Doc Burnout -- Worse Than Other Workers'

Robert M. Centor, MD; Robert W. Morrow, MD; Roy M. Poses, MD; Charles P. Vega, MD


November 13, 2012

In This Article

The Solution to Burnout: Doing Good and Doing Well

Comment From Robert W. Morrow, MD (Family Physician)

The thoughtful comments by Drs. Centor and Poses are quite helpful in their analysis of the issue. Let me respond a bit with some observations, including about hopeful changes that are growing around us.

The idea of corporate medicine, run by large entities with the intent to gather as much of the medical slice of the GNP as possible, indeed is the monster in the waiting room. The processes of disease mongering, such as social anxiety disorder, low testosterone, hormone replacement, and the prostate-specific antigen and bone mineral density screening juggernauts, as well as the purchase of practices by large entities, the price bubbles of old and creaky pharmaceuticals, and the drastic decrease in payment for services by commercial carriers, are discouraging to those of us who would like to do good as well as do well. None of these cycles is new, of course; they also occurred in the '80s and '90s. But that's another article.

What's good?

I recently returned from a training session for the Patient-Centered Outcomes Research Institute (PCORI), where I am a reviewer. PCORI does indeed plan to put patients at the center and have at least a third of reviewers be patients and stakeholders rather than scientists. (Please apply to be reviewers!) The comparative effectiveness work by the Agency for Healthcare Research and Quality is stunning, and CMS has raised the bar, as well as the fees, for primary care -- noticeable enough for my income.[11]

I have started to view my practice as a test bed for new ideas, as a place to do good while finding out what's good. Steady feeds of outcomes evidence from several sources create a sense of currency, of being up to date. And medical students around my area, in New York City, are full of energy and clearly are responding.

So, what of the connection between energetic students and continuing education? Simply put, nothing we teach to students, residents, or docs shouldn't be taught to all. In other words, the "continuum" between undergraduate, graduate, and continuing education is aimed at better patient outcomes, not simply smart docs who are divorced from their patients, and so all education in medicine should be shared. After all, competencies shouldn't end at the exit from residencies. Practice reform and improvement is an ongoing vehicle for improving both our own craft and that of those being educated to work with us.

Patient centeredness, integrated education for practice improvement, a constant stream of new ideas -- these all add to the richness and pleasure of practice.

And how about health information technology (IT) that looks more like a consumer product than an old fashioned typewriter? Remember how the old Smith Corona (for you newer docs, that's a typewriter, not a cigar) had a keyboard designed to slow you up so the keys wouldn't jam? We can make records that reflect the organic nature of practice and be based on sharing important data rather than supporting billing and the brands of big institutions, who feel patient data is money in the bank, not to be shared. Could IT exchanges, with patient data flowing easily to treating practices, make your life better? It could happen if we make it happen.

Working with the public, as they say in theater, is always complex. Can we design practices that support each other rather than the big institutions who view us as the loss leaders that bring the customer into the showroom for stents, hips, and biologics? Can we be comfortable enough in our skins to share information with the public -- our patients -- through portals and chart openness?

Let me end with a word about implementation science, with a side look at cognitive load.[12] Many of us are focusing on methods to design, implement, and measure changes that are patient centered. What fun! We can teach each other; we can share with many disciplines to create humanistic, "locavore" practices embedded in communities. The IT is there, the math is ready (and it ain't your mother's frequentist approach to P values), and you better start learning how to talk to sound designers as well as public health designers. We have the tools now to do so.

Cognitive load -- what we can handle is limited and relates to what we already know. Intelligent design that recognizes cognitive load will gradually help extinguish burnout and return healthcare to a craft and a pleasure.


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