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Wednesday, March 23, 2016

Clinician Burnout

"Burnout." a recurrent topic in recent years, and, while it's by no means confined to the health care sector, it certainly can have particularly acutely adverse consequences there.

THCB recently posted an interesting long read, "The Antidote to Physician Burnout: A Nine Step Program" by Martin Samuels, MD.
I have some strategies for preventing “physician burnout.” I am a little over 70 years old and am not experiencing any of the symptoms of “physician burnout.” I do not state this out of any sense of pride, but I have tried to be introspective about this so as to offer some advice as to how to avoid this problem...
Job burnout is not a new idea, and it is not specific to medicine.  It has been in the psychology/psychiatry literature for quite a long time. It may be defined as a feeling of emotional exhaustion characterized by cynicism, depersonalization and perceived ineffectiveness.

In recent years, many have argued that “burnout” is extremely prevalent; not only in society as a whole but in particular in medicine. It has been said that 50% of physicians have at least one of the three cardinal features:  exhaustion, depersonalization and inefficacy...

What are the alleged causes of “burnout?” There are many, of course, but there are five major categories. The first is what is termed “overwhelming demands and work overload” often associated with sleep deprivation and a need to be “superhuman,” by which is meant the intolerance of any errors and the enormous fear that errors will cause harm to patients and /or risk of malpractice litigation. Some physicians believe this is a “zero tolerance game”.

The second alleged cause of “burnout” is what many call social conflicts, conflicting values and a breakdown of the community. In this category falls the so-called work-life balance. That is, what proportion of one’s life can one spend in work, including thinking about work, versus other endeavors, such as family, athletics, artistic pursuits, hobbies, vacation, reading and others. The third of the causes of “burnout” is the lack, or perceived lack, or loss of various resources. In the context of medicine, this might be inadequate information systems, physicians’ assistants, nurses, secretarial help and scheduling systems. The fourth cause is insufficient rewards. These can be divided into two categories:  monetary and nonmonetary rewards. In the latter category might be a sense of feeling respected and of doing something that is meaningful. The last of the five major causes of “burnout” is what many have termed “lack of fairness.” This issue of fairness affects not just medicine, but is pervasive all over the world in many different contexts. In fact, it is really a zeitgeist, or a spirit of the times. Many groups, defined by multiple criteria, feel marginalized. This could be a religious group, a racial group, a gender orientation, and so on...

In summary, the five major causes of “burnout” are: overwhelming demands, social conflicts, lack or loss of resources, insufficient rewards, and absence of fairness...
"Overwhelming demands" goes to the "productivity treadmill," no? "Social conflicts"? How about a lack of "Just Culture" organizational dynamics? "Lack or loss of resources"? Implications of poor HIT "usability" there? "Insufficient rewards, and absence of fairness"? Well, just compare the typical physician and nurse salaries to the comp packages of hospital administrators, Big Rx and AHIP execs, and a raft of Health IT 501(c)(6) "non-profit" leadership.

Then there're the eager hordes of us tiresome, meddling "process QI" and "patient satisfaction" people. From a link in one of the comments under the Samuels post:
"I don't know if any other physicians have had to suffer through a business consultant-based inservice on how to improve "customer satisfaction scores". There are discussions on how to introduce yourself to the "customer". There are the usual business based mnemonics. Physicians may actually have to demonstrate that they know how to introduce themselves to "customers"! Think about that for a second, especially if you are a psychiatrist who was trained for years in how to interact with patients rather than customers. If you are a psychiatrist who passed the oral boards, you know that failing to make the appropriate introduction led to an immediate failure on that exam. Now flash forward to the bizarre world where patients are "customers" and now there is a formula designed by business people who know relatively nothing about interacting with patients in a therapeutic manner. You are expected to demonstrate competency in this shallow business paradigm that is setup to optimize results on customer satisfaction surveys. This is a great example of how physicians are stressed on a regular basis in health care organizations and their time is wasted. It is also a great example of how public relations, rather than the latest medical knowledge is the dominant performance metric for healthcare organizations. If there is a recipe for burnout - this is it." - George Dawson, MD, DFAPA
I return to a book I cited some time back:

I love being a physician. I love it for many reasons, but the main one is because of what I am able to do for people like Antonio. And the incredible thing about being a doctor is that every one of the almost one million physicians in the United States has a similar story— not a cleft lip necessarily but a story in which the physician changed someone’s life in a magnificent way. Countless specialists and primary care physicians alike have stories in which they literally saved a life— reached in and rescued the patient from the edge of the precipice. Or they saved many lives— of children, expectant mothers, and aging grandparents. The joy and satisfaction in those moments for physicians is unlike any other experience. 

