LMS President’s Message, April 2018

LMS President’s Message,
April 2018
by Tuyen T. Tran, MD, MBA

Physician burnout is increasing faster than any other profession in the U.S. Compared with the general U.S. population, physicians experience a much higher rate of burnout (54.4% vs 28.4%)1 and the risk of suicide is 1.4 and 2.3 times higher for male and female physicians, respectively.2 The fact that burnout has increased across all medical specialties, while the general population remained stable, suggests that this is a workplace issue. Anything that interferes with patient care, whether it is systemic or environmental, should be the focus of change. Physician burnout provides an early indication, a warning sign, of our dysfunctional healthcare system’s impending failure. With physician burnout at 54%, decision-makers need to change course and offer solutions now to avoid a healthcare catastrophe.

Surprisingly, there is very little research to assess the effectiveness of interventions aimed at resolving this problem. We need to seek effective strategies to promote physician well-being. We need studies looking at physicians’ well-being, or burnout, and its correlation with healthcare outcomes. We need to estimate the economic costs of physician burnout. We need policy makers to develop a comprehensive framework for intervention directed at how to evaluate and improve the physicians’ work environment, promote physicians’ well-being, and support those who are already experiencing distress.

Throughout physicians’ education and training, the emphasis was caring for others, especially their patients. However, they were never taught or trained to care for themselves. They will work beyond exhaustion to provide quality care for their patients. But the tipping point occurs when emotional strain is added to the physical exhaustion. This happens when physicians feel helpless or trapped by demands to see a certain number of patients, mandates requiring documentation which may have little relevance to the patient encounter, ever-changing rules and regulations established by insurers regarding what labs to order and what medications to prescribe, and numerous clerical tasks that take them further away from direct patient care. This creates a sense of depersonalization which can often lead to cynicism and a dehumanized attitude toward patients. Fortunately, there are groups like the Lexington Medical Society which will assist distressed physicians through the Physician Wellness Program. LMS wants to intervene before the physician fails.

The motivation for many physicians to practice medicine is a calling to help people. At a societal level, the public benefits from having a group of people who will work to benefit others. This public trust in the medical profession is dependent upon the confidence that physicians will have the patients’ best interest at heart. If physicians stop viewing medicine as a calling but instead see their work as a means to earn a living, a very concerning consequence of physician burnout is that physicians’ motivation to work may change from a calling to help others to a way to earn a living. This erosion of professional identity may result in loss of personal satisfaction in serving a greater good, which will negatively impact their performance, and most importantly, the quality of care patients receive will suffer. Encouraging better performance through financial incentives will exacerbate the problem further by undermining physicians’ professional sense of autonomy and competence. There is growing evidence suggesting that physician burnout is associated with lower patient satisfaction, increased medical errors, poorer patient outcomes, and higher costs to deliver healthcare. (Figure 1) Thus, decision-makers, practice leaders, insurance payers, and policymakers should examine the current workplace environment, identify opportunities to promote physician well-being and implement performance-based incentives which support physicians’ sense of calling. Perhaps, the Institute for Health Improvement (IHI) should augment its IHI Triple Aim framework to improve healthcare delivery (1 – improve patient experience of care, 2 – improve health of the population, and 3 – reduce per capita cost of healthcare delivery) with promotion of physician well-being.

Figure 1

Medscape has been publishing survey results of physician burnout by subspecialties for several years. Physicians from multiple subspecialties were asked to grade the severity of their burnout on a scale from one to seven. They were also asked to list the contributing factors to their burnout. Troy Parks, Staff Writer for AMA Wire, compiled a tremendous graph showing physician burnout trends by subspecialty from 2013-2017. (Figure 2) The physician burnout rate continues to rise! But not surprising are the top issues which the physicians reported as major contributing factors to the burnout. The top four issues were regulatory, systemic, and practice environment – too many bureaucratic tasks, spending too many hours at work, feeling like just a cog in a wheel, and increased computerization of practice. A recent time-motion study looking at the allocation of physicians’ time revealed that for every hour of direct clinical face to face time, physicians spend nearly two additional hours on the Electronic Health Record (EHR). And, after leaving the office, physicians often spent an additional 1-2 hours of personal time completing additional computer and clerical work.3

Figure 2

Tait Shanafelt, hematologist and physician-burnout researcher at Mayo Clinic, in a presentation at a NEJM Catalyst event in June 2017 stated, “Today’s medical practice environment is destroying the altruism and commitment of our physicians…We need to stop blaming individuals and treat physician burnout as a system issue.”4 Because physicians play such an integral role in the healthcare system, any detrimental effects will certainly impact the physicians who are experiencing the burnout; but, more importantly, the patients and the entire healthcare system. Comparable in magnitude to the Institute of Medicine’s To Err is Human initial report, the IOM needs to report on physicians’ burnout in relation to building a safer health system.

References

1. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613.
2. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004;161(12):2295-2302.
3. Sinsky C, Colligan L, Li L, Prgomet M, Reynolds S, Goeders L, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Inter Med. 2016;165:753-760.
4. Sinsky C, Dyrbye L, West C, Satele D, Tutty M, Shanafelt T. Professional satisfaction and career plans of US physicians. Mayo Clin Proc. 2017;92(11):1625-1635.
5. https://catalyst.nejm.org/physician-burnout-endemic-healthcare-respond/