COMMENTARY

Docs Take On Burnout in Neurology

Andrew N. Wilner, MD; Neil Busis, MD

Disclosures

March 13, 2017

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Andrew N. Wilner, MD: Welcome to Medscape. I am Dr Andrew Wilner. Today I have the pleasure of speaking with Dr Neil Busis. Neil is the chief of neurology at the University of Pittsburgh Medical Center, Shadyside. Dr Busis is also the lead author of an article[1] that appeared in the journal Neurology regarding physician burnout. Welcome, Dr Busis.

Neil Busis, MD: Thank you.

Dr Wilner: I read your article in Neurology about neurologists' burnout. I must say that some of it did resonate, but then I saw an article just this week in the Journal of the American Medical Association on burnout. There is a long article in the Mayo Clinic Proceedings by Dr John Noseworthy, the CEO of the Mayo Clinic, also about physician burnout. Is this a real problem?

Dr Busis: This is a real problem and I think it has been around for a long time but until relatively recently was not recognized. A lot of us were told just to suck it up, to work like we always have, and we did not have the awareness of burnout. Now, through the work of Tait Shanafelt, who is one of the coauthors on our study, and his colleagues, burnout has come to the fore as a major issue to be dealt with in healthcare.

Dr Wilner: It seems that if I am burned out, I am among the majority.

Dr Busis: Yes; 60% of the neurologists in our study fit at least one criterion of burnout.

Dr Wilner: The articles outline the institutional problems, and, of course, the electronic medical records seem to feature very highly as a stressor. However, one of the fundamental problems seems to be that we are measured on volume; a good day is a highly productive day. For neurologists, I think that can present frustration.

Dr Busis: You have put your finger on it. What we found was that you can divide burnout drivers into internal and external factors. As Terry Cascino, the president of the American Academy of Neurology—who is the person who instigated all of these studies by our group—points out, you can have two neurologists sharing the same practice characteristics, and yet one has burned out and one has not. There are individual factors, but probably the predominant factors are external ones. Burnout is described as something that is in the context of work, as opposed to depression, which is context free.

 
Those of us who are measured in terms of volume have certain regulatory hassles. It's not as if the regulations go away as we move to value.
 

If you look at the increasing demands that we have as physicians, you find that we are measured more, we are regulated more, we are mandated to do more nonclinical work. In fact, there is a groundbreaking study by Christine Sinsky,[2] representing the American Medical Association, and others that shows that for every hour we spend with patients, we spend 2 hours documenting and doing nonclinical clerical tasks. This is only increasing. On the one hand, those of us who are measured in terms of volume have certain regulatory hassles. It's not as if the regulations go away as we move to value; it actually may increase as we are measuring more things—quality measures, etc—that were not measured before.

Dr Wilner: I remember being just shocked that physicians would say that they actually see fewer patients when using an electronic medical record than they did before, until I tried it myself and found out that this is exactly what happens. It seems to be the opposite of the intended effect.

Dr Busis: That is exactly right. There are a lot of unintended consequences in the current medical environment. No one would argue that quality is an important thing to have in medical care. It is how you measure it and what you measure that are big issues. We found in our study that the majority of neurologists found their work meaningful and would become neurologists again, but that the drivers of burnout were meaningless work and clerical tasks that did not directly tie in to patient care.

What we would like to do moving forward is to have the work you do be meaningful, to allow you to do what you became a neurologist for in the first place, which is to take care of patients with neurologic conditions; and also to try to reduce the regulatory burden, the hassle of clerical work—either reduce it or be able to transfer it to other people, such as physician assistants, scribes, or other support staff. This would help our physicians tremendously.

Dr Wilner: What can neurologists do about it, and is the American Academy of Neurology doing anything about what seems to be a pretty severe problem?

Dr Busis: We are doing a lot. The reason that we founded the Burnout Taskforce was to understand the prevalence and epidemiology of burnout, to understand the drivers and then use that evidence to come up with resources to prevent or mitigate burnout and promote and engage in neurology. As Shanafelt and others point out,[3] you can think of burnout as being in four domains: There is the (1) individual—a person's resilience, mindfulness, awareness, etc. There is the (2) work unit and (3) organization, which of course have some overlap. The work unit would be the practice or the department; the organization is the bigger entity. And then there is (4) nationally.

The American Academy of Neurology is ideally situated to deal with individual resources, and we have a number of them on the Live Well portion of our aan.com website. We are making more of them. We are having programs at the annual meeting about the individual. We are having a Train the Trainer Leading Well Program in the fall about this. We are handling the individual aspect.

In terms of the national aspect, we are the leading voice of neurology to the federal government, to the payers, to the policymakers. We are working very hard on the Hill, whereby we come to Capitol Hill and speak with representatives and senators about ways to enhance the care of patients with neurologic disorders.

In terms of the work unit and organizations, we cannot reach into every work unit, practice, or organization in the country, but what we can do is try to identify and then disseminate best practices. We can work in all of those spheres. Let me just give you an example of something that we could do at the national level, where it is a win-win situation for both patients and for physicians.

One of the big issues with physicians is preauthorizations. Another big issue with physicians is being marked as a high-cost provider in some value-based program and having a risk of being dropped from that insurer because you are considered high-cost. This is true, for example, of people who work in neuromuscular diseases, who prescribe a lot of IVIG treatments, or of multiple sclerosis specialists who prescribe a lot of expensive disease-modifying therapies.

If drug costs were lower, not only would it enhance patients' access to the drugs they need for their neuromuscular or autoimmune disease, but it would also potentially decrease the hassle that an individual neurologist would have in getting preauthorization for those medicines. It would also lower their cost profile so that they would not be as likely to be penalized by the insurance companies for choosing that type of disease to treat. That is an example of the things we are looking for, things that can help patients and help neurologists take care of their patients while minimizing the hassle, the current impedances to providing excellent, high-quality care.

Dr Wilner: Neil, I want to thank you for at least beginning this discussion with Medscape. It sounds like there is a lot more to talk about, but I would like to thank you for spending time with us today. This is Dr Andrew Wilner. I would like to thank Dr Neil Busis for joining us today on Medscape.

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