To reach the point where we can do these things requires years and years of hard work, including the rigor of a heavy science load in college followed by the unrelenting demands of medical school. Academic work combined with clinical training builds the skills that gradually transform the student into a clinician who advances to residency training and fellowship, ranging from three to eight years. Only then comes the great reward: the ability to care for people who need you. 

This is the heart of the matter. Physicians love being doctors because we have the privilege of being able to calm fears and alleviate suffering— to change and save lives. This is what motivates doctors virtually every single day of their lives. When the structure and culture in which physicians work are well aligned, it is a most rewarding job. 

But something has gone wrong in the physician world, and it is urgent that we fix it. Fundamental flaws in our system make it more difficult and less rewarding than ever to be a doctor. A 2012 Physicians Foundation survey found that nearly eight in ten doctors were “somewhat pessimistic or very pessimistic about the future of the medical profession.” A report from Harris Interactive, a leading research firm, described the practice of medicine today as “a minefield” where physicians feel burned out and “under assault on all fronts.” Mayo Clinic physicians Liselotte N. Dyrbye and Tait D. Shanafelt wrote in a commentary in the Journal of the American Medical Association (JAMA) that 30– 40 percent of physicians in the United States are “experiencing burnout.” Dyrbye and Shanafelt note that physicians suffering from burnout “are more likely to report making recent medical errors, score lower on instruments measuring empathy, and plan to retire early and have higher job dissatisfaction, which has been associated with reduced patient satisfaction with medical care and patient adherence to treatment plans.” 

Never before have physicians been under so much pressure from so many sides. Many physicians feel inundated with administrative matters that prevent them from devoting their full talents to their patients’ well-being. Ask doctors about the atmosphere in which they practice, and you often hear words such as “chaos,” “conflict,” and “dysfunction.” How can a nation transform its health care system when so many physicians feel such deep pessimism about the future of their profession? 

The reality of our situation in the United States is clear. We cannot achieve high-quality, accessible, affordable health care for all unless we solve the doctor crisis. Unless physicians are provided with the team-based support they need to focus on patient care— and are not weighed down by work that other team members can do— progress will stall. And lest anyone read into our view that we are being overly physician-centric by focusing on the doctor crisis, we strongly believe that freeing doctors to concentrate on providing excellent care is, by definition, patient-centered. In fact, when the question “what do physicians want?” is asked, the answer is clear. Physicians want the team support to be able to give their patients the time, attention, and care they need. That is what drives the great majority of doctors in our nation, and while the crisis is most acute within primary care, it applies across the specialties as well. As Dr. Jay Crosson, vice president of Professional Satisfaction, Care Delivery, and Payment at the American Medical Association, observes, “Taking physician satisfaction seriously does not mean giving physicians anything they want, but it should mean creating an environment where physicians are always able to put patients first.” 

And that is the heart of the doctor crisis. Far too often, physicians are prevented from putting their patients first— ahead of administrative hassles, finances, insurance company demands, regulations, and more. These barriers nearly all make sense when one looks at them from a point of view other than the patient, but if we put the patient’s well-being ahead of every other consideration, then it is clear that these barriers must be breached. 

Why a book focused on doctors at a time when the language of health care reform is about being patient-centered? Because my coauthor Charles Kenney and I believe that one of the most patient-centered actions we can take is to fix the doctor crisis in our country. Solving this problem is a prerequisite to creating a health care system that is patient-centered, safe, equitable, accessible, and affordable— in other words, to achieving the health care system that we so urgently need in the United States...

