When physicians burn out, solutions are elusive
Support groups can’t counter the root causes of a crisis
Phone calls in the middle of the night and on weekends eventually overwhelmed Dr. Barbara Morris, a geriatrician who served five years as medical director of a retirement community in Colorado.
It wasn’t that the calls were inappropriate. She simply couldn’t endure responding to the constant barrage, and the health system where she worked had no plans to add more staff.
“I actually loved that job,” Morris recalled. “But you hit your wall. And you realize you can’t continue if you’re not going to get the resources that you need.” About four years ago, she started looking for a new job, found one and quit.
Why Morris hit her wall is obvious to her in retrospect: She was burned out. That experience is not unique among physicians. And as awareness grows about burnout and its destructive consequences for doctors and patients, ideas to address the problem have proliferated. But no organization has arrived at a set of sustainable solutions.
Healthcare systems, practices and medical schools are deploying an array of tactics to help physicians cope with the unique stress of modern medicine. Some programs offer regular moments of reflection, connection with other doctors or other sources of catharsis.
Healthcare leaders maintain that using other methods to engage physicians will mitigate the main drivers of burnout— electronic health records and multiplying reporting requirements—in a more systematic fashion. “We have to, in this profession, find a balance,” Morris said. “There are ongoing struggles that we don’t have answers to.”
Such struggles threaten doctors and patients alike. Burned-out doctors don’t collaborate as well with colleagues and they make more mistakes, which can harm patients. Sometimes, they exit the profession altogether, dealing a blow to an industry with a looming shortage of nearly 95,000 physicians in the next decade.
Some piecemeal solutions address individual burnout, but few efforts target systemic change. Those that do often face opposition.
Proposals to expand the work of clinicians who aren’t physicians, such as nurse practitioners and physician assistants, to further treat patients and prescribe more medications have met with resistance from doctors’ groups. Although these changes could help alleviate burnout and allow clinicians to practice at the top of their licenses, physician societies see them as incursions into physician territory.
The American Medical Association and the American Academy of Family Physicians have issued cautious warn-
ings about expanding nurse practitioners’ scope of practice to prescribe controlled substances, for instance. When California passed a law in February allowing pharmacists to prescribe birth control, the American Congress of Obstetricians and Gynecologists opposed it, although it advocated for fully over-the-counter contraception.
“There’s a lot of focus on building individual resilience,” Dr. Tejal Gandhi, CEO of the National Patient Safety Foundation, said of efforts to counter burnout. “We think there needs to be a focus on systems as well,” she said, calling for redesigning processes in healthcare to