Thursday, January 29, 2015

The Root of Physician Burnout

Regardless of all the politically correct statements about primary care, and the need for more physicians to be an entry point into the healthcare system, the simple truth is that the 'burnout rate' for family physicians, or general practitoners is very high.


Richard Gunderman, MD, PhD, is a contributing writer for The Atlantic. He is a professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy, and vice-chair of the Radiology Department, at Indiana University. Gunderman's most recent bookis X-Ray Vision.

"Last week Dr. Elaine Shattner described a new report in the Archives of Internal Medicine that indicates that rates of burnout among U.S. physicians significantly exceed those of the general population. This is a very serious issue with effects that will ripple throughout society, and it warrants widespread, earnest attention. The solution, though, does not lie in incentivizing physicians with money or restructuring systems to minimize stress on physicians -- it lies in finding earnest professional fulfillment.

According to psychologists, signs of burnout include decreased enthusiasm for work, growing cynicism, and a low sense of personal accomplishment. As the name implies, individuals suffering from burnout feel as though a fire that once burned inside them has dwindled, and perhaps even been entirely extinguished. In many cases, they report a sense of having "run out of fuel," and like my colleague, feel as though they "have nothing left."

Of nearly 7,300 physicians who participated in the Archives of Internal Medicine's national survey, 46% reported at least one symptom of burnout, and the overall rate of burnout among physicians was 38%, as opposed to 28% among other US workers. The highest rates of burnout were reported among primary care physicians, including family physicians, general internists and emergency medicine physicians.

Why should rates of burnout be higher among physicians? For one thing, physicians tend to work longer hours than other workers, on average about 10 more hours per week. Moreover, striking an appropriate work-life balance appears to be a bigger challenge for physicians, in part because they often tend to keep work and personal life more separated than other workers. The authors of the study speculate that such a high rate of burnout could only result from system-wide issues in medicine, as opposed to the personal susceptibilities of a few physicians.

Despite all the talk about the affordable care act and how it will make health better for patients, it offers physicians nothing, whether they are generalists or specialists, rather it increases the burden of caring for patients by physicians, who are now at the mercy of insurers, government and regulators. The burden is not just an increase in the quantity of patients, but also the increase in non-clinical bureaucracy, and a perceived decrease in quality of care as digital influences and algorithms replace physician wisdom.

There is no solution for this problem, and none in the forseeable future. Physicians have been forced to make decisions that outright conflict with their sworn hippocratic oath. At one time physicians were captain of the ship, now they have a ship at which they have nothing to say in the wheelhouse.  

The issue of physician burnout is important. As the US population grows and ages, the number of physicians needed to care for them increases. When burnout leads physicians to reduce or cease their practice altogether, patient access to medical care is diminished. Moreover, burnt-out physicians are likely to be less productive, make more mistakes, and generally deliver a lower quality of care than their fully engaged colleagues. Finally, physicians are human beings too, and their suffering should summon no less compassion and concern than anyone else's.

Physicians react to burnout in a number of ways. Some, like my colleague, withdraw from their practices, reducing their workloads or leaving the practice of medicine entirely. Others become less engaged with their patients and the profession and suffer a decline in the quality of their work. Still others turn to unhealthy and even self-destructive habits, such as alcoholism, excessive or inappropriate use of prescription drugs, and even illicit substances. Some consider suicide. Others may turn to colleagues, friends, or family for help, or seek professional counseling.

Unfortunately, individuals and organizations often respond to burnout by recommending coping strategies focusing on the reduction of stress. The rationale for this approach is straightforward: individuals suffering from burnout seem to be overly stressed. They feel overworked, excessively scrutinized, or overburdened with unnecessary or unfulfilling tasks. To combat burnout, some suppose, we need only reduce such stressors, by cutting back on working hours, relaxing intrusive oversight, and finding ways to lift the burden of "busywork" from the shoulders of physicians.

While useful in some respects, the stress-reduction approach addresses only the less important of the two sides of the problem. Reducing stressors in the work environment may offer real benefit, but often it does get at the problem's real roots. It is like providing symptomatic relief to a patient without ever addressing the underlying disorder or encouraging the development of life habits that foster a positive state of well-being. Instead of merely reducing the bad in medical practice, we need to enhance the good.

The key to combatting physician burnout is not to reduce stress, but to promote professional fulfillment. And promoting professional fulfillment is not merely a matter of reducing costs and error rates or increasing clinical efficiency. Nor is it a matter of protecting and promoting the incomes of physicians. As Herzberg reminds us, efforts to alter physician behavior through income-based incentives and disincentives are inherently demoralizing. The reason is simple: they imply that physicians care more about money than their patients. This constitutes a self-fulfilling prophecy of cynicism.

At their core, good physicians are not mere moneymakers. Good physicians are professionals. And though today we often forget it, being a professional means more than merely getting paid for what we do. Being a professional means above all professing something, declaring openly in work and life that we stand for something beyond our own narrow self-interest. The more we treat physicians as though they were self-interested money grubbers, the more we de-professionalize them. And a de-professionalized physician is inevitably a demoralized and burnt-out one.

Medicine is not a job. It is not even a career. At its heart, medicine is a calling. When it comes to physician burnout, an ounce of prevention is worth a pound of cure. We must begin early in medical education to help medical students and residents explore and connect with a sense of calling to the profession. Even late in their careers, physicians need to recall that they are summoned to something older, larger, and nobler than themselves. They must never forget that a career in medicine represents one of life's greatest opportunities to become fully human through service to others."

It reminds me of when I was a young physician and I was told, "don't be afraid to borrow money, you will have a high income and pay it back." This  obscures and identifies the fallacious belief on non-physicians that money will make up for all the negatives of providing health care."

The current generation of students are borrowing more and more, equivalent to a home mortgage.  

"If we are genuinely concerned about physician burnout, we need to focus less on reducing stress and more on promoting what is best in physicians: compassion, courage, and above all, wisdom. Only by keeping what matters most at the forefront can we reap a full harvest of professional fulfillment. Burnout is not a disease. It is a symptom. To combat it, we must focus primarily on what underlies it. And here the key is not eradicating the disease but promoting professional wholeness, which flows from a full understanding of the real sources of fulfillment."

This article contains vignettes about medical students and practicing physicians who sucumb to the unimaginable burdens of solving patient's problems when there is no one else to turn to.  Insurance companies who thwart physician judgment for the sake of saving their insurance company profits are a key factor for physician disillusionment.

A message from Greg

Subject: Piece of My Mind
Read this if you have time. It resonated with me especially well this morning. I like these two paragraphs:
“I love practicing medicine. Unequivocally. Yet it sometimes seems as much a burden as a privilege. We begin our careers in the anatomy room, a ghoulish lab in which many ‘civilians’would faint. We cut our teeth in bloody operating rooms and intensive care units from which few people leave intact. We spend our lives bearing witness to the sufferings and diseases of troubled souls. We are well paid, intellectually stimulated, and, if we are lucky, trusted and maybe even loved by our patients. Yet on certain days, when our patients do not do well, the trade-off seems untenable.
How are we to protect ourselves from the emotional hazards of the practice of medicine? How are we to stand with our patients through the very worst while avoiding depression, significant stress reactions, and even substance abuse or addiction?”
Love, Greg

The thrill of saving lives and/or improving the quality of a patient's life is sometimes inadquate in the face of a system designed to thwart  physician judgment.

Would they be alive?

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