Cochran, Jack; Kenney, Charles C. (2014-05-06). The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care. Public Affairs. Kindle Edition. Locations 137-190.
Necessarily takes us back to Nortin Hadler MD as well:

"Figuring out a way to monetize altruism"

Chapter Nine: Medical Professionalism in the Twenty-First Century 
It is one thing to champion a trustworthy patient-physician relationship that promotes informed medical decision making and proclaim the physician to be the wise facilitator in such a relationship. But it is quite another thing to extricate such a relationship from the current dialectic, which is heavily funded to promote a systems approach to patient care. I find it impossible to remain passive in the face of this dialectic. There is an old proverb in medical circles that internists know everything but do nothing, and surgeons know nothing yet do everything. I am an internist. But I am a loose-cannon internist. 

There is a desperate need to position the patient’s narrative as raison d’être and a desperate need to provide wise ears to hear it. The only way that will happen is to create an atmosphere that demands it, an administrative structure that supports it, and a reimbursement scheme based on fees for serving. Getting there is an uphill battle, somewhat Sisyphean given the powerful push-back from stakeholders in the status quo, but it is not insurmountable. The top of the hill is the moral high ground. Medical professionalism must plant its flag there because there is no other way to serve patients well in the twenty-first century...

Again, apropos of HIT,
"If there is a role for computers in decision making, it is to facilitate dialogue between patient and physician, not to supplant the input from either or to cut health-care costs."

It bears repeating for the umptieth time that clinicians typically have to traverse hundreds of variables in a compressed time interval during patient encounters. Anything that gets in the way of that is inimical to health outcomes and patient safety. In this regard, the importance of (and difficulties in) effective clinical UX design are difficult to overstate.

So, Google "physician burnout" (including quotation marks). Bring a Snickers, you're gonna be a while. ~184,000 results.

Q: To what extent does the apparently increasing "fragmentation" of the U.S. health care system contribute to clinician burnout? You might want to re-visit some Einer Elhuage, here, and here.

I should probably also again note the excellent Danielle Ofri book "What Doctors Feel."

Beyond the paperwork, medical care itself can seem like a never-ending time commitment. Medicine has always been a full-time occupation, even for part-timers. Patients do not confine their illnesses to business hours, so night and weekend work is part of the territory, especially for primary care doctors. Doctors understand that this is built into medicine, and it is part of the commitment for which they earn respect, as well as a salary higher than that of many other professions. 

Nevertheless, as our society ages and illnesses become more chronic and complex (most people in developed countries no longer die of simple infections), the time required for medical care is expanding, and this spillover is affecting more and more doctors’ personal lives. It can be hard for physicians to voice a complaint about this, because it is part of the professional commitment. Yet at some point, this spillover can eat away at marriages, time with children, sleep, and sanity. Even when doctors are doing the clinical medicine that they enjoy and find meaningful, when it erodes the rest of their lives, they become disillusioned. Many consider quitting. 

A group of researchers followed geriatricians— primary care doctors who take care of older patients— to see how much medicine crept into their personal lives. They found that nearly eight additional hours of medical care— patient care outside of office hours— was given each week, mostly in phone calls with patients and families. A similar study of internists showed that 20 percent of their total work was spent after hours. This is equivalent to almost a full additional day of work every week. 

It’s hard to imagine a lawyer or plumber providing eight extra hours of work each week for clients just because it’s the right thing to do. And of course, it is impossible to imagine lawyers or plumbers not billing— heavily!— for it. But that is the expectation of medicine. Again, for most doctors, this is an understood part of the deal, but as these extra hours increase, they have a distinct negative impact. Eight more hours of work comes directly from the rest of the doctor’s life— family time, sleep, exercise, recreation. (Based on the standard American work schedule, that’s ten full weeks each year.) Many doctors’ lives are suffering because of this. And yet when your beeper goes off, or the hospital calls, or the answering service wakes you, there’s no other option. You must attend to it. 

