Evaluating Physician Burnout and the Need for Organizational Support

Physician well-being in the United States is in jeopardy as they face unprecedented levels of stress and burnout. While organized medicine has implemented some programs to counteract these pressures, rates remain relatively stagnant. We aim to analyze current practices meant to ensure the well-being of clinicians in organized medicine and external sources of dissatisfaction that have yet to be addressed. This brings us to the critical question: How are medical organizations engendering policy that improves upon current standards of well-being?

Introduction

Despite an increased focus on physician wellness in recent years, the vast majority of literature fails to conceptualize this issue. While most reports include at least one measure of mental well-being, only about half discussed social, physical, and integrated measures. Explicit definitions of physician wellness tend to be either sparse or vague.¹ Although clearer understanding of wellness in this specific occupation is necessary, the vast majority of literature agrees that it is dependent on the following criteria.

Burnout can be characterized by emotional exhaustion, depersonalization from work, and a perceived reduction in personal accomplishment.^1,2 Balancing organizational constraints with the heavy demands of patients often stifles effective patient engagement and treatment. Physicians often develop feelings of cynicism towards work, succumbing to the feelings of inadequacy that perpetuate burnout.² A distinct factor concerning burnout is its dependency and effect on relationships.³ Interactions with colleagues, patients, and superiors can be either a reward or burden. Likewise, the ripples of these interactions are most heavily carried over to other relationships.³ Physician wellness should not only be devoid of burnout but must also maintain strategies to actively combat it.

Burnout seems to be an indirect cause of depression but a unique phenomenon, nonetheless. This correlation is clearly exhibited by the rates of depression in physicians.^4,5 While exact proportions vary between gender, age, and ethnicity, the vast majority of literature agrees that doctors exhibit greater rates of depression and suicide than other professions.^5,6 Managing the transfer of burnout in the workplace to depression in physicians’ personal lives should play a significant role in ensuring physician well-being.

Dissatisfaction in work-life balance is experienced in a unique way in physicians. A study involving over 7,000 participants found that more than forty percent dissatisfied with work-life balance, almost double that of the general population.^7,8 Even when considering those with professional degrees, medicine is the only field that worsens work-life balance with increased education.⁶ Furthermore, female physicians appear to be more prone and tend to work fewer hours than their male counterparts.^7,9 One could presume that, if women were to work at a similar rate as men, they would display less work-life balance. This can be attributed to the disproportionate number of women who limit or cease practice to address family needs.^7,9 Regardless, physician well-being appears to hinge on addressing the root cause of a healthy work-life balance.

Causes

The causes of the criteria listed above are extensive and can be traced throughout a physician’s career. Beginning in medical school, future physicians are conditioned for years to completely ignore physical, emotional, and spiritual needs in favor of the needs of a patient. An excessive workload with bizarre hours is the status quo and, compared to the general population, physicians work longer hours.^7,10 The effects of this arrangement pervade throughout every aspect of their lives. Long bouts of separation from family and friends can have a massive strain on relationships, and physicians are also unlikely to utilize coping mechanisms to deal with this stress, often fearing that their vulnerability may be held against them professionally.^10,11

Additionally, as medicine has increasingly been dominated by large insurance companies, physician autonomy has diminished drastically.^12,13 A litany of restrictive practices have introduced concerns that insurers are interfering with physicians’ professional judgement.¹² High copays force patients to seek inadequate treatment, prior authorization limits access to medicine, and meager reimbursement rates burden physicians financially.^3,12 Physicians want their patients to understand that they are on their side, so this powerlessness can take a heavy emotional toll and fuel disillusionment with their work.

Similar effects can be seen from the introduction of electronic health records (EHRs). Today’s physicians spend half their time on EHR data entry while only about a quarter is spent on direct patient contact.^13,14 This skewed time allocation contributes to cynicism with work and erodes relationships with their patients.¹³ Of course, physicians want to do everything they can to salvage these relationships, but unhealthy work-life balance, decreased physician autonomy, and excessive administrative burdens continue to perpetuate burnout.

