COMMENTARY

The Very Serious Issue of Physician Burnout

Seth Bilazarian, MD

Disclosures

November 29, 2012

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Hello, and welcome. I am Seth Bilazarian. I wanted to address physician burnout, something that has been in the news lately. Information on physician burnout came chiefly from an article[1] in the Archives of Internal Medicine that was written by the Mayo Group, in which they showed that 46% of 7000 physicians who were surveyed felt at least 1 aspect of burnout.

I presented these data recently to our journal club and wanted to share with you some comments that other physicians made, as well as some thoughts about burnout and what is happening. I didn't see anyone in the press talking specifically about why this is happening. For me, one of the conflicts is that objectively, there are reasons why one would say that physicians are working less hard now than they were before, and yet physicians are being burnt out more. Why is that?

Burnout, by definition, is a physical or mental collapse caused by overwork or stress. The psychiatric definition is an exceptionally mediated job-related dysphoric and dysfunctional state in an individual without major psychopathology.

The article I mentioned surveyed over 7000 physicians, using emotional exhaustion, depersonalization, or low personal accomplishment as criteria, and found that 45.8% of physicians had 1 of these 3. It spawned a bunch of articles about doctor burnout in the New York Times, Wall Street Journal, Time Magazine, and a variety of places .

I have certainly been hearing, for some time now, physicians expressing frustration about the amount of work that is not patient-centered and is increasingly bureaucratic. I recently blogged about the review of systems in the electronic medical record and how that was a burden and took away from patient care, and many commented on that. So what is the issue? Why should we even care about physician burnout?

First, I would say that qualitatively, if a physician is detached from his work, he is obviously not going to give good-quality work. This is not good for patient/physician interaction, it is not good for the physician, it is not good for the specialty, it is not good for the quality of care, and it is not good on any grounds.

Second, there are concerns about physician shortages. If physician burnout continues, many physicians will quit. It was predicted that 6 out of 10 physicians would quit today if financially able, in a survey that was presented to 13,000 physicians.[2]

Why is this happening? Certainly, the physician/patient interaction is changing. How we interact with patients -- patient autonomy, oversight, choosing wisely, and appropriate use -- is no longer an interaction between the patient and physician making decisions. There are changes in the law, and the uncertainty in the law is contributing significantly to this.

I thought it was very interesting that the one thing that physicians are conflicted about and contributes to emotional exhaustion is the big picture. I saw many physicians and bloggers giving a 2-handed assessment of the Supreme Court's ruling on the Affordable Care Act. On one hand, they are saying that it is wonderful that patients are being covered, but on the other hand, what will this do to societal costs, delivery of medicine, American innovation in medicine, and a variety of other things? All of these things are contributing to physician burnout.

Many have weighed in on this. Doctors who view medicine as a calling are certainly more satisfied. That would make sense. If you view this not as a job and don't care about any aspect of billing, coding, or reimbursement, and you just want to deliver your care on a voluntary basis, then that is certainly much more rewarding. But for most physicians, their profession is their livelihood, and that is how they feed their families.

Another continuing trend that I think is a concern is the progressive changes in the overall practice of medicine, the move from smaller practices to so-called "big medicine." Atul Gawande wrote about this in an article called "Big Med" in the New Yorker, which I would highly recommend.[3]

At the end of the day, why is this so frustrating? Should we care about burnout? Hopefully, I have convinced you to care. I think that physicians who just try to suck it up and move on are likely to have frazzled nerves and eventually get robbed of quality interactions with their patients, as well as suffer from a significant wearing down of their professional lives.

Why is this frustrating? The electronic medical record has frustrating aspects, but there are certainly good things about it. It is more portable. You can work at home after hours. You can get home to have dinner with your family. There are a variety of things that make life easier. Most primary care doctors in our group and certainly in our area don't round at the hospital. Hospitalists, nocturnists, and night floats are now commonplace, so life is easier. So why is this physician burnout happening?

Probably the most significant paper that I would recommend is Richard Gunderman's article in the Atlantic.[4] He writes that the contributors to burnout are "dissatisfiers " -- which are all those frustrating things, but also a lack of professional fulfillment. The changes in the way we interact with patients have reduced that aspect of the good part of medicine. Even if we improve dissatisfiers, Gunderman argues that we will probably still have a fair number of physicians that are burnt out.

When I presented these data to my colleagues in our journal club, a senior physician -- a pediatrician -- asked the group, "How many of you get Christmas presents anymore?" The point that the physician was making was not that he wants Christmas presents, but that they are a message or a reminder of the appreciation patients have for their physician, and it is no longer happening. The physician/patient interaction has now devolved to just care providers, like trades people. The same appreciation you might have for someone who does work in your home is the appreciation that many patients now have for their physicians, so that has reduced the fulfillment aspect of being a physician.

In summary, burnout is real and has both qualitative and quantitative risks for healthcare delivery and our profession. My take is that physicians are dealing with this transition and are stressed about it. Like it or not, we are becoming more like tradesmen and not professionals with a calling. It would be desirable, but that is where it seems to be moving.

The changes to the system (eg, the physician work- hour limitation for trainees) that contributed to this had noble intent, but I think it has changed physicians- in- training from viewing the patient as first and their own health and well-being as second to a different kind of approach. We certainly see that in our own group with our primary care doctors not rounding at the hospital. They are no longer being the chief responsible healthcare providers for the patients; we are just part of the system.

Finally, I would like to say that aspiring to conduct that moves one's profession from a career to a calling would be noble, but is certainly very difficult in this time. We are going to be living in a time of transition for several years, so the issue of physician burnout will be with us. Recognizing it and dealing with it on a personal and also a group level will be valuable for best outcomes for our patients.

If you are interested in what others might be thinking, you can see the slide set[5] that I have prepared with some more information on physician burnout. Until next time, I'm Seth Bilazarian. Thanks.

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