A recent report in the Archives of Internal Medicine on burnout covered a survey of more than 27,000 physicians, which suggested that burnout is more common among physicians than among other US workers, with the highest rates among family physicians, internists, and emergency medicine physicians. We asked our primary care roundtable for their insights -- if this reflected what they have experienced or observed and if there were ways of reducing it.
Causes of Burnout? Look to the Values of Our Institutions
Commentary From Roy M. Poses, MD (Internist)
Editor's Note: We introduce this discussion with Dr. Poses' blog post on this article, which covers the subject in great depth.
The article was a survey of physicians in all specialties with over 7000 respondents (unfortunately, a less than 27% response rate). Its most notable findings were:
• The rate of burnout among physicians was 45.4%.
• Physician specialties with higher than average rates were emergency medicine, general internal medicine, neurology, and family medicine.
• The proportion of physicians who may have been depressed (using the Primary Care Evaluation of Mental Disorders screening instrument) was 37.8%.
So almost half of all physicians, and more than half of the front-line physicians who treat adults, appear to be burned out, while more than one third of physicians may be clinically depressed. So it is not surprising that the authors called the rate of burnout "alarming."
They also commented on the implications of their data. "Unfortunately, little evidence exists about how to address this problem. Although extensive literature suggests that contributors include excessive workload, loss of autonomy, inefficiency due to excessive administrative burdens, a decline in the sense of meaning that physicians derive from work, and difficulty integrating personal and professional life, few interventions have been tested. Most of the available literature focuses on individual interventions centered on stress reduction training rather than organizational interventions designed to address the system factors that result in high burnout rates."
Previous studies of burnout and dissatisfaction. This study, in fact, is just the latest in a long series of studies showing physicians' growing angst, dissatisfaction, burnout, or whatever one calls it. In 1987, in an AMA survey of physicians over 40, 44% replied that were they given chances to do it all over again, they would not go into medicine. In a 2001 survey of Massachusetts physicians, 62.3% were dissatisfied with the practice environment. In 2002, a national survey by the Kaiser Family Foundation showed that 45% of physicians would not recommend that a young person should go into medicine. In a survey of primary care physicians in 2007, 38.7% were somewhat or very dissatisfied. I have a 6-inch-thick set of paper files containing articles on the subject, although it is remarkable how many research studies reported only average scores on instruments and hence did not report proportions of physicians who were burned out or dissatisfied.
The causes of dissatisfaction and burnout. What is most remarkable about this voluminous literature is its relative lack of attention to the external forces and influences on physicians that are likely to be producing burnout and the general aversion to promoting any interventions that could conceivably affect these external threats. Instead, burnout has been addressed as if it were some sort of psychiatric disease of physicians. This was noted by Shanafelt and colleagues.
In fact, the reason that we did the crude qualitative research that led to my articles on healthcare dysfunction, and to the establishment of Health Care Renewal was a general perception that physician angst was worsening (in the first few years of the 21st century) and that no one was seriously addressing its causes.
Our first crude research suggested that physicians' angst was due to perceived threats to their core values and that these threats arose from the issues this blog discusses: concentration and abuse of power, bad governance and leadership of healthcare organizations, and the rise of various dishonest and unethical practices that affect physicians. We have found hundreds of cases and anecdotes supporting this viewpoint.
There is some corroboration of these assertions. Some written comments from the 2001 Massachusetts survey made similar points about the causes of dissatisfaction. For example: "Too much emphasis on the bottom line. Taken over by large corporations. Quality of care and interaction now subsumed by productivity and profit," and, "the once most noble profession has become a factory job with a facade of ethics." Pololi and colleagues' qualitative interviews of young medical faculty included anecdotes of angst due to academic leaders who put revenues ahead of patient care, teaching, and research; and who allegedly used deception for personal gain. (Also, see our comments on this paper.) Pololi and colleagues' large survey of US medical faculty showed that over half thought that managers were only interested in them because of the money they brought in. We were able to show in a preliminary analysis of data from a physician survey that an instrument meant to measure physicians' perception of the integrity of the leadership of their organizations, which incorporated questions about whether leaders supported core values, put patient care ahead of revenue, supported transparency about quality issues, put patient care ahead of self-interest, and displayed honesty strongly correlated (negatively) with stress, intention to leave the practice, and burnout.
Yet, at best, studies of physicians' burnout, angst, or dissatisfaction only vaguely allude to "system factors" and not greedy, money-focused, self-interested, or corrupt leadership as its causes. And again, as noted above, most interventions meant to improve burnout have treated it like a psychiatric illness, not a rational response to a badly led, dysfunctional health-care system.
Why has nothing changed? The real question is why has so little changed given this now 20-plus-year history of the documentation of burnout, and why has there been such avoidance of what appears to be the real causes of the problem? One question worth raising again at this time is why have the organizations one might think would be interested in helping physicians address causes of burnout not done so?
One might think that medical societies, foundations interested in improving health and health care, bodies that accredit physicians, and academic medicine in general would all be interested in addressing the causes of physician burnout, dissatisfaction, and angst. However, I am aware of no significant action on their part. (There have been some marginal actions by the smallest of these organizations [eg, the Society of General Internal Medicine's call to "chuck the RUC"]; see this post.)
We should not be surprised, since most of these organizations have become more creatures of healthcare corporations than noble proponents of physicians' core values. Most of these organizations have substantial institutional conflicts of interest and are often led by individuals with their own individual conflicts of interest.
Medical societies, in particular, now often get significant financial support from industry (pharmaceutical, biotechnology, medical device, and even health insurance companies). The societies' leaders are often full-time executives, not necessarily physicians, who may look to their industry sponsors to continue to provide the funds that support nice salaries and luxurious offices. The society's officers and boards are often dominated by physicians with their own conflicts of interest. (Look here for more examples and see, in particular, the case of the American Association of Orthopedic Surgeons.
Similar conflicts may affect accrediting organizations, healthcare foundations, and especially academic medical institutions, as we have profusely discussed. (Look at our posts on conflicts of interest and institutional conflicts of interest.)
So if physicians really want to address what is making them burned out and dissatisfied, they will have to regain control of their own societies, organizations, and academic institutions and ensure that these organizations put core values, not revenue generation and providing cushy compensation to their executives, first.
Medscape Family Medicine © 2012 WebMD, LLC
Cite this: Robert M. Centor, Robert W. Morrow, Roy M. Poses, et. al. Doc Burnout -- Worse Than Other Workers' - Medscape - Nov 13, 2012.