We Need to Reflame the Fire Before It Burns Out

Loss of control over work, EHR burdens, and hours at work, all contribute to spike in physician burnout.

As physicians we are faced with challenges in patient care that involve making many decisions in a concentrated time frame and interacting with our peers to give appropriate care to our patients. We expect this as we have been trained to diagnose difficult problems and work long hours that lead to stress between our work and personal lives. The physician selection process is rigorous and eliminates those unable or unwilling to accept this lifestyle. Most physicians are altruistic and committed to their profession. They are taught to address complex problems and to embrace challenges, including grueling training, ongoing night calls and long work hours.

A Public Health Care Crisis

An escalating problem which is beginning to receive much-needed attention from health care leaders is physician burnout. Burnout is a long-term stress reaction characterized by depersonalization, including cynical or negative attitudes toward patients, emotional exhaustion, a feeling of decreased personal achievement and a lack of empathy for patients. The rate of physician burnout ranges from 30–65% across medical specialties, with the highest rates among physicians in the front line of care including emergency medicine and general internal medicine. We must address burnout among physicians as a national imperative as health care reform necessitates greater reliance on primary care.

The Quadruple Aim recognizes that a healthy, energized, engaged and resilient physician workforce is essential to achieve the national health goals of higher quality, more affordable care and better health for populations we serve. Studies continue to show more than half of physicians report at least one symptom of burnout, a substantial increase over previous years. This indicates that burnout among physicians has become a national health crisis that CEOs of institutions are recognizing. They are stating their commitment to address the root causes of burnout and reposition the health care work force for the future.¹

We will address this scope of burnout and ways in which this is being dealt with in the medical community.

The Scope of the Crisis

Physicians from 27 specialties graded the severity of their burnout on a scale of one to seven in a recent Medscape survey—one being that it does not interfere, and seven indicating thoughts of leaving medicine. All but one specialty selected a four or higher. The most affected specialty? Emergency medicine, with nearly 60 percent of ED physicians saying they feel burned out, up from half in 2013. How can the rising prevalence and severity of burnout be addressed? Regulatory, systemic and practice environment issues appear to be key.

More than 14,000 physicians surveyed designated four concerns of too many bureaucratic tasks, spending too many hours at work, feeling like you’re just a “cog in a wheel,” and increased computerization of practice.² “Today’s medical practice environment is destroying the altruism and commitment of our physicians,” said Tait Shanafelt, MD, a hematologist and physician-burnout researcher at the Mayo Clinic, in a presentation at a NEJM Catalyst event last June. He also stated that “We need to stop blaming individuals and treat physician burnout as a system issue … If it affects half our physicians, it is indirectly affecting half our patients.”³ In any other business this would call for immediate assignment of a team of system engineers, physicians and administrators to correct this catastrophic problem that affects quality of care, limits access to care, and is eroding patient satisfaction.

Issues of burnout get in the way of physicians’ ability to provide care to a patient. This primarily relates to the physician’s professional spirit of life, involving individuals who work in intense interaction with people. A physician’s present daily activity is a double-edged sword: what makes doctors great also drives burnout!⁴

The quality and safety of patient care, and indeed the very vitality of our health care systems, depend heavily on high-functioning physicians. In light of this compelling evidence that burnout negatively affects patient care, health care leaders are rightly alarmed and are searching for answers.

Burnout is a term that many professions both medical and non-medical experience on a daily basis. Does the physician burnout rate differ from that of the general working population? The AMA and the Mayo Clinic study published in the Mayo Clinic Proceedings found that physicians work a median of 10 hours more per week, display higher rates of emotional exhaustion and report lower satisfaction with work-life balance. This clearly is driving increases in physician burnout at a higher rate compared to the general U.S. population.⁵

Sources of Burnout … The Flame Will Flicker

Studies clearly show that the more satisfied physicians are, the less likely they are to leave their practices. Physicians who have tried a go-at-it-alone approach have found they were impacted negatively. We must find ways to relieve this burden through team-based care.

As physicians we entered medicine to help patients. Obstacles that get in the way of patient care which are systemic or environmental should be the focus of change. The EHR system requires half of the physician work day to be devoted to entering data and performing other administrative desk work. The AMA and Dartmouth-Hitchcock Health Care System Time Motion Study found that only 27 percent of physicians’ time is spent on direct clinical care. They also found that for every hour of face-to-face time with patients, physicians spend two additional hours on their EHR and clerical desk work.²

This spike in burnout is directly related to lost control over work, increased performance measurement, escalating complexity of medical care and EHR burdens and waste, all leading to altered workflows and changed patient interaction. The end result is that many previously well-adjusted physicians are prompted to retire early, give up teaching and mentoring young physicians, go into “nonclinical” business, or leave the profession altogether.