The nation’s response to the COVID-19 pandemic has only exacerbated these issues. Despite the United States’ woeful unpreparedness to a global outbreak, physicians still rushed to answer the call of an ailing nation. In return, doctors have been met with abuse at every administrative level.^14,15 Federal and local governments across the country refused to support and acknowledge the imperative need for protective equipment while treating patients. After taking pay cuts and giving up bonuses, physicians were forced to respond to drastic unilateral changes from their employers.^14,15 As a result, the mental health of doctors plunged as 39% of physicians felt that the COVID-19 had taken a toll on their ability to cope with their profession.¹⁵ The coronavirus pandemic provides an apt microcosm of the relationship physicians have with their work. They will go to extreme measures to ensure the health of others but, in turn, are undoubtedly sacrificing their own physical and mental well-being.

Existing Organizational Support

Because physician burnout is largely driven by organizational factors, large organizations have taken a significant role in alleviating them. Over the past two decades, an abundance of research has made them well aware of this reality.^2,4,7 In response, various programs have been implemented to counteract burnout and promote wellness. A commonality between most organizations was the need for a shift in paradigm.¹⁶ Before introducing new programs, most employing authorities reemphasize the importance of their employees. Aside from this, support against burnout has been diverse. Large organizations like the American College of Physicians (ACP) have honed in on the day-to-day stressors of physicians. Their “Patients Before Paperwork” initiative works to reduce the administrative burdens and unessential tasks that detract from the physician-patient relationship.^17,18 In addition, the ACP’s own policies provide a framework that helps to identify whether administrative tasks need to be revised or totally removed.^16–18 Some organizations have focused on redefining the very understanding of a physician. The American Academy of Family Physicians (AAFP) has consistently opposed implications of uniformity in skill or care.¹⁹ According to the AAFP, these generalizations contribute heavily to moral injury and physicians’ recent disillusionment in their work.¹⁹ Similarly, the AAFP has advocated heavily against the current administration’s push for non-physician independent practice.¹⁹ Allowing nurse practitioners and physician assistants to function unsupervised would only exacerbate the already prevalent detachment from work.

The vast majority of individual hospitals have also worked to promote wellness. Eighty-three percent of hospitals in the United States offer workplace wellness programs, compared to only 46% of all employers.²⁰ Sixty-three percent offer health screenings, compared to 27% of all employers.²⁰ Every level of organization has, on some level, worked to limit the amount of burnout endured by their physicians, yet their returns on these investments can be described as modest at best. From 2011 to 2014, rates of burnout increased from 45% to 54% as physicians spent less time with patients and shouldered more administrative burdens, largely due to the popularization of electronic health records (EHR).^13,21 Despite the diverse efforts of organizations, rates as of 2019 have returned to 2011 levels at about 44%.^22,23 The root causes of burnout, increased administrative burden and reduced patient interaction, have yet to be addressed.

Organizational Inadequacy

While national-level organizations do carry some weight in influencing change, more needs to be done to truly reach individual physicians. The American Medical Association, the largest organization of physicians in the country, has seen its membership rate decline every decade since the 1970s.²⁴ Even within the membership of this large organization, most are cynical of their motives.^25,26 A survey done by Jackson and Coker found that less than half of physicians felt that the AMA’s stances and actions represented their views.²⁴ Doctors sense that organizations have become increasingly out of touch with the struggles they face in their careers. While there is little associations like the AMA can do to understand the unique needs of each hospital, they can try to address the systemic issues driving burnout across the nation.

In a recent poll done by Stanford medicine, doctors gave electronic health records an ‘F’ on a usability scale, while common search engines like Google earned an ‘A’.^25,27 Over the past two decades, the government and other large organizations have spent years funding and designing EHRs with little input from physicians.^27,28 As a result, over half of all doctors believe that the system needs a complete overhaul.²⁸ In response to such negative reception, the AMA has been active in conducting research to understand how EHRs induce burnout and decrease physician autonomy.^13,26 Their research agrees that, for every hour spent with patients, physicians spend two hours on EHRs and other clerical work.²⁹ Further study done with the RAND corporation isolated eight EHR requirements that would lessen burnout.^13,29 This list includes standards like enhancing physicians’ ability to provide quality patient care, product modularity and configurability, and reducing cognitive workload.¹³

