By RONALD DIXON
Week after week, I hear from colleagues in diverse specialties about how exhausted they are from practicing medicine.
It’s no surprise that they are looking for careers outside of medicine. The demands and strain are unsustainable.
So it’s also no surprise that a recent survey showed 40% of primary care clinicians are worried that their field won’t exist in five years and that 21% expect to leave primary care in three years as a result of COVID-19-related burnout.
While COVID-19 is the tipping point, this burnout is the result of the relentless and mounting administrative burden placed on us by electronic medical records (EMRs), coding and billing requirements and prior authorizations. And then it is exacerbated by uncertainty mounting in the primary care field, with new medical care entrants popping up everywhere — from retail pharmacies to digital health startups — aiming to create their own primary care model, replacing rather than working with existing ones.
Where it All Began
The roots of this burden began three decades ago with the advent of an acronym that few outside of the healthcare world know of today — the resource-based relative value scale (RBRVS). This payment system, launched in 1989 and subsequently adopted by Medicare in 1992, led to what we know now as the foundation of the U.S. healthcare payment system.
The RBRVS system assigns procedures a relative value which is adjusted by geographic region. Prices are based on physician work (54%), practice expense (41%) and malpractice expense (5%).
Since the initiation of the scale, the relative value of specialist work has remained much higher than primary care. This disparate compensation, in combination with most health maintenance and patient supportive tasks delegated to primary care, has led to significant fatigue.
By GREG HAMMER, MD
Burnout among healthcare professionals is at an all-time
high. Its drivers include longer work hours, the push to see more patients,
more scrutiny by administrators, and loss of control over our practice. We seem
to spend more time with the electronic medical record and less time
face-to-face with our patients.
I have faced burnout personally. My son passed away at the
age of 29, which was beyond painful. At the same time, I felt burdened by the
growing number and complexity of metrics by which I was judged at work. Days in
the operating room and intensive care unit seemed more and more exhausting, and
my patience was becoming shorter and shorter. I was fortunate to have had a long-standing
meditation practice as well as sabbatical time that I used to decompress and
re-evaluate my career. Many of us are not so lucky. More than half of
physicians have serious signs of burnout, and more than one physician commits
suicide every day.
So many of us feel burned out these days because in our
rapidly changing profession we are asked to do more for less and with
inadequate resources. We suffer from exhaustion, self-criticism, and worry
about what will happen next to our practice, our families, and ourselves. If we
want to save our practices, patients, marriages- even our lives, we must
acquire personal resilience.
Fortunately, we can increase our resilience and happiness and reverse burnout by embracing a few simple principles—Gratitude, Acceptance, Intention, and Nonjudgment (GAIN)—that we can put into motion in our everyday lives at the hospital, at home, or wherever we are.
By SANJ KATYAL, MD
If you are like most doctors, you are sick of hearing about burnout. I know I am. There is a big debate on whether burnout is real or whether physicians are suffering from something more sinister like moral injury or human rights violations. That doesn’t matter. In the end, no matter what name we give the problem, the real issue is that physicians are in fact suffering. We are suffering a lot. Some of us—around one physician per day—are forced to alleviate their suffering by taking their own life. Each year, a million patients lose their physicians to suicide. Many more physicians suffer in silence and self-medicate with drugs or alcohol in order to function.
We are losing more physicians each year to early retirement or alternate careers. There are an increasing number of coaches and businesses whose single purpose is to help doctors find their side gigs and transition out of medicine. This loss comes at a time of an already depleted workforce that will contribute to massive physician shortages in the future. Perhaps even more troubling is that those physicians who remain in medicine are often desperate to get out. It is the rare physician these days that recommends a career in medicine to their own children. We now have a brain drain of the brightest students who would rather work on Wall Street than in a hospital.
As a physician trained in positive psychology, I have been committed to helping other physicians and students improve their well-being. The focus on well-being is a welcome change in medicine. But is it enough?
