Healthcare reform has led to an alarming prevalence of physician burnout in the United States. The increased workload, productivity demands, reduced autonomy, and overburdening administrative tasks for physicians have led to feelings of emotional exhaustion, depersonalization, reduced personal achievement, and decreased effectiveness. As a result, there are higher rates of job dissatisfaction, cynicism/apathy, absenteeism, depression, suicide, and substance abuse. A recent Mayo Clinic study revealed that 54.4% of physicians, spanning all specialties, reported burnout in 2014, compared with 45.5% in 2011.
Source: AthenaHealth (https://insight.athenahealth.com/technologys-role-fixing-physician-burnout)
Physician burnout has negative impacts on the healthcare system. It leads to reduced quality of care, poor patient satisfaction ratings, increased medical errors, decreased patient safety, decreased productivity, and increased healthcare costs. This decline profoundly impacts the doctor-patient relationship.
Since demand for physicians is outpacing supply, AMA estimates a shortage of up to 90,000 physicians by 2025. The viability of the healthcare system is at stake when physicians retire early, reduce clinical work, or leave the profession, thereby further reducing the workforce. The cost to replace a physician leaving clinical practice is up to $1 million, depending on specialty.
In pursuing improved population health, enhanced patient care experiences and reduced costs, institutions neglected the front-line people who bear these burdens. Despite being crucial to the health care industry, physicians are the forgotten patients. Physician burnout is becoming a public health crisis. Given the scope of the problem, national, state, and local healthcare organization leaders must focus on addressing this problem now, before it’s too late. Physician burnout equates to physician abuse. It is imperative that the healthcare industry culture change to value physician well-being over profits. To achieve high quality and affordable health care, a symbiotic relationship must exist between those who provide and those who seek care. Everyone must help to stop this impending train wreck from becoming a national health crisis.
Social, Cultural & Behavioral Issues in PHC & Global Health 
August 21, 2017 at 5:57 am |
I agree that the push to achieve the IHI triple Aim is resulting in higher rates of physician burnout. I work with multiple primary care and outpatient specialty clinics, and have experienced many tired, overworked physicians who flat-out refused to “hit another button on a screen to make a report.” More administrative and clinical support is crucial. In the grants that I work with, there is often incentives for clinical support to hire additional nurses and social workers; but the funding does not exist for skilled administrative assistance or new/updated technology. When there are so many reporting requirements (which are not streamlined in and of themselves, so that there are different reporting requirements for different credentialing organizations and funding sources), a clinic needs nearly a specialist in that type of work itself. Add to that the current norm of fee-for-service, and you end up having physicians who are stacking patients through their lunch breaks and are working 6-8 hours per day after the doors close to finish documentation. It is not uncommon to see SOAP notes completed in the early hours of the morning. This is absolutely a problem that is not being talked about enough. Thank you for your post.
August 21, 2017 at 9:53 am |
Thank you for this extremely accurate post as supporting with data.
Seasoned physicians have practiced through “healthcare change and reform” that has been significantly less then optimal. Business and politics have worked their way to the top the healthcare field, beginning with the advent of Medicare. It is no longer controlled by the hard working physicians and nurses who are the backbone of the healthcare industry.
Medicare was initially signed into law by President Johnson in 1965, insuring retired individuals had access to healthcare. Many retired patients had no access to preventive healthcare prior to that date. Regular physician preventive visits were not affordable on a retired persons salary. Many physicians opted to join Medicare in support of retired persons, usually those over 65 years of age living on a limited income. It did not take long for Medicare to sign all the physicians and begin changing the rules in favor of dropping the reimbursement rates to physicians and hospitals over the next 20 years.