Organizations like the AMA have been less zealous, though, in their response to these causes as they continue to honor a nearly decade-long partnership with vendors like AmericanEHR.¹³ Despite their robust understanding of how to structure EHRs, doctors clearly feel that these standards have yet to be met four years later.²⁷ A significant roadblock to reform is the unopposed lobbying power of EHR vendors themselves. The five largest vendors to American hospitals spend millions on lobbying annually.³⁰ Yet, neither the AMA nor American Hospital Association (AHA), two of the largest lobbying groups in the country, spent any significant portion of their combined 44,344,842 dollars on pressuring EHR vendors to improve their products or collaborate with physicians.³⁰ The inability to fight the monetary power of insurance giants like BCBS make systemic improvements nearly impossible.^30,31 Even when accounting for large pharmaceutical corporations like Bayer AG, a significant obstacle maintaining physician autonomy in prescription of medication, the AMA and AHA are only slightly outmatched.^30,31 These associations do not lack the means to combat the primary drivers of burnout in today’s physicians, yet they remain complacent as EHR vendors, health insurers, and pharmaceutical corporations invade healthcare.

Despite an apparent partiality for the institutions promoting burnout, large organizations have made efforts to combat its symptoms and have empowered hospitals to do the same. For example, in 2015, the AMA launched its “STEPS Forward” program. This initiative offers a catalog of over fifty online tools for medical teams that are designed to streamline and reduce common stressors of practice.³² Each tool is designed to improve workflow, personal satisfaction with work, or administrative tasks. A prime example of implementation is the 2018 GROSS (Getting Rid of Stupid Stuff) initiative at the Cleveland Clinic.^33,34 After compiling a list of outdated practices, administrators were able to make changes that varied from minor improvements to EHRs to totally restructuring triage.^14,33 Similar examples of success can be seen across the country.^23,32 Aside from this keystone initiative, the organization continues to generate new baseline measures for hospitals to assess their physicians’ wellbeing, provide regulatory clarifications for their administrative products, and offer a national conference on protecting physician health.

Most hospitals have also implemented their own wellness programs to alleviate symptoms of burnout within the last decade.^30,35 For example, motivational programs like gratitude and thankfulness events have consistently presented modest decreases in burnout rates among physicians.³⁶ However, team-based and incentivized exercise programs appeared to have insignificant effects compared to interventions oriented toward team dynamics.^23,35,36 Unlike the AMA and most other large physician organizations, though, hospitals are limited to concentrating their efforts on combating symptoms rather than underlying causes.

The futility of programs at both the hospital and organizational level can be reflected by the relatively stagnant rates of burnout over the past decade. While fluctuation has occurred, physicians remain at essentially the same place they were a decade ago. One may point to the years of meditation groups, exercise incentives, and other Band-aid solutions that have helped some institutions, but the national trends still point toward stagnation.³⁴ While isolated improvements do exist, broader trends suggests that physicians continue to express their displeasure with burnout’s underlying causes.^22,28 Until physicians are relieved of their massive administrative burdens and physician autonomy is restored, these issues will persist. A truly “normal” balance is almost impossible to reach with the status quo. The profession, as it stands today, inherently lends itself to overwork to uphold reliable patient access.¹¹ Individual physicians can implement plans in their own lives to maximize their personal time, but hospitals would be hard-pressed to simply lower their hours.¹¹ Therefore, hospitals and organizations must be the ones to address physician autonomy and inefficiency in administrative tasks on the national level.

Recommendations

Organizations must be prepared to implement comprehensive reform and restructuring of existing practices to truly mitigate the effects of increasing administrative burdens, dwindling professional autonomy, and an unhealthy work life balance.