By HANS DUVEFELT, MD
I looked at a free book chapter from Harvard Businesses Review today and saw a striking graph illustrating what we’re up against in primary care today and I remembered a post I wrote eight years ago about burnout skills.
Some things we do, some challenges we overcome, energize us or even feed our souls because of how they resonate with our true selves. Think of mastering something like a challenging hobby. We feel how each success or step forward gives us more energy.
Other things we do are more like rescuing a situation that was starting to fall apart and making a heroic effort to set things right. That might feed our ego, but not really our soul, and it can exhaust us if we do this more than once in a very great while.
In medicine these days, we seem to do more rescuing difficult situations than mastering an art that inspires and rewards us: The very skills that make us good at our jobs can be the ones that make us burn out.
Doctors are so good at solving problems and handling emergencies that we often fall into a trap of doing more and more of that just because we are able to, even though it’s not always the right thing to do – even though it costs us energy and consumes a little bit of life force every time we do it. And it’s not always the case that we are asked to do this. We are pretty good at putting ourselves in such situations because of what we call our work ethic.
By GUS MALEZIS
It’s no secret that healthcare providers are among the
hardest working of all professionals – their skill and intelligence are matched
only by their creativity and commitment to their patients. But the healthcare
IT sector, while it has made an effort to assist, has failed to support our
providers – doctors, nurses and caregivers – with technology solutions that
meet the increasing demands for better, faster, more efficient patient healthcare
delivery. Instead, we have cast these providers in the dark, forcing them to
function blindly, devoid of necessary information, pushing many of them to the
brink of what they can withstand as professionals, pushing them to burnout.
The thing about providers is that, in addition to being
hardworking, dedicated, and outstanding professionals, they are incredibly
creative and innovative, willing to embrace new technologies and workflows – as
long as they can add value to their patients. So how about we – the broader healthcare
IT solutions vendor community – focus on delivering technologies that don’t
force them to compromise care and efficiency for the sake of security, or
compliance and access to data?
We need to do so to address an industry crisis. Physician
burnout is on the rise, and it’s increasingly clear that overworked providers have
reached the breaking point. They spend valuable minutes battling technology on
virtual desktops, mobile devices, biomedical equipment, and clinical SaaS
applications – typing in usernames and passwords, loading various apps, and
more. All the while, standing beside a patient that is desperately seeking
Right now, nearly one-half of all physicians (44 percent) report
having feelings of burnout (according to Medscape‘s 2019 National
Physicians Burnout & Depression Report). While these numbers should
alarm everyone, what the healthcare IT industry should be especially concerned
about is that a leading cause of this physician burnout are tools that hinder provider
productivity. Instead of simplifying work for doctors and nurses, technology
tools are having the opposite effect. Isn’t technology supposed to make things
By TALAL HILAL, MD
A survey of 200 physicians under the age of 35 showed that 56% reported unhappiness with the current state of medicine. That number didn’t seem surprising to me at first. I was not particularly “happy” at the time of reading this survey either.
I’ve aspired to become an
oncologist for as long as I can remember. In oncology, despite my inability to
cure, I can always try to heal. I form connections with patients and their
families as they embark on a journey that is quite often their last. I learn
from my patients as much as, and at times more than, they learn from me.
But all of this is overshadowed by
a sense of heaviness that I frequently encounter as I enter the clinic room. That
sense of heaviness hits when a patient tells me of the time when they were placed
on a “brief hold” for more than half an hour in order to reach someone to get a
prescription refilled or reschedule an appointment. Or when their insurance refused
to cover the drug that I had prescribed to them. It is when I hear that clinic
visits or treatments are not scheduled due to insurance authorization delays. Or
when I’m asked about the cost of drugs and end up having to explain how nobody
By the time I hear these stories,
the “allotted time” for the clinic visit is coming to an end. The emotional
burden and physical symptoms of my patient’s cancer diagnosis or chemotherapy
side effects often not adequately addressed.
