and depression scores. While technology and electronic health records (EHRs) can be reasonably faulted for some of the problems, there is plenty of blame to go around. I often write about how to wrangle healthcare IT to make it better for frontline clinicians, but in this post, I’d like to explore another angle: leveraging support staff, specifically medical assistants.
The requirements to become a medical assistant (MA) and their job description vary considerably, not just from state to state, but even from office to office. Today, most MAs graduate from non-degree programs and are eligible to become certified medical assistants (CMAs). The American Association of Medical Assistants notes that the duties of MAs include both clinical (e.g., taking histories, preparing and administering medications and immunizations, and taking ECGs) and administrative (e.g., using and updating an EHR, answering patient questions, and scheduling appointments).
Evidence shows that the use of MAs decreases clinician burnout. How? By acknowledging that healthcare in general, and primary care specifically, are team sports. The physician, while properly being the quarterback of the team, needs help to achieve their goals. As noted in the National Academy of Sciences report Implementing High-Quality Primary Care (2021), “Typically, medical assistants are assigned to a partnering clinician and can develop long-term relationships with care-seekers and families. They are often an early point of contact and have familiarized themselves with the patients’ personal and medical histories. Their role focuses on preparing patients for visits, helping them flow through the clinic, and ensuring that their primary care clinician has the information and resources needed for a whole-person visit."
But wait, there’s more! Medical assistants can also play a key role in population health and education. While physicians are seeing patients in the clinic or virtually, MAs can be dealing with specialized tasks like panel management or health coaching. As noted, the MA often develops a close relationship with frequently seen patients or those with chronic conditions. This connection engenders trust, which enables medical assistants to often be even more persuasive than physicians when it comes to behavioral change, medication compliance, and even showing up for diagnostic testing.
Is the key to clinician happiness simply to hire more MAs? If only it were so easy. Unsurprisingly, it turns out that medical assistants are not cogs that can be moved around a healthcare system as the needs of the day dictate. In fact, a large part of the “magic” of teamwork is creating a stable, thoughtfully developed team!
Researchers from Northshore University Health and the University of Chicago studied the difference between rotating assignments for MAs versus a matched pairing of one MA to the same physician. They ensured the MAs and physicians were compatible and developed standardized playbooks for each dyad to agree upon office workflows, task delegation, communication patterns, and schedule management. The research reached several conclusions as trust between the two grew:
Physicians also delegated more tasks that had not been routinely performed by these MAs in the rotating model. Examples include pending orders for appropriate screening tests and labs, assistance with physician in-basket management, and follow-up directly with patients to assure adherence to agreed-upon care plans. Some physicians also entrusted their MAs to close the visit by summarizing after-visit care instructions.
The study ultimately showed that:
[The] one-on-one continuity model offloaded some nonclinical work, provided greater physician control of the practice micro-environment, improved physician productivity (11% average increase in relative value units (RVUs) per physician) and significantly improved hemoglobin A1c values, cervical cancer screening rates, and depression screening rates. Physicians reported increased satisfaction and observed an enhanced sense of personal accountability and investment in success by the MA often lacking in the rotating staff model.
Technology and EHR improvements are absolutely essential to improve healthcare delivery for clinicians and patients. But let’s not forget other important operational factors that can sometimes dwarf the updates that a new EHR module might bring. Not only do we need to have the right people involved in the process, but we must ensure that the relationships between them are productive and consistent. While it may not just be the medical assistants, they’re an integral part that should be overlooked at healthcare system leadership’s peril.
