Physician Burnout: The Other “Healthcare Crisis”
Most discussions of the “healthcare crisis” in the United States include the fact that the numbers of physicians, particularly those on the front line of care such as critical care, emergency medicine and primary care, are in shorter and shorter supply.
And yet, according to several nationwide surveys in recent years, these physicians and many of their specialty colleagues are burning out at an alarming rate, impacting not only their own lives but the institutions in which they work and the patients they serve.
In a 2011 physician survey, 87 percent of respondents named paperwork and administrative tasks as the primary causes of work-related stress and burnout. Sixty-three percent said their stress was rising.
In 2013, an editorial in the Journal of General Internal Medicine reported burnout rates between 30 and 65 percent across all specialties.
In a 2014 survey, 68 percent of family physicians and 73 percent of internists said they would choose a different specialty if they could start over.
And in this year’s annual Medscape survey, half of all family physicians, internists and general surgeons surveyed reported feeling burned out. Bureaucracy, administrative tasks, and too much time spent at work were cited as the more frequent causes.
In an effort to prompt conversation on this important topic, MED opened the floor to several area physicians (and one out-of-area physician, for a retiree’s perspective) for their insights into the problem of burnout, its causes, and what should be done to combat it. Our contributors included:
Daniel Lister, MD, Orthopedic Surgeon – Sanford Aberdeen Clinic, Aberdeen, SD
Jill Kruse, DO, Family Medicine, Medical Director of Avera’s LIGHT program – Avera Medical Group, Brookings, SD
Quentin Durward, MD, Neurosurgeon – CNOS Clinic, Dakota Dunes, SD
Craig Uthe, MD, Family Medicine, Sanford’s Physician Wellness Lead – Sanford Family Medicine, Sioux Falls, SD
Albert Strauss, MD, Retired pediatrician – The Children’s Doctor, Hagerstown, MD*
*Father of MED Editor Alex Strauss
Not all of these physicians answered all questions, but we have included their top answers below. See the MED website for a chance to add your own voice to the conversation.
Is physician burnout a real problem? Have you seen it in yourself or your colleagues?
Dr. Kruse: Yes, physician burnout is real and burnout has been well researched and studied since the 1970's. I have personally experienced a bout of burnout during my second pregnancy and shortly after delivering. My maternity leave was devoted to working on dealing with my burnout and finding my love of medicine back. Once I went through that experience I could see the signs in several colleagues, but it is usually something that we as physicians try very hard to hide from others and sometimes even from ourselves.
Dr. Strauss: It is a terrible problem particularly in the realm of primary care, just when we need MORE primary care as the ACA brings many more people into the healthcare system – hopefully into the primary care office rather than the Emergency Room.
Dr. Durward: Yes. One colleague currently has gone half time. One has announced a slow-down and early retirement in 2 years. Another one has just retired early.
Dr. Uthe: Yes, it is a real problem, although most do not like to admit it. We do know that physicians are at slightly higher risk than the general public for addiction.
What do you feel is the primary reason for burnout among physicians?
Dr. Lister: The primary reason is the ever-increasing amount of information that has to be processed with respect to documentation, as well as keeping current and efficient in an ever-expanding body of medical knowledge while being held accountable for any failures but at the same time having a lesser role in the decision-making process.
Dr. Kruse: I think there are many contributing factors. First of all, we are never taught how to take care of ourselves during medical training or residency. In fact, the workaholic “never need help, go it alone” mentality is praised. So when we do have issues, many students, residents, and even seasoned doctors don't feel comfortable asking for help or even knowing where they can turn for help that will be a safe environment to share these concerns. They’re often just perceived as "personal weaknesses" that need to just be pushed through.
Dr. Strauss: Terrible reimbursement is the number one cause, at least as far as primary care is concerned. Primary care is devalued in the insurance world, particularly when time is spent in counseling or providing follow-up care. Number two is the number of hours required to earn a living. The hours are impossible when one is trying to do something other than just practice medicine.
