Burning Down the Docs

“Watch out, you might get what you’re after.”

-Talking Heads 2006

Once again, let us take up the subject of burnout. There has been a great deal of talk over the last some years about this, including a piece by yours truly². But it’s not going away. It’s getting worse. Some recent publications have focused on intensivists³, the subject for today. In the most recent Medscape physician lifestyle survey, intensivists scored a 53% burnout rate⁴. This was the highest in the study. Emergency medicine physicians (the former champs!) scored 52%. Overall, physicians scored 46%. The level was 40% only two years ago. In the Medscape survey, burnout was defined as “loss of enthusiasm for work, feelings of cynicism, and low sense of personal accomplishment.”⁴ In more descriptive terms, you just don’t give a flip anymore.

Burnout was found to be somewhat age dependent. The peak age range was 46 to 55. Burnout dropped off dramatically above 65. But the important message is this: burnout symptoms were seen in more than 40% of physicians from 35 to 65. That’s most practicing physicians. Colleagues, if 40% of us just don’t care anymore, we’re in trouble.⁴

Back to intensivists? Besides the U.S. survey, an Australian survey noted very similar findings in 115 intensivists.⁵ Some 80% had at least one symptom, with about 40% having all or most of the syndrome. Intensive care medicine shares some characteristics with emergency medicine. Both specialties require shift work, both have frequent (although predictable) night work, and both, apparently, are perceived to be associated with a loss of control over the working environment.

A study from France of critical care physicians and nurses showed a high rate in both. Some 50% of physicians and 33% of nurses showed symptoms. In physicians, burnout was associated with number of night shifts and time worked since last vacation. In nurses, it was associated with organizational factors and end-of-life issues. In both, it was associated with the occurrence of conflict situations. It’s not very surprising that a happy workplace reduces burnout. That said, it is very doubtful that “happiness” appears on the list of objectives for critical care unit administrators. Evidently, it should.

We are moving strongly towards focusing critical care on intensivists, in the expectation that this will improve care. But if we destroy the physicians and nurses giving this care, we will not improve anything. Indeed, we may make things worse. And intensivists are only somewhat worse than physicians in general, 50% versus 40%.

What can we do? How can we make things better for our colleagues, and for ourselves?

There are outside or personal factors which can at least reduce the incidence of burnout. Physicians who do volunteer work were less likely to be burned out than those who do none. Almost any sort of volunteer work seemed to be associated with less burnout. Modest exercise (at least twice a week) was associated with less burnout. Physicians with “adequate” savings, self-reported, were less likely to have burnout symptoms. Attending church services was associated with less burnout. Interestingly, political affiliation (liberal versus conservative) had little effect⁴. So… marriage is good, volunteer work is good, church is good. Getting out of oneself seems to be a common factor. And financial security is also good. Hardly takes a survey to figure that one out. The advice “take time to take of yourself ” remains sound.

But as good as these things may be, all are simply associations. They do little to get to the causes of the malaise. In the Medscape survey, participants were asked to report things they thought caused burnout. The top six were “too many bureaucratic tasks,” too much time at work, too little income, increasing computerization (yes, electronic health records), the impact of the Affordable Care Act, and “feeling like just a cog on a wheel.” This last captures much of the frustration felt by many physicians. It is somewhat disturbing that three or four of these six have been imposed on our profession by outside forces, be they hospital systems or government. Hence, they are outside our control, except as we can influence Congress, Federal bureaucrats, or hospital administrators. As the current saying goes, “Good luck with that.”

Medicine has always been a stressful occupation, and will no doubt remain so. But stress and its effects seem to be getting worse. There are many forces converging to make physicians unhappy with their lot. Is it paranoid if some people are really out to “get” us? More to the point, as the health system is changing, many of the changes are adverse to physicians. These include the increased debt of young physicians, the loss of autonomy, the bureaucratic tasks, electronic medical records, and the ceaseless questioning of our judgement. And, of course, the ever-present risk of malpractice suits. Was this intended? Or is it simply a consequence of poor planning and implementation?

As sometimes said, “Never attribute to malice that which can be explained by stupidity.” (While this is called Hanlon’s Razor, sometimes Heinlein’s Razor, similar thoughts go back at least to Goethe, and probably further back.⁸ Even if no one was out to “get” physicians, many of the changes were made with little or no physician input, and without considering their effects on physicians.

Truly, we are getting the results to be expected from a badly-designed system. So, in the words of the song above, we have now “got what we’re after.” Neither medicine nor society at large is happy with this. And the term “designed” is definitely a misnomer. More accurately, we have something which simply evolved, and been tinkered with for the last century. We may choose to blame “Obamacare,” but the Affordable Care Act introduced nothing new. It simply doubled down on many of the existing flaws of the system. But whether because of the ACA or because of prior factors, the pressure on physicians seems to be increasing. Many of us are frustrated, and burned out.

It shouldn’t be this way. Besides taking care of ourselves as individuals, we need to take care of our profession as well. We need to become more radical, both as individuals and as groups. For example, one cause of stress has been the increasing number of physicians employed by large organizations. But that’s also making it much easier for physicians to change jobs. Frustrated where you are? Get out. You may not have the autonomy of private practice, but you aren’t tied down, either. After all, if you look for a new job, you will look at your present job in a new light. You may find you aren’t so badly treated. Alternatively, you may actually find a better job. But either way, you force your employers to pay a lot more attention to keeping you happy, and productive, and on board.

But our organizations need to be stronger. The biggest criticism I hear about organized medicine is that its leaders “go along to get along.” (Or is that the other way around?) We often support the status quo, when we should be disrupting it. Our organizations should express our grievances, loudly and often, and try to do something about them. And we should not be active just in our interests. Many patients are ill-served by our health care system. If we are to be their advocates, we must recognize their grievances. True, organizations must do a certain amount of political log-rolling. Compromise is the way political bodies work. But to compromise, we have to have to start from a firm position. Too often, our organizations just react, or else fiddle around the edges.

This is the best time to be advocates for ourselves, and for a better health system. Nobody likes Congress. Politicians are neither trusted nor respected. Physicians are more trusted than almost any other group in society. We had a physician, Ben Carson, seriously running for President (two, if you counted Rand Paul). OK, neither of them made it. But does anyone remember the last time that happened?⁹ We have the credibility, the public respect, and the standing to clamor for changes.

It’s time.

Biography

Charles W. Van Way, III, MD FACS, FCCP, FCCM, MSMA member since 1989, and Missouri Medicine Contributing Editor, is Director of the UMKC Shock Trauma Research Center.

Contact: cvanway@kc.rr.com

Reprinted with permission from Kansas City Medicine Winter 2016.