Oxford Insurance was the first managed care company started in 1985. It was modeled after the Medicare business plan by a creative pharmacist. It did not take long for more and more physicians to “sign up” to be part of this new trend in “insurance and reimbursement” promising increased patient visits. Most managed care organizations followed with similar business plans; convince all the physicians and hospitals to sign up and join, then gradually decrease reimbursement to physician, hospitals and patients. Yes, patients gradually pay higher yearly premiums, pay more per visit in the form of increased co-payments and get less service as required to see a physician on the plan and have tests, medications and procedures pre-approved. This was the hidden 20 year business plan, similar to Medicare/CMS and always lurking in the background. The only descent salaries are paid to the business people who run hospitals and clinics and those who own and run managed care companies, insurance companies and new businesses geared to “fight” and “assist” physicians and hospitals to get timely and fair reimbursement. A fight that should be necessary and not exist.
While this is happening, the underpaid and overworked abused physicians and nurses remain holding the front line and working in the trenches. Unfortunately, unless reinforcements come we are bound to be overrun by smart business people (if it’s not already too late), burn out, retire early or seek other more rewarding work experiences that does not include patient care as mentioned in the blog.
Physicians need to take back the practice of medicine and not be influenced by the titles they were awarded, the hospital administration they work for, or the incentives paid to see more patients, order less tests, discharge patients sooner then necessary, or complete more courses, forms, and CME’s; all at increased cost to the physicians, resulting in less actual patient time and care.
August 21, 2017 at 11:01 am |
Thank you for the highlighting this important issue. I do agree that this is a growing problem and the result is not only on the physician themselves, but also a ripple effect on all their patients. It is estimated that in the US. approximately 400 physicians take their own lives annually (1). This is complex topic with many variables affecting it. I completely agree that the culture itself creates an added burden on physical wellbeing. One cannot discuss physcian burnout without mentioning resident physician health effects. Even after duty hour changes in 2011, high rates or burnout still remain (2).
One important intervention would be to alter the training in a way to nurture resilience (3). Teaching healthy coping skills and approaches to the stress and suffering that is encountered may be beneficial. Equipping front line workers more generally may be beneficial to address part of the issue of burn out.
I do think that local and national policies governing physician work load also needs to be addressed. A structure that it currently in place priorities productivity over wellbeing. However, ultimately there is little consensus on how to approach this topic, and an evidence based approach is needed to identify the appropriate course of action (4).
References:
1. Andrew LB, Brenner BE. Physician suicide. Medscape Drugs & Diseases. 2015.
2. Oakley SH, Estanol MV, Westermann LB, Crisp CC, Kleeman SD, Pauls RN. Resident burnout after the 2011 accreditation council for graduate medical education duty-hour restrictions: a cross-sectional survey study. Obstetrics & Gynecology. 2014 May 1;123:117S-8S.
3. Goldhagen BE, Kingsolver K, Stinnett SS, Rosdahl JA. Stress and burnout in residents: impact of mindfulness-based resilience training. Advances in medical education and practice. 2015;6:525.
4. Dyrbye LN, Trockel M, Frank E, Olson K, Linzer M, Lemaire J, Swensen S, Shanafelt T, Sinsky CA. Development of a Research Agenda to Identify Evidence-Based Strategies to Improve Physician Wellness and Reduce BurnoutIdentifying Strategies to Improve Physician Wellness and Reduce Burnout. Annals of Internal Medicine. 2017 May 16;166(10):743-4.
August 21, 2017 at 1:36 pm |
Thank you for your post. The problem is well outlined here.
It is important to realize that solutions that address physician burnout can be directed at individuals or systems. Systems-based interventions include duty hour changes, instituting policies that mandate that food be available 24 hours per day in hospitals, and providing counselling to residency programs. Individual-based interventions include resiliency training (as mentioned by emergdoc), and mindfulness training. Two recent meta-analysis demonstrated that systems-based interventions that address physician burnout are likely to be most effective.
Advocating for evidence-based, systems-level changes to medical training and the medical profession are crucial to reducing burnout.
References:
Panagioti M, Panagopoulou E, Bower P et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Internal Medicine 2-17’177(2):195-205.