Dr. Durward: Massive increase in work and frustration related to electronic medical records, Medicare mandated rules on privacy and documentation, second-guessing by medical insurance companies of physician patient care decisions, increasing overhead costs to stay legally compliant but decreasing reimbursement from insurance companies and Medicare.
Dr. Uthe: I think it’s just about overload. I can only be on the top of my game for so long. Capacity is finite. But the workload is not. And that has grown exponentially. When your capacity is less than your workload, that’s overload. Most physicians like and want to be challenged but you can only handle overload for a short period of time. Most are working on overload all the time. With new documentation requirements, it often, it comes down to, ‘If I pay attention to the patient now, I will have several more hours of work to do later and that is time that I can’t spend with my family.’”
Are physicians in our region more or less likely to feel burned out? Why?
Dr. Lister: I feel physicians in our region are more likely to feel burned out due primarily to the fact that we are in an underserved area with limited resources and support as compared to larger metropolitan areas.
Dr. Kruse: Burnout is a worldwide problem. Geography doesn't
dictate it as much as medical specialty, as noted in the Medscape article. Each
clinic is a unique environment with a culture that can promote or prevent
How do you personally avoid feeling burned out?
Dr. Lister: After 30 years of practice, I have come to accept my limitations and strive hard to try to improve on a daily basis, one patient at a time.
Dr. Kruse: Burnout isn't something you just fix once and it goes away, it requires mindful attention to where your priorities are that day. Journaling has always been a stress reliever for me. I have also worked very hard at developing healthy boundaries between work and life. Learning when it is appropriate to say "no" after years of training when you couldn't is a hard skill to learn and practice. Spending time with my family and not feeling guilty for doing so after I sign out a patient to a colleague or leave for the weekend has been a great help for preventing burnout. I’ve also learned how to work as a better team with my nurse.
Dr. Strauss: I personally loved what I did and was lucky enough to have practiced in the era before electronic medical records. Things were simpler and more patients could be seen comfortably so that one could earn a good living. Now, with EMR, the number of patients that can be seen in a certain period of time has markedly diminished and this, of course, affects the bottom line. I also loved children and got to meet and play with them on a regular basis and this was therapy for me. I eventually did burn out, even though quite late in a long career.
Dr. Durward: I have had to hire extra staff to help me manage and control the incredibly burdensome requirements of these mandates at my own cost. In other words, I've had to take a significant pay cut in order to stay sane in practice.
Dr. Uthe: Personal health and wellbeing is number one. I know what my five deepest core values are and I know what the three top loves of my life are (Faith, family, friends) so I just focus on those things. I ask myself is the thing I’m being asked to do is a worthy endeavor? How is it going to affect my three loves? And third, what am I going to give up in order to do it? Then I make a decision based on my answers.
Can anything be done about the problem of burnout in healthcare providers?
Dr. Lister: In the little over a year that I have been with Sanford Health I am encouraged by their team-oriented approach and genuine concern for the delivery of quality healthcare in a cost-effective manner. As an organization, Sanford has positioned itself well to meet these ever-growing demands on the healthcare system and its providers and I am definitely encouraged by this degree of support.
Dr. Kruse: The first step is to acknowledge that this is a problem and that we need to do something about it. This is where Avera is unique nationwide. We are one of the first health systems in the country to create a program specifically designed to acknowledge that burnout is a problem and to work on ways to prevent and treat it - the Avera LIGHT program. [see sidebar]
Dr. Strauss: The answer to this is way too long for this forum. Primary care must be valued and the practitioners' time must be reimbursed rather than basing pay on a per patient basis. Also, the idea of pay being based on results is a terrible one and will cause even more docs to quit. The basic premise of this idea is flawed and assumes that people will always behave in a pre-determined way. Patients are not machines and never will be.
Dr. Durward: We need to see cut backs on the mandated requirements, particularly the punitive EMR requirements, many of which not only are burdensome, but quite frankly dangerous. The crisis that was engendered in Texas last year by the Ebola patient whose travel history to West Africa was lost in the EMR and missed by the treating ER doctor is a classic EMR screw-up. The EPIC EMR system used at the Texas hospital and in Sioux City is so complicated to use that missed critical clinical information, errors in entering medical treatment orders, inability to share patient information with other hospitals and clinics are frequent daily occurrences in our city in my experience.
