Physician burnout

1
Physician burnout

• Tuesday, March 27, 2018
• Seth D Bilazarian, MD
• DrSeth_at_pmaonline.com

2
Physician burnout

• Nearly 46 percent of 7288 surveyed physicians
  said they experienced at least one symptom of
  serious burnout, according to a study published
  in the Archives of Internal Medicine.
• Compared with workers in the general population,
  physicians had an 8.6 higher risk of emotional
  exhaustion and 10 higher risk of overall
  burnout.

Arch Intern Med 2012 DOI10.1001/archinternmed.20
12.3199.
3
Defining burnout

• What is it?
• Should we care?
• As individuals?
• As a profession?
• As a society?
• Why is it happening?

4
Burnout and satisfaction with work/life balance
among US physicians 

• Burnout among physicians was measured using the
  Maslach Burnout Inventory (MBI)
• 45.8 of physicians reported at least one symptom
  of burnout
• The MBI has three subscales to evaluate each
  domain of burnout
• Emotional exhaustion
• Depersonalization
• Low personal accomplishment

Arch Intern Med 2012 DOI10.1001/archinternmed.20
12.3199.
5
Lay press articles

• The root of physician burnout - The Atlantic
• The physician burnout epidemic What it means
  for patients and reform - The Atlantic
• The widespread problem of doctor burnout -
  NYTimes.com
• Doctor burnout Nearly half of physicians report
  symptoms USA Today
• Is your doctor burned out? Nearly half of US
  physicians say they're exhausted Time
  Healthland

6
Shortage of physicians?

• "By 2015, the US will be 62 900 doctors short,
  and the future looks even worse," Archambault
  said. "By 2025, the estimated shortage of doctors
  will more than double, as baby boomers require
  more care and Obamacare grants more insurance
  cards. Seeing a doctor in a reasonable amount of
  time may be a thing of the past, unless
  meaningful consumer-directed reform is passed
  soon."

Romneycare hints at future doc shortage.
BostonHerald.com
7
Six in 10 physicians would quit today

• Doctors are working less, seeing fewer patients,
  and many would quit if they could, a sweeping
  survey of 13 575 physicians from across the
  nation shows.
• A Survey of America's Physicians Practice
  Patterns and Perspectives was commissioned by the
  Physicians Foundation. It is the latest and
  perhaps the largest and most comprehensive of a
  number of surveys that have identified wide,
  deep, and increasing discontent among the
  nation's physicians regardless of their age,
  gender, specialty, location, or employment
  status.

A Survey of America's Physicians
8
Changes in patient-physician interaction

• EMR
• Patient autonomy Can a patient demand care the
  doctor feels is inappropriate?
• Patient satisfaction?
• Appropriate-use criteria and Choosing Wisely
• Patient-centric care

9
Changes in the law

• ACA or Obamacare
• Romneycare
• Physicians' reaction to it
• Physicians being blamed for the inefficiencies
  and inadequacies of the healthcare system

10
Cardiologists speaking after SCOTUS upholds ACA

• Almost universally praised aspects of it
  (universal coverage)
• Almost universal in expressing uneasiness, poorly
  articulated views about
• Impact on societal costs
• Practice and delivery of medicine
• Impact on American medical innovationdrugs and
  devices
• Clumsy

11
The Anti-ACA view

• This bureaucratization will amplify everything
  patients and businesses despise about the current
  system the unintelligible 103 234.61 bill for a
  turned ankle, the doctor who can't take a phone
  call because of how the hospital schedules shift.
• Why aren't mom's eight specialists aware of each
  other's existence? Why is healthcare mostly
  conducted via a pad and pen and beepers and fax
  machines in the iPhone era? Why are there so few
  geriatricians when the first wave of baby boomers
  is already turning 65? Why is it still so hard to
  find usable information about quality and prices?

Cheesecake Factory Medicine WSJ August 27, 2012
12
Doctors who view medicine as a calling are more
satisfied (part 1)

• They feel better about caring for patients with
  complex conditions such as obesity and alcohol
  addiction than other physicians, research shows.
• The reasons that drive doctors to practice
  medicine can have an impact on how satisfied they
  are caring for patients with challenging
  conditions, says an Archives of Internal
  Medicine research letter published online August
  27.
• Researchers analyzed data from a national survey
  of 1504 primary-care physicians. They found that
  doctors who see medicine as a calling are more
  likely than other physicians to be satisfied
  treating patients who are obese or addicted to
  nicotine or alcohol.