West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 2016;388:2272-81.
August 21, 2017 at 10:36 pm |
Great post and thoughtful responses. The factors which contribute to physician burnout require a multifaceted approach. Resilience needs to be developed in residents, but I’d emphasize the need to go even further upstream and develop resilience in medical school. Medical schools are slowly starting to transform in general to catch up with the needs of today’s patients and tomorrow’s healthcare system (still a lot of work to do), but that is an important first step towards building more resilience into physicians.
Another opportunity is exploring practice/setting workflow and division of labor. We have existed in a largely physician-centric healthcare system for the past several decades (centuries?). However, are practices configured to maximize the skills of docs, Nurse Practitioners, Physician Assistants, Medical Assistants, secretaries? As much as possible, the administrative burden should be shared where practical to enable all providers to function at the “top of their license”. Though not universally available, there are several resources available through CMS/HRSA/AHRQ for technical assistance in primary care and specialist practice transformation. Once specific CMS pilot is the Comprehensive Primary Care Plus (CPC+) program, and other similar initiatives with different combinations of front end investments, enhanced per member per month payments, and modified fee-for-service schedules to support investments in human and technical resources needed to enhance primary care practice infrastructure. Not by any means a once-size-fits-all solution, but it’s another opportunity to support practice transformation.
I’ll end by saying that I am fully in support of doing all it takes to improve provider retention and improving provider well being. My organization is reevaluating how we support increased access to primary care in addition loan repayment/forgiveness incentives and improving the utility (and reducing the burden) of health information technology. My suggestion has been that if there is a hole in the bottom of a sack of marbles, it doesn’t matter how many you add to the sack, you will always need more marbles. We must fix the hole which we have some influence over – provider burnout – otherwise we will never be able to meet the looming or current (depending where you are) physician shortage. Thanks again for your post.
August 22, 2017 at 2:30 pm |
Physician burn out is a very real phenomenon that I see everyday in my colleagues. It is driven by a number of factors. Most physicians go into medicine in order to treat patients and help people. As the percentage of time treating patients is chipped away from and replaced with administrative tasks, physicians will increasingly become unhappy and burned out. Furthermore, as additional metrics of physician evaluation are created and emphasized, physicians are likely to experience additional stress, and, in my opinion, for unnecessary reasons. The biggest offender in this regard is the trend towards emphasizing patient satisfaction scores and the infamous Press Ganey scores. While I think it is completely reasonable for physicians to be judged on their patient outcomes, how frequently they meet or deviate from expected standards of care, and how cost-effective their practices are, relying on patient satisfaction scores as the primary means of evaluation is a disservice. Physicians always strive to develop rapport with patients and to have a meaningful interaction. Some physicians are certainly better at this than others, but many times patient satisfaction is out of the control of the physician and has nothing to do with the actual interaction. At other times, patient satisfaction is fundamentally opposed to good medical practice. Take for example a patient who comes in with chronic pain looking for a surgical cure when there is no structural cause for the pain that can identified and that would be amenable to surgery. If a surgeon recommends against surgery, many patients are unhappy and dissatisfied. If a surgeon bows to the desire to improve patient satisfaction scores and offers surgery, then the patient is placed at undue risk by an unnecessary and ineffectual surgery and health care resources are utilized inappropriately. These are the considerations on the minds of physicians every day. I think, for the most part with the best of intentions, physicians have traditionally been more interested in taking care of patients than in the business of medicine or the administrative side of medicine. Due to this though, physicians have not done a good job of advocating for ourselves and have not been appropriately involved in decision-making regarding the design of health care systems. While it would add one more role to an already overburdened group of physicians, I think it is important that physicians take an interest in the practice of medicine outside of patient care, get involved in the administrative details, and band together to advocate for ourselves, ultimately to the benefit of our patients.
August 23, 2017 at 1:52 am |
Excellent post and thoughts regarding a critically important topic! I hate being somewhat late to this discussion; however, I agree with many of the thoughtful comments by our colleagues above.
