Transcript Physician burnout

Physician burnout
Monday, April 13, 2015
Seth D Bilazarian, MD
[email protected]
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; DOI:10.1001/archinternmed.2012.3199.
Defining burnout
• What is it?
• Should we care?
– As individuals?
– As a profession?
– As a society?
• Why is it happening?
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; DOI:10.1001/archinternmed.2012.3199.
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
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
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
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
Changes in the law
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ACA or Obamacare
Romneycare
Physicians' reaction to it
Physicians being blamed for the inefficiencies
and inadequacies of the healthcare system
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 innovation—drugs and
devices
• Clumsy
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
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 primarycare 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
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/prsc0910.htm
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/2012/08/13/120813fa_fact_gawande
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 there—especially if it's run by the government."
Cheesecake Factory Medicine. Wall Street Journal
Big medicine–Cheesecake 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
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
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
• Hospital—appropriate-use criteria, malpractice,
public reporting
• Daily practice hospital computer systems—not
ready for prime time order preop antibiotic, nine
signatures prior to cath
• Post hoc scrutiny
Is life is easier?
• Night float, hospitalists, nocturnists
Exclusive: Nocturnists on hand for the critical hours. news-press.com
Relevant articles in the Atlantic
• The Physician Burnout Epidemic: What it
means for patients and reform
• The Root of Physician Burnout
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?
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
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 burnedout 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.
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 affirmation—less 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?
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 Medicine=HCA (family farm=ADM)
• Geographic variability (Dartmouth Atlas) and
recent reports of grotesque fraudulent care (HCA
in NY Times)
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"
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?
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 targets—
and docked those who did poorly—did 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
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
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 transition—like
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