As a physician, I find a very trying problem is the “challenging patient.” I do not mean patients who challenge my clinical expertise or that of my colleagues. I am referring to the patients whose circumstances make it impossible to arrive at a satisfactory therapeutic plan.

The example I will give is the 88-year-old who lives with her frail husband. Their children live in another state, their friends are no longer living or able to help, and they have difficulties finding transportation to office visits. She was stabilized in her recent hospitalization and sent out doing well, only to return as a readmission within the next 30 days. She refuses to be placed in a nursing home or assisted living facility. Since the social work team rates her as mentally competent, she is sent home from the hospital. She refuses home health services, saying she “does not need them.” The medical team knows at the time of discharge and her follow-up visit in the office, that it will be only a matter of time before she will land in the ER as a readmission.

As the population ages, we will see more of these types of patients. We must find ways to deal with these situations in case management and public assistance to enable them to live independently. I am thankful for the many patients who do not fall into this category of the aging-challenging patient, but their number is increasing and that is very concerning.

Another problem I see in the “new” health care delivery reimbursement system is the primary care providers (both the physician and hospital) are the ones that have to bear the costs of these types of patients who are readmitted due to reasons beyond the provider’s control. This creates a large amount of stress on the providers because the new value-based payment systems require the providers to pay back the system for something they cannot control. Yes, we as physicians are responsible to an extent, but we should not bear the burden for those who are incapable of caring for themselves or those patients who are irresponsible and non-compliant as they continue to smoke, not follow directions to change lifestyle, and/or do not take their medications.

Another primary care physician stress I have experienced is inheriting a patient in an advantage risk plan who has not been adequately worked up for a previous problem by their prior risk-participating physician who “gained” by not ordering certain tests. As the unhappy and undiagnosed patient then changes his care to another physician in the risk plan, the new physician and hospital system then become responsible for the high costs to treat that patient. Examples can include aortic valve replacement, defibrillator placement, or long-needed back surgery/intervention. This new physician and provider network may have to pay back the system if the limited funds for treatment are exceeded. Since the risk is now on the physician assuming care, he or she becomes a “victim” of this system. Unfortunately, the patient is caught as the victim as well. These are the added new stressors that make a physician look at early retirement and shorten a career which one thought would continue until we eventually “push up the daisies.”

The experience from Atrius Health suggests that replacing a physician who retires early or leaves to pursue other career opportunities can cost between $500,000 and $1 million due to recruitment, training and lost revenue. All of this is in addition to the significant toll, sometimes with tragic consequences, that burnout exacts on physicians and their loved ones.¹

Changing the Flicker to a Flame … Solutions and Help

I am sure that those reading this are not surprised by these results which are undercutting the patient-physician relationship. These problems take up the majority of our work day. Kevin Hopkins, MD, a family physician at the Cleveland Clinic, was staring at his computer screen rather than looking at his patient, when he concluded that if he did not have to do this documentation he would really like his work. His team developed templates for health maintenance reminders and he has made workplace modifications such as curtains to allow medical assistants to remain in the exam room to document while maintaining “privacy” for his patients. Multi-tasking skills have been developed for his MAs to be more engaged in patient care than they have ever been and they enjoy their work. Utilizing the MAs can give a big return on investment and achieve a real sense of team work resulting in better satisfaction for both the physician and the patient.⁶

Another suggestion is reducing the work time outside office hours, since physicians spend another one to two hours of personal time each night doing clerical work related to EHRs. (I have frequently referred to this as more “bean-counting work as we click!”) By getting documentation support either through dictation or documentation assistant services, we may be able to increase direct clinical face time with patients and reduce “home office clerical hours.”

Ways to Reflame the Fire

A very good collection of practice improvement start strategies can be found in the AMA Steps Forward Module as it relates to bringing team documentation to your practice. The collection offers several models to help physician relieve the burden of current EHR in deficiencies as well as aiding EHR software selection, purchase and implementation.

An excellent local source is the Missouri Physicians Health Program which is sponsored by MSMA and local medical societies along with other health care systems. Sharing office space with SLMMS, MPHP is available to help physicians in many areas of mental health. They “know more than just substances abuse” as they address physician problems with mental health which include stress, burnout, depression and suicidal thoughts. Their other areas of professional assistance are numerous.

Another source of assistance can be found in the article, “10 Bold Steps to Prevent Burnout in General Internal Medicine,”⁴ which was initially presented at the annual meeting of the Society of General Internal Medicine in 2013:

Institutional Metrics

• 1. Make clinician satisfaction and well-being quality indicators.