I read the Mayo study highlighted in your post with great interest, particularly the section addressing “asymmetrical rewards.” Although this issue has yet to be addressed directly by commenters, I think that this asymmetry underpins the other factors mentioned above and most areas contributing to physician burnout – especially with increasing administrative requirements, ongoing systemic change, business/insurance dominance of the industry, and patient-satisfaction issues. We ask physicians to do more work with fewer resources and less time; to reap fewer financial, professional, and personal benefits; to lose autonomy and control of decision-making, even as the subject-matter experts. What rational professional would be satisfied with such trends?
Really, I think that physician burnout has far less to do with individual/physician factors, including resiliency, and more to do with common sense. The asymmetry discussed relates to a simple cost-benefit analysis: Once the costs of practicing medicine exceed the benefits, perceived or real, physicians will leave the profession.
Also, the Mayo authors’ emphasis on negative medico-legal aspects is particularly salient, given the increasing availability of patient data, the assumption of significant personal risk by physicians, and expectations regarding posthoc litigation for medical errors, no matter how small. The personal risks now borne by physicians are simply too great. Moreover, our insistence on producing zero-defect physicians is unrealistic.
As you aptly describe, “physicians are the forgotten patients.” Until we can rebalance the asymmetrical rewards now common in this profession, I fear that the negative trend will continue and the competent clinician pool will continue to dwindle.
August 23, 2017 at 2:43 pm |
You have obviously hit upon an important topic as there are so many comments. Let me add my admiration for your data-driven blog and great graphics.
I have worked in a variety of practice models and sites across the US over the past 20+ years and I do believe that physician satisfaction has become somewhat of a holy grail. System changes have not only occurred on the practice side but also in medical education, as Larry points out above. We must examine the system to control the bleed and innovative solutions are necessary.
Meanwhile, although it may be putting a finger in the dam, approaching the individual physician to “fix” the burnout is an IMPORTANT temporizing measure. I counsel college students and medical students contemplating their career choices and I listen to their past experiences and what they are looking to achieve in medicine before I help THEM figure out possible paths. We need this type of counseling on a REGULAR basis for residents, fellows, early/mid/late career physicians and that is sorely lacking.
There are many avenues to pursue within medicine and for physicians to assume that their paths will be straight lines is foolhardy. Family lives,academic interests, social interests all evolve over 5-10-20 years and thus the MD should be questioning his or her path that often.Mentorship helps but what if your mentor is holding you back within the only field the mentor knows?
Let’s focus on the different behavioral levels and find solutions at all of these levels.
August 23, 2017 at 3:35 pm |
I was doing a little more digging to read up on the stats provided in your pie chart about physician suicide and I found it interesting that depression/suicide resulting from physician burnout, male physician trainees are more likely to die by suicide. Moreover, they are more likely to suffer from these mental health crises at a much higher rate than the general public. This information is according to a Johns Hopkins Medicine article written last summer.
http://www.hopkinsmedicine.org/news/publications/hopkins_medicine_magazine/features/spring-summer-2016/stuck-in-despair
On a different note, I work in an inpatient department at a major hospital as the supervisor. One of my duties to schedule physicians for service, they submit which days they want to work and I schedule them.
One of the actions that is not encourage is physician working day and nocturnal shifts back-to-back. The day shift is from 8am – 8pm and the nocturnal shift is from 7:30pm – 8am on the weekend. This would constitute as an entire 24hr shift with seemingly no time to detach from work and taking a “mental health break.”
There is a link between residents working long hours and barriers to seeking health services because of working long hours.
Causes of Death of Residents in ACGME-Accredited Programs 2000 Through 2014: Implications for the Learning Environment / DOI: 10.1097/ACM.0000000000001736
Although this “rule” is not enforced, especially when a shift needs to be covered last minute, we notice that more and more physicians are likely to take longer hiatuses from practice to focus on bettering themselves mentally.