Dr. Uthe: At Sanford, we really stress staying healthy, getting enough sleep, eating nutritiously, exercising regularly, and seeking spiritual and emotional wellbeing. And we try to find all sorts of resources we can to help them do that. Most physicians like their work. It’s just that balance is needed. You need enough partners to share the call. You want enough flexibility in your schedule that you can take care of the patients you have. Putting a TEAM together helps to take the pressure off. The Medical Home concept helps with this.
Dr. Kruse: Burnout is common, but it should never be accepted as normal or seen as doctors just whining about their jobs. We can do something about it together so we can all love the profession we all worked so hard to achieve. When doctors love their work and their life outside of work everyone wins - happier doctors, happier families, happier nurses/staff, happier patients. If doing the right thing isn't reward enough (for the financial office people) - treating burnout saves the health system tons of money. A Florida Hospital system with a mature burnout program estimated that their program saved the hospital more than $5 million dollars in 2 years.
Dr. Strauss: I worry for our country and its medical system. I worry about who is going to take care of ME as I get older and who will take care of my children and grandchildren. I do not know the answer(s) to what can be done but I do know that practicing physicians must be the majority of the people on whatever committee makes future medical decisions. Not having this sort of committee make up is partially what is wrong with our system today. I hope we still have men and woman willing to put up with the rigors and expense of medical education in the future. The profession has certainly lost the allure and prestige it once had.
Dr. Durward: Doctors, not administrators, should be allowed much more control of patient care in the medical system. We are the ones who live by the oath we have taken to put patient care and safety above all other considerations. Administrators, health policy advisors, politicians and insurance executives do not live by that sacred oath.
Three classic signs of physician burnout:
1) Emotional Exhaustion - The doctor is tapped out after the office day, hospital rounds or being on call and is unable to recover with time off. Over time their energy level begins to follow a downward spiral.
2) Depersonalization - This shows up as cynicism or a negative, callous, excessively detached response to their job duties. Often burned out doctors will begin to blame and complain about their patients and their problems.
3) Feelings of Reduced Accomplishment - Here physician burnout has the doctor start to question whether they are offering quality care and whether what they do really matters at all.
Source: The Maslach Burnout Inventory
One Approach to Physician Burnout
A conversation with Mary Wolf, program director of Avera Medical Group’s LIGHT Program
Why do physicians burnout?
MW: Some qualities more common in physicians than in the general public put them at a higher risk for burnout. Those qualities include a driven personality, competitiveness, high standards and a need for control. Other factors that make physicians more vulnerable to burnout are the lack of self-care training in medical school, and many physicians do not have a primary care physician.
From your perspective is physician burnout worse in our region than it is elsewhere?
MW: People in our region tend to wait to ask for help until the end stages of burnout when depression or substance use disorder has developed. LIGHT’s goal is to proactively offer support and resources to reduce and prevent the symptoms of burnout. We want physicians to feel comfortable and safe seeking assistance earlier.
When was the program established and why?
In September 2014, the Avera LIGHT program started as a burnout prevention program for physicians and advanced practice providers. LIGHT offers proactive strategies for enhancing resiliency at both work and home. Whether physicians are looking for ways to renew their enthusiasm in their practice or are feeling overwhelmed by burnout, LIGHT offers resources to help. The LIGHT program shows them that they are cared about as people and not just for their productivity. In addition, we know that physician burnout effects medical errors, malpractice claims, patient satisfaction, turnover rates and suicide rates. LIGHT helps to optimize performance while improving quality of life.
How does the LIGHT program help?
MW: LIGHT (Live, Improve, Grow, Heal, Treat) teaches physicians how to recognize burnout and understand its causes and gives simple tools to lower stress and prevent burnout. This program will provide multiple strategies to enhance personal and professional well-being through a website with self-assessments and resources, CME’s, and eventually peer coaching. Also, LIGHT has implemented a steering committee charged with using doctors’ suggestions to build a better work environment.