Doctors who view medicine as a calling are more
satisfied. amednews.com
13
Doctors who view medicine as a calling are more
satisfied (part 2)

• Of the three conditions, physicians were most
  satisfied treating nicotine dependence (62),
  followed by obesity (57) and alcoholism (50).
• Physicians who are unhappy with their career
  choice are less likely to be satisfied treating
  those disorders, and they often blame patients
  for their conditions.
• The findings are significant, given high rates of
  burnout in the profession, said study coauthor Dr
  John D Yoon, an assistant professor in the
  University of Chicago's Section of Hospital
  Medicine and associate faculty member at the
  MacLean Center for Clinical Medical Ethics.

http//www.ama-assn.org/amednews/2012/09/10/prsc09
10.htm
14
Changes in response to legal and financial
pressures by the healthcare system

• Family farm vs ADM
• A1 Deli vs Cheesecake Factory

http//www.newyorker.com/reporting/2012/08/13/1208
13fa_fact_gawande
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Anti-Cheesecake view

• Political counterpoint to the Big Medicine piece
  of Dr Atul Gawande in the New Yorker
• The highlighted aspects are the corporatization
  of medical practices and the payment advisory
  board.
•  
• "The 'most important institutional change' after
  ObamaCare passed in 2010 the independent payment
  advisory board composed of 15 philosopher kings
  who will rule over US healthcare."
• The unknown aspects of who, what, and why and
  perceived hazards of this decision-making process
  are discussed.
• "The longer-run danger is . . . cost board starts
  to decide what types of care 'work' for society
  at large and thus what individual patients are
  allowed to receive."'
•  
• "The Cheesecake Factory is a great place to eat
  but you probably wouldn't want to be operated on
  thereespecially if it's run by the government."

Cheesecake Factory Medicine. Wall Street Journal
16
Big medicineCheesecake Factory Where they fall
short

• No discussion on inelasticity of pricing
  (high-end restaurants don't cost the same as
  fast-food restaurants)
• Not responsible for patient's care before and
  after interactions
• Restaurants are incentivized to capture as much
  business as possible but are not required legally
  or expected ethically to serve all comers
• There is no defensive-medicine equivalent in the
  dining industry
• The problem of poor coordination as described is
  real and serious but this has been foisted on
  doctors ("Too many cooks spoil the pot") but we
  are complicit
• I didn't have as good a meal as Dr Gawande did

17
Should we care about burnout?

• "Ultimately resistance that is not addressed
  creatively can frazzle nerves . . . and overly
  burden. . . . Prolonged contact with conflict and
  criticism wears them down, robs them of joy.
  Many . . . simply want out"

Leadership Essentials by Greg Ogden and Daniel
Meyer p 154
18
What's frustrating

• EMR has several advantages but reviewing it is
  time consuming"Where's the beef?"
• Oversight in the office ICAEL, ICANL 48-hr
  turnaround
• Hospitalappropriate-use criteria, malpractice,
  public reporting
• Daily practice hospital computer systemsnot
  ready for prime time order preop antibiotic, nine
  signatures prior to cath
• Post hoc scrutiny

19
Is life is easier?

• Night float, hospitalists, nocturnists

Exclusive Nocturnists on hand for the critical
hours. news-press.com
20
Relevant articles in the Atlantic

• The Physician Burnout Epidemic What it means for
  patients and reform
• The Root of Physician Burnout

21
The root of physician burnout "Incentivizing
with money is a self-fulfilling prophecy
of cynicism. We must promote compassion, courage,
and wisdom among our physicians before we "make a
sordid business of this high and sacred
calling."

• Reducing dissatisfiers
• Reduce stressors by cutting back on working
  hours, relaxing intrusive oversight, and finding
  ways to lift the burden of "busywork" from the
  shoulders of physicians.
• Fair pay

• Enhance fulfillment
• Focus on the work itself.
• Do physicians recognize what they find most
  fulfilling?
• What does their best work look like?
• Are they making full use of their knowledge,
  skills, and innate abilities?
• Are they growing and developing as human beings?
• Do they feel that they are making a real
  difference in the lives of their patients and
  communities?

22
The widespread problem of doctor burnout (NY
Times and the Atlantic)

• Almost half complained of being emotionally
  exhausted, feeling detached from their patients
  and work, or suffering from a low sense of
  accomplishment.
• She feels increasingly frustrated with what she
  calls the "bureaucratization" of medicine and
  resents spending "more time filling out forms
  than caring for patients." 