August 24, 2017 at 2:01 am |
Thanks for your excellent post, and I couldn’t agree more with you that physician burnout is an emerging public health crisis. What is more worrying is that we might be dealing with a crisis of pandemic proportions as this burnout syndrome is wide-spread across healthcare systems in many countries. Having practiced in Ghana, Nigeria and in the UK, I can attest that a significant proportion of doctors have become disillusioned with the profession and many are seeking alternate career paths. Many factors contributing to this burnout are similar across board, but some additional factors are peculiar to individual healthcare systems especially in poorer countries with underfunded health systems.
A notably contributor to burnout in these underfunded health systems, is the lack of opportunity for career advancement. In Nigeria, many doctors cannot get into specialty training because the spaces available in teaching hospitals are woefully inadequate. Many are bored with routine of being “junior doctors” and dissatisfied with the stagnation in their career. This often leads to mass emigration of doctors to western countries in search of better training opportunities and prospects for career advancement. It is estimated that about 500-700 Nigerian doctors emigrate annually and over 15,000 doctors currently practice abroad. This figure is around 25% of the total number of doctors in the country (60,000), and current patient doctor ratios stand at about 1 to 4,250 patients.
Another cited reason for high levels of dissatisfaction among doctors is the loss of public confidence in their services and gross under-appreciation of their efforts. Many doctors work with full commitment and a passion despite the inauspicious conditions of service and poor remuneration. For many, their motivation is the smile on their patients faces and the simple words of appreciation from patients. However, in the face of numerous complains, negative reviews, lawsuits and in some countries physical assault and harassment, many doctors have lost their drive to serve the public. The frustration is heightened by the fact that they feel powerless to change the systems that has caused this loss of public faith in their services.
As you rightly noted, due attention must be paid to this ticking time-bomb by the WHO and the individual health ministries to solve this problem of physician becoming patients before it goes beyond limits of control.
August 24, 2017 at 9:54 pm |
Thank you for your post. Full disclosure, I oversee a large group of Primary Care Physician engaged in an MSSP contract, and my wife is a Primary Care Physician, so this topic is near and dear to me.
Although, I agree that the transition to value-based care from volume-based care is going to be rough, I do think that our health system is moving in the right direction. The reimbursement model and expectations just need to catch up to support these physicians in a team based approach to primary care.
An interesting twist accounting to these physicians on the brink of burn out is the push by insurance companies to use Urgent Care Facilities. Yes, this is a less cost alternative for the Emergency Room, but many patient also now use this for their acute symptoms. I often hear that physicians feel that they used to get “breaks” from their most chronically ill patients by caring for patients with acute symptoms throughout the day. Now however, since they are still fee-for-service, and there are less “easy” visits, they are seeing more complex patients, which is more draining. Restructuring Urgent Care so that they did not replace Primary Care could also benefit this cause.
August 25, 2017 at 12:10 am |
This is such a timely and important issue. We now live and operate in a world of documentation, regulation, performance (by what standards?) all while patient needs and physician job satisfaction are not really calculated into the equation. This has been a hot topic in residency training for several years, and for good reason. Studies have shown that burnt out residents believe they provide lower quality care. One thing I learned as a chief resident attempting to implement a resiliency program was that the system must change to address this problem. We can give residents (or any physicians) resiliency training, coping strategies, mental health resources, but we can’t give them time, time for themselves and time to spend with patients – that has been consumed by endless documentation, patient advocacy battles (for prior authorizations, for example), and ever increasing numbers of visits, admissions, consults, and complexities of patient care. Moving to a more sustainable model for life balance is the only way to definitively solve this problem and improve quality of life, for both physicians and their patients.
https://www.ncbi.nlm.nih.gov/pubmed/11874308
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4162717/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4703144/
https://www.ncbi.nlm.nih.gov/pubmed/27238875