By PETER YELLOWLEES MD
Telepsychiatry is now an established form of mental health care. Many studies demonstrate that it meets all appropriate standards of psychiatric care and may be better than in-person consultations for certain groups of patients, such as children, adults with PTSD or anxiety disorders, or those who find it hard to leave their homes. At UC Davis all patients are now offered the option of either seeing their psychiatrist in person, online at home, or in any private setting. Many patients now choose to receive their care in a hybrid manner that can be significantly better than being seen exclusively in the clinic office for numerous reasons.
From the patient’s perspective it is more convenient, allowing them to fit their consultations into their lives, rather than having to take several hours out to travel and attend a clinic. Many patients also find this form of care to be more intimate and less threatening, with the slightly increased “distance” from the therapist allowing them to feel safer talking about stigmatized or embarrassing topics, such as trauma and abuse. We also know from numerous satisfaction studies that patients like being treated using video. In fact some groups, such as children and young adults, prefer this to conventional methods.
What has not been examined scientifically in as much detail is the impact telepsychiatry has on providers, although the latter are voting with their feet. Latest figures suggest that up to 15% of psychiatrists are now using video with their patients There are numerous advantages for psychiatrists and it is becoming clear that treating patients in a hybrid manner using telepsychiatry, as well as other technologies like messaging and secure email, may be a major response to the problem of physician burnout, making providers both more efficient and clinically effective.
So what are the advantages of telemedicine for mental health providers?
By SANJ KATYAL
The absence of burnout does not equal wellness. While the focus on physician burnout as an epidemic is finally gaining more attention, we may be missing a larger issue. Most physicians are not burned out. We are able to function. We get through our days, make it to some of our kids’ activities and even manage to go out to dinner on the weekends. We survive the work week as we look forward to our next vacation. We do this because that is what we have always done. We put our heads down and do our work. We often project ourselves past the next exam or to the next stage of our lives to help us get through the stress. We become masters of delayed gratification. We develop the mindset of “I’ll be happy when…” I get into medical school or match into a good residency spot or make partner or have enough money to retire etc…Along the way, we may have some bright spots – falling in love, having kids, taking great vacations. We may even reward ourselves for our hard work with a new car or nicer house. We deserve it. But deep inside, “something is missing”. We have achieved most, if not all of the goals we have set for ourselves. Yet despite our hard work, many of us remain unfulfilled with our careers and often with our lives. What is it that we need? A better job with more money? A different car? A different title? Better vacations?
I have struggled with these questions and many more. How do I stop wanting what I don’t have and start wanting what I do have? How can I fully enjoy the present while also preparing for a better future? How can I spend quality time with my kids while they are still around? How can I have a career that uses all of my potentials? Of all the questions that I’ve asked myself, the most important one was this – How can I learn to flourish and not just function?
Fortunately, I found answers in the relatively new field of Positive Psychology which is the scientific study of human flourishing. Unlike traditional psychology which alleviates distress and moves a patient from a -8 to a 0 or +1 (if they are lucky), positive psychology focuses on a patient that is functioning at a +1 and tries to move them to a +8 on the flourishing scale. We need both areas of focus. There are many people that are functioning well by most standards but are nowhere near their potential level of fulfillment.
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.
My approach is fourfold. I shall begin by reviewing the definition of burnout, and, in particular, physician burnout. Much has been written about this recently, but in order to address the individual issues, it is important that we are using the same definitions. Secondly, I shall review some facts about the reality of American medicine. Third, I shall articulate a paradox between what seems to be an epidemic of physician burnout in the context of the reality of American medicine. Finally, I will offer a nine point set of suggestions, which are meant to help to avoid the symptoms and signs of this syndrome.
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. The problem with these kinds of data is that are no adequate controls. It is probably quite common for many people, at some point or another, to experience one or more of these cardinal features. The real question is whether this is more than in a control population and whether they are persistent, rather than transient, symptoms. That information is not available. For these reasons, it is likely that the problem of “burnout” is being exaggerated. Nonetheless the problem undoubtedly does exist in an unknown proportion of physicians.