Why Internists Are Number One in Physician Burnout

Neil Chesanow


June 23, 2015

The Demon of Burnout

Much has appeared online of late about physician burnout, including a recent Medscape survey, but internist Gregory A. Hood's eloquent essay explored the subject with uncommon sensitivity, depth, and wisdom that resonated with many doctors.

"Burnout is defined as loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment," Dr Hood observed. "Medscape's study showed that 50% of physicians in internal medicine say they are 'burned out.' This rate, which is compatible with other similar surveys, exceeds the rate found with other US workers. Perhaps it is that physicians have selected their profession and view their work as 'more than a job.'"

Among the 26 specialties surveyed by Medscape, "internal medicine faces the highest combination of prevalence and intensity of burnout," Dr Hood pointed out. He speculated that this may be an unfortunate by-product of "a high idealism among internists, who not only chose what they wanted to do in their professional lives but accepted doing this work knowing that they were accepting a lower relative evaluation of their services, economically and noneconomically.

"Idealism," Dr Hood noted, "can predispose for disappointment, particularly when the locus of control is outside that of the physician."

Like many doctors, Dr Hood apportioned some of the blame to "bureaucracy," including "the American Board of Internal Medicine (ABIM), which recently belatedly admitted that they 'were wrong' about maintenance of certification (MOC), as well as bureaucracy of group practices, hospital/Joint Commission requirements, and so forth."

"Time is a very potent mechanism by which burnout burns," Dr Hood noted. "It is a hot but slow burn." The "endless flow of forms" grinds physicians down, and makes them feel like "cogs in a wheel." Making MOC more challenging, as the ABIM has attempted to do, adds fuel to the fire.

As a result, physician burnout, which once peaked in middle age, is now affecting physicians aged 35 years and younger, Dr Hood lamented. "Few will remain in the profession and tolerate the stress, depersonalization, and emotional exhaustion for 20 years, should no relief be found within the profession."

"Great perspective," an internist commented. "It feels that the general attitude has been to expect internists to do more with less, work harder to avoid revenue reductions/penalties, and spend more and do more to maintain the same certification we already hold. Hopefully internists and other physicians will continue to work to get their voices heard over the next few years as substantial changes are made in healthcare."

"What's going wrong? Really? How about what's not going wrong?" another internist acerbically wrote. "Insurance companies playing doctor; federal and state lawmakers who openly junketeer on insurance and pharma dollars, then pass legislation that blatantly benefits those industries; federal agencies and private certification bodies that actively engage in racketeering practices targeting physicians; and a general public that thinks Dr Oz is the bee's knees."

"Burnout is occurring across professions that focus on people, where those practicing really want to do their best for their clients/patients," a psychologist commented. "Unfortunately, our society rewards those who look after themselves, rather than those who look after others. It is a basic conflict of values, which causes disillusionment, exhaustion from fighting systems that work against your goals and values, cynicism, and eventually the need to escape either physically or emotionally."

"I personally find prior authorizations to be among the most demoralizing features of my workday," wrote a psychiatrist, no doubt speaking for colleagues in many specialties. "The new CPT codes imposed on psychiatry further degrade the notion that my time has value or is under my control. Patients benefit from my attention, but an ever-increasing number of regulations sabotage my ability to provide it."

"The real root cause of burnout is why we all became physicians in the first place—to take care of people," a surgeon ruefully observed. "Unfortunately, patient care doesn't matter anymore. If the i's are dotted, the t's crossed, the EHR looks pretty, and the length of stay is okay, I don't think they would care if every patient died."

"The most effective way to combat job burnout is to quit doing what you're doing and do something else, whether that means early retirement or changing careers," an internist contended.

"One of the most accurate and straightforward articles I have ever read on this topic," a radiation oncologist opined. "I have not forgotten my roots in internal medicine, and I feel great empathy for my colleagues who have limited their practice to that specialty. It is not easy to soldier on when it seems that one's opinion means nothing after so much preparatory work."

"Yes, we all know that burnout is real and is adversely affecting our physician (and patient) population," an internist commented. "The real issue is how we can help. When it comes to stress and burnout, physicians are either too busy to notice; too stoic to admit it; feel that they can handle it themselves; and/or are reluctant to seek outside help for fear of exposing a human weakness, potential questions about competency, or concerns about confidentiality. Because we won't take action on our own, we—colleagues, societies, and organizations—need to take the first step to offer help and support."

"The true 'demon' of burnout has been that we have not always felt comfortable talking to each other about our problems," an orthopedic surgeon agreed. "We have not been able to create a supportive environment where it is safe and acceptable to share with each other the many emotional struggles we all face."

"Opting out is what saved me," an internist believed. "Patients appreciate your efforts more when it clearly costs them something as opposed to 'It's free' or 'Insurance owes me this.' My overhead is ridiculously low compared with hospital or group practice, so I can charge a lot less and document precisely what I need to. Now that so many people have insurance they can scarcely afford to use, I am busier than ever."


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