The widespread problem of doctor burnout. New
York Times
23
Dave Scott (Cornwall Bridge, CT)

• Burned-out doctors will not question or fight the
  system. They will cheat to survive. And those who
  profit from the system as it is will want to
  leave burned-out doctors as they are.
  Unburned-out doctors would try to change things.
• If you want to find out why doctors are burned
  out, figure out who benefits from burned-out
  doctors. Those who benefit from burned-out
  doctors would be those whose routines and
  practices would be disrupted by doctors who
  weren't burned out, who were still trying and
  caring. Burning people out gets rid of their
  idealism, and medicine is one of the fields
  (teaching is another) that uses idealism and
  service to attract people.

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My comment Why are physicians frustrated and
burning out?

• Weak?
• Entitled (I've worked really hard and got all
  As)?
• Anxiety from transition, change, and uncertainty?
  "Broken contract"
• Addicted to affirmationless appreciation shown
  by patients
• Frustrated with blame for ills of the system
  (especially cost)
• More deep rooted? This is not what I signed up
  for, this is not my calling, these are not my
  values.
• Is it because physicians' values are being
  compromised?

25
Systemic American healthcare system values are in
evolution

• ACA
• MA referendum on physician-assisted suicide
• Impact of declining small group practices and
  rise of Big MedicineHCA (family farmADM)
• Geographic variability (Dartmouth Atlas) and
  recent reports of grotesque fraudulent care (HCA
  in NY Times)

26
Physician values

• Largely comes during training internship,
  residency, and fellowship
• Messages I heard
• "Did you sleep?"
• "Trust no one"
• Things I saw
• Meticulous review of every lab and imaging value
  prior to discharge
• Want everything at discharge to be tied up in a
  neat package"put a bow on it"

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Ethical concerns Always put the patient first

• Not treat (therapeutic nihilism)
• Treat
• Treat if the patient wants treatment (patient
  centric)
• Treatment if guidelines and evidence warrant
  treatment
• Avoid treatment if uncertain (nonagenarians, PFO,
  renal stenosis, atherogenic dyslipidemia, vitamin
  D)
• What would you do if I were your mother?

28
Studies question P4P (part 1)

• Programs that reward doctors and hospitals for
  hitting certain quality targets are being rolled
  out in Massachusetts and across the country. A
  major focus is that doctors should be paid for
  keeping patients healthy rather than for the
  volume of tests or treatments they order.
• A review of seven studies of primary-care
  programs that paid doctors extra for meeting
  certain targets, published by the Cochrane
  Collaboration in September, was inconclusive
  about the effect on quality of care.
  "Implementation should proceed with caution," the
  authors wrote.
• Published in March (NEJM) a large Medicare pilot
  program that paid providers more if they met
  certain process targetsand docked those who did
  poorlydid not reduce short-term patient
  mortality rates. A version of the program is
  being rolled out nationally. The authors of the
  paper called the results "sobering."

Studies question medical rewards. Boston.com
29
Studies question P4P (part 2)

• In BMJ editorial 8/14/2012
• Explains why they think paying doctors more based
  on quality metrics is inherently problematic
• Hospitals and doctors can easily change their
  reporting practices to improve their quality
  scores
• Financial incentives can undermine doctors'
  intrinsic desire to help their patients. The idea
  that people will be motivated to do better if
  they are paid more as a result may seem like
  common sense, but medicine is complex. Often the
  measures used to determine success do not match
  the conditions of care or patient outcomes the
  program is meant to address
• Other fields have struggled with
  pay-for-performance programs. Under national
  education policy, schools that score poorly on
  standardized tests receive less funding. "They're
  the ones who need it most," he said. "Is the
  right reaction to poor quality that those
  institutions need fewer resources, not more?"

Studies question medical rewards. Boston.com
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Conclusions

• Burnout is real and has both qualitative and
  quantitative risks for healthcare delivery and
  our profession
• My take Physicians are dealing with a time of
  transitionlike it or not we are becoming more
  like tradespersons than professionals with a
  calling
• The systemic changes that contributed to this had
  noble intent(eg, physician work-hour limitation)
  but have diminished physician autonomy to such an
  extent that following the rules and feeling
  "excessively scrutinized" and avoiding criticism
  is becoming the chief professional motivation
• Aspiring to conduct oneself in a profession as a
  career with a calling is a noble intent and may
  have benefits for both patients and physicians