Firstly, organizations need to push vendors to improve the usability and effectiveness of EHRs. Nearly three out of four primary care physicians agree that improving existing user interfaces is the most important challenge to address in the immediate future.²⁸ Today’s physicians point to how they have been reduced to data clerks, constantly scrolling, checking, and clicking tabs. More specifically, a meta-analysis of 50 unique studies of EHR usability found that these features consistently violated common standards of usability like information presentation, interaction, cognitive load, error prevention, and naturalness.^37,38 To combat this rigid and cluttered format, hospitals should adopt EHRs specific to specialty or physician. Currently, the majority of EHRs contain a sizable compilation of electronic forms that link to a main system or data bank.^37,39 Because every physician in a hospital uses the same compilation of forms, much of the necessary information is redundant and overwhelming. Tens of data fields and text-entry boxes violate efficient interaction with these forms.^13,38 This ineffective use of language is especially harmful when attempting to diagnose with these inaccurate symptoms.⁴⁰ Allowing specialties to customize these interfaces would help physicians streamline this process and reduce their cognitive load.³⁹ Physicians would only see what they know they need. Similarly, the physician takes control of the language used to describe what they see. Promoting a more natural and personalized record would also improve efficiency.^38,39 While standardization may worsen, intuitive organization would compensate for any translation between formats. Rather than wasting time searching for information that may be inaccurate, physicians would be able to quickly understand their colleague’s opinions or diagnoses.

About Rayyan Abid.

Rayyan Abid is currently a senior at Blue Valley West High School planning on pursuing a career as a physician.

Coming from a household with two academic physicians, Rayyan has had the privilege of seeing different sides of medicine. His mother is an internist and his father practices pulmonology and sleep medicine.

Seeing his parents interact with patients, learners, mentees and their community has given him a great sense of appreciation and admiration for their work. He has also seen, first hand, how long work hours, stressful days on service, and the struggle to find a work-life balance take a heavy toll on physicians’ lives.

Rayyan says that his parents’ unconditional love and support has come with the condition of making a fully informed decision of choosing the medical school path. This inspired him to learn more about physician burnout as he witnessed similar symptoms in fellow high school students.

Rayyan believes that as a leader and a future physician, it’s important to learn what the medical community can to address systemic issues plaguing this wonderful profession. This realization became even more real for him when his parents entrusted him with their living will at the beginning of the pandemic. At the time, the effects of COVID-19 were still unclear. Yet, his parents, along with countless other physicians, didn’t hesitate to risk their lives for their patients. It was this conviction that cemented his desire to pursue medicine.

As an aspiring physician, Rayyan wants to find ways to preserve this passion for work while protecting mental, physical, and emotional health.

Unlike EHRs, the constraints on physician autonomy driven by insurance and pharmaceutical companies are not in the hands of hospitals or physicians. The rising insurance costs protected by federal policy lay far outside the influence of individual institutions.⁴⁰ Hospitals are also powerless to the lobbying that defends disproportionately high pharmaceutical costs.³¹ Corporations’ ability to influence policy without any opposition allows them to drive up premiums and exert their influence on patient care.³⁰ Nationally-based physician organizations like the AMA, ACP, and AHA should direct lobbying funds to issues related to reducing drivers of physician burnout such as prior authorizations for medications, surgeries and imaging studies. In the last two sessions of Congress, the AMA has lobbied for 18 unique issues unrelated to healthcare. The AMA’s lobbying has addressed health insurance coverage for only one issue in this time frame: Coronavirus Aid.³⁰ The AMA’s lobbying funds dedicated to fields unrelated to medicine, including fringe tax cuts, homeland security, and law enforcement, must be diverted to counteracting insurance and pharmaceutical companies. Without meaningful opposition, these companies have proven that they will not hesitate to keep increasing the time physicians devote to tasks unrelated to direct patient care contributing to physician burnout. Organizations that support physicians have an obligation to extend their backing beyond support groups and truly challenge the companies that threaten the wellbeing of today’s physicians.

Conclusion

Physician burnout is a unique problem that must be effectively addressed by organizations representing physicians. An overwhelming amount of research clearly delineates its causes, yet hospital-based efforts to reverse the current trend have only had marginal success. The organizations meant to fight for physicians remain complacent in the face of EHR vendors and insurance companies. In the future, advocacy must be driven by physicians themselves. Only they understand the unique struggles they face throughout their careers. Perhaps this could even begin from the onset of medical school with grassroots organizations like Physicians for Patient Protection. Regardless, many physicians do not trust their national associations to combat the underlying threats to their wellbeing, and until they can unify behind a truly representative form of advocacy, burnout is here to stay. In the future, advocacy must be driven by physicians themselves.