• 2. Incorporate mindfulness and teamwork into practice.

• 3. Decrease stress from electronic health records.

Work Conditions

• 4. Allocate needed resources to primary care clinics to reduce health care disparities.

• 5. Hire physician floats to cover predictable life events.

• 6. Promote physician control of the work environment.

• 7. Maintain manageable primary care practice sizes and enhanced staffing ratios.

Career Development

• 8. Preserve physician “career fit” with protected time for meaningful activities.

• 9. Promote part-time careers and job sharing.

Self-Care

• 10. Make self-care a part of medical professionalism.

These 10 steps are presented to identify stress at its earlier stages and choose programs to prevent it. Institutional success must include physician satisfaction and well-being. It also incorporates mindfulness and teamwork for training practicing clinicians. Mindfulness, a known stress reducer, is a means for internally accommodating external stress orders. Teamwork is critically important for burnout prevention through sharing and support of clinician workload. The patient-centered medical home is an example of this.

CEOs of health care institutions have a vital role; their attention is paramount to help in easing this problem of physician burnout. To further this objective, the CEOs of 10 leading health care delivery organizations held a summit meeting aat AMA headquarters in Chicago in September 2016. They concluded leaders must recognize burnout in the physician/health care worker and work in areas of burnout prevention and restoring the joy in medicine. Boards should hold CEOs accountable to implement these approaches to address physician burnout.¹

The strength of the physician’s immediate supervisor’s leadership has been shown to matter. Each one-point increase (on a five-point scale) in leadership decreases the odds of the physician burnout by 3.3 percent and increases satisfaction by 9 percent. Successful leaders hold career development conversations with their physicians, inspire and empower their physicians to do their job well, and recognize the physician for a job well done.¹

This meeting came to the consensus that addressing burnout is a matter of urgency. A local hospital is addressing low patient satisfaction scores and is having mandatory physician meetings to improve scores in the future. They must address “physician burnout” as a source and contributor to these low patient satisfaction scores and how to constructively deal with this problem.

Volunteering

Last but not least, giving back to the community “recharges a doctor’s battery” and provides new motivation as a full reset for physicians. It reminds us of why we chose medicine as our calling. Physicians deal with problems that have no easy fixes, including increased scrutiny, more administrative hassle, and rising costs and responsibility for controlling these costs—all while we are trying to give the best of care to our patients. Volunteering has its own rewards and the research bears that out. After adjusting for socio-demographic factors, multiple studies have shown that adults who volunteer enjoy better mental and physical health and have lower mortality rates. There are additional benefits for physicians as volunteering can serve as inoculation against physician burnout even to causes unrelated to medicine, according to Gail Gazelle, MD, hospice and palliative care physician in Boston, who provides executive coaching for physicians and physician leaders.⁷

Volunteering can be done in the form of serving the medical community or the nonmedical community. Since the early 1990s, I have found this to be very beneficial as I have served in a homeless center and coordinate one night a month in serving a group of 15–20 homeless people in our community. When I watch the impact on their lives and see their faces, sometimes the tears and hugs, it humbles me and makes me recognize that what I do has a lot of value. We can truly make a world of difference for people. It is true that I am tired on that Friday evening after working in the office as “I may drag into the door of the homeless shelter but on the next morning I am skipping out.” My office staff volunteers to help; they have prepared food and worked with these homeless that we serve. It is a great team builder and I feel has helped bond our office. This has been an opportunity to help someone else and get our busy minds off of ourselves and the “hassle” of running an office

Thoughts Overall on Turning Up the Flame

We need comprehensive, systematic and sustained efforts to improve physician well-being. The drivers of physician well-being must be addressed from the three reciprocally related areas: practice efficiency, a culture of wellness and personal resilience. A balanced approach is necessary to build this platform to drive sustained improvements in physician well-being and our health care performance. All of us in the health care system owe it to ourselves, to our patients and to generations to come, to work together for improvement in all areas of health care delivery.

Our patients deserve care from a compassionate, competent, caring, engaged and resilient physician. We must be committed to work with our patients, EHR vendors, medical leaders of our institutions, insurance companies, pharmaceutical companies, hospital CEOs, physician health programs, and last but not least our physician/health care colleagues and assist them in their daily dance with the crisis of burnout.

Biography

J. Collins Corder, MD, FACP, MSMA member since 1980, has been practicing internal medicine for 36 years at Missouri Baptist Medical Center in St. Louis and is affiliated with BJC Medical Group. He was the 2017 president of the St. Louis Metropolitan Medical Society.

Contact: jcorder20@aol.com.

Reprinted with permission from St. Louis Metropolitan Medicine.