Is Physician Burnout a Looming Public Danger?

Neil Chesanow

Disclosures

April 19, 2016

Physician Burnout Is a Public Health Crisis, Ethicist Says

The literature on physician burnout is voluminous and growing, but a recent Medscape video by Art Caplan, PhD, director of the Division of Medical Ethics at New York University Langone Medical Center, was perhaps the first to view the problem not merely as one within the medical profession, but as a public health crisis—because doctors, after all, are a finite public resource, and as such should be treated with respect, not with abuse.

Dr Caplan noted that over 50% of doctors feel burned out. They suffer from compassion fatigue. They are unable to empathize with patients. They may commit more potentially harmfully errors as a result. They have problems managing their lives away from work. They retire early at a time when we desperately need more doctors. Moreover, 400 doctors took their lives last year. "We like to think that doctors can handle everything," Dr Caplan reflected, "but that's clearly not true."

"One type of fix is to make sure that hospitals and other healthcare environments try to create better conditions for a happy workforce and for happier doctors," Dr Caplan suggested. "This might include yoga, mindfulness training, having more therapists to talk to, encouraging people to come forward when they feel this way, peer groups, and better mentoring."

"When we institute new software or when we have new bureaucratic regulations, I think somebody ought to ask what this does to the workforce... A lot of the software and computer assistance that's out there doesn't seem to help the doctor; it makes more work or makes them frustrated. It also seems to me that if you look at what's going on with respect to regulations and administrative or bureaucratic requirements, nobody is saying, 'Hey, is this user-friendly? What's the burden that it's putting on the doctor?'"

Although the video was aimed at physicians, it was also addressing society at large. "Morally, we've got to make sure that a highly trained workforce that takes a very long time to get the ability to practice medicine is a resource that we preserve and really take seriously," Dr Caplan said, adding, "We also have to view it as part of patient safety, and I think we should start spending some resources to figure out how we can make the physician workplace more user-friendly."

The video inspired hundreds of doctors to offer cries of anguish and often complex multidimensional diagnoses of the reasons for physician burnout.

"I feel burned out, and I know that I am not alone," one doctor wrote. "Half my colleagues feel the same. I don't have enough time for my family and myself. For the past 8 years, I haven't had any vacations. I am so exhausted. As a primary care provider, I cannot take vacations because I always have patients to take care of."

"Burnout is a really big problem, but often one that is not detected before a major incident occurs," another doctor pointed out. "Physicians are not likely to admit they are burned out. Physicians don't like to think that they need help."

"The doctor's autonomy is now nonexistent," one doctor lamented. "We are being dictated to by insurance companies, hospital administrators, national medical boards, and state medical boards. We are being recurrently credentialed by the same entities. All of this constrains our ability to perform as physicians. We are cogs in a system designed for the maximum profitability. There is no continuity of care, and younger doctors are perfectly happy to work from 9 to 5. Mindfulness training and yoga can't cure those problems. There has to be mass action to get insurance companies, politicians, and government out of the practice of medicine, and physicians need to take back their responsibilities."

"I agree with Dr Caplan and others that physicians have a problem. However, I disagree with the diagnosis and the prescribed treatment," a physician wrote. "The problem is a crisis of professional identity, work overload, powerlessness, and job insecurity. We are responsible for the operational capacity of the system [and] are held accountable for all the outcomes, but have little say in how decisions are made and the direction in which things are going. The only effective treatment is physician independence! The employment model is bad for patients and bad for healthcare costs. Worst of all, it is destroying physicians. Burnout is a symptom, not the problem. We are not suffering burnout. We are suffering because of feelings of helplessness and deep dissatisfaction."

"Physicians are the ones who bring money into hospital organizations," a doctor observed. "Yet there is no consideration of the fact that we are all human. We have all seen what happens when a doctor who is having difficulty dares to admit it or opens up to anyone whom they feel might be able to help. Administrators say, 'Come to us with any problem.' They open their arms; talk about how much they value each doctor as an individual; offer warm, fuzzy encouragement; and offer reassurance that they will 'take all the time needed.' However, behind closed doors, doctors are seen as expendable and completely replaceable. They are not seen as people who need, or even deserve, compassion. There is little, if any, help available. Administrators often find a way to dump the doctor. Then, without another thought, it's on to the next physician who can see 25-30 patients a day without any hassle."

"The large institutions treat us like interchangeable cogs," a doctor commented. "We cannot offload any work onto the nursing staff in verbal orders. We are responsible for every quality improvement initiative and are to maintain our relative value units. Every nuance of every visit, positive or negative, needs to be recorded, or we are assumed to be cheating, and every nurse practitioner thinks they can do our job with 18 months of training. The new electronic health records (EHRs) are hospital-centric and cumbersome, leaving us less face time to placate an already-demanding patient population. Add this to our worrying about Press Ganey patient survey scores while decreasing our prescribing habits. Include a legal system that can't seem to spit out enough attorneys with television ads ready to sue us for using medications that are indicated. Lastly, throw in our governing bodies (American Medical Association or American Osteopathic Association) that have sold out to big government and allowed healthcare reform without physician input. What's to be burned-out about?"

"The problem, in large part, is that physicians remain poorly organized and do not adequately voice their own needs as well as the true needs of their patients," a plastic surgeon wrote. "Our professional organizations are typically more interested in their own economic viability, which they maintain with such endeavors as the sale of coding books and the organization of meetings, rather standing united against the threats presented by large interest groups."

"Yoga? Counseling? User-friendly software? Really?" a general practitioner scoffed. "How about relieving us from seeing too many patients at a time, which prevents us being able to work with them in depth in order to really help them? How about relieving us from being controlled by insurance companies and hospital bureaucracies? How about giving us reduced work hours and reduced patient volume that would enable quality work and work/life balance? Is there even time for yoga and counseling? Therein lies the real problem."

"Well said, but is anyone listening?" a doctor wanted to know. "We need to dump EHRs and go back to pen and paper, and how [much] easier it was before the EHR. Patients were happier, doctors were happier, and guess what? No one got care any different from today. All EHRs have done is make life easier for Medicare and insurance auditors to see that care was provided and find ways to pay us less! A disservice and an embarrassment! I love taking care of patients and actually doing my job, but I am tired of being a glorified secretary. We must take back healthcare for our patients and our profession!"

"Let's all—every single medical doctor in the United States—take the month of May off," an otolaryngologist suggested. "Take a spa holiday in whatever relaxing holiday resort setting you and your family would like. After a month of vacation, we could return to practice tanned, fit, rested, and ready again. And America, in that month, would have regained a sense of the true value of their doctors."

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