Because of the rigors and length of their training, many doctors start families later than other professionals. The “junior” swath of physicians— those in their thirties and forties— enter their prime career-building years at the very same time they are starting families. A generation or two ago, there was no work-life balance issue, since most doctors were men, and they usually had wives who were home with the children. Today, of course, nearly half of all doctors are women, 12 and almost none— men or women— have spouses handy to be home with the kids full-time. Additionally, most young male doctors recoil at the experiences of their predecessors; they don’t want to miss out on their children. 

The desire to have control over one’s working hours— and especially those after-hours hours— is behind the trend of medical students drifting away from primary care specialties (internal medicine, family medicine, pediatrics, gynecology). Increasingly, students choose to stay— as the jargon has it— on the ROAD: radiology, ophthalmology, anesthesiology, and dermatology. This trend is far more alarming than the fears raised by the health-care reform bill. Doctors here are voting with their feet and moving away decisively from primary care. A survey of more than seven thousand physicians showed the highest burnout rates in front-line fields— internal medicine, family medicine, and emergency medicine. It also noted that doctors as a group demonstrate more burnout symptoms than workers in other fields. 14 Many patients— and many doctors— are asking themselves, Who will be my doctor when I need one?

Ofri, Danielle (2013-06-04). What Doctors Feel: How Emotions Affect the Practice of Medicine (pp. 156-158). Beacon Press. Kindle Edition.

Dr. Samuels' concluding observations:
Nine Step Program to Combating Physician Burnout

Be a Professional
1. Work and learn in a truly resource limited environment but don’t be condescending
2. Empathize with your patients but don’t expect empathy for you in return
3. Spend less energy on “mindfulness” and more time on developing a theory of the mind; work is life and life is work
4. Appreciate irony and cultivate a sense of humor; don’t take yourself too seriously
5. Collect one’s own mistakes and share them but don’t expect them to stop happening
6. Study history; you aren’t that special
7. Stop feeling sorry for yourself. Realize how lucky you are to be a doctor. Others wanted to be there.
8. Find a mentor and be a mentor; you are bridge from the past to the future
9. Be realistic; no one can do everything well and stuff (sh__) will happen

Martin Samuels is the Chairman of Neurology at Brigham and Women’s Hospital in Boston and a regular contributor for THCB.
See what you think. There will be pushback. Read the entire piece. One physician commenter said "I got burnout trying to get through this long article."



From my April 2015 post "Nurses and doctors in the trenches."
"... my elevator speech:
Their hard-won, sophisticated, indispensable clinical skills aside, nurses and physicians are just people like the rest of us, people more or less beset by all of the frailties, foibles, insecurities, and neuroses that typically dog us all across the breadth of our lives. The fractious, high-stakes, irreducibly high cognitive burden organizational environments within which they must function are neither of their design nor under their control, and can (and unhappily do) exacerbate interpersonal difficulties that are counterproductive to optimal patient care. I call the syndrome "psychosocial toxicity," and have blogged about it at some length in prior posts.

It's hardly confined to healthcare, to be sure, but organizational cultural dysfunction in healthcare is ultimately a patient safety issue. To the extent that we continue to view clinical co-workers through "transactional/instrumental," "superior/subordinate" lenses, our improvement efforts will be significantly hampered.

Thinking about nursing school or med school? Read both of these books ASAP. Thinking about healthcare QI, healthcare policy more broadly? Read both of these books ASAP. Thinking that you may become an acute care patient? Read both of these books ASAP.
I read everything I can relating to clinical pedagogy and process imperatives in order to better inform my views on digital health IT (the nominal topic that started this blog nearly five years ago) and healthcare process improvement. apropos, as I asserted last June:
In the face of a dysfunctional healthcare work culture, the best talent will take their skills elsewhere at the first opportunity. A psychosocially healthy workplace, then, is a significant profitability and sustainability differentiator.
A lot to think about today. Beyond citing illustrative excerpts from these books, we'll have to be going back "Down in the Weeds'," and thinking more about "The Art of Medicine." And, ruminating a bit more on the clinical process implications of Marx's "Just Culture."


Staying with the opening matches meme above,

And, this is funny:


On twitter I asked "Clinician burnout. Is #HealthIT partially to blame?"

Dr. Carter responded forthwith:

See his post "EHR Malpractice—Coming to a Location Near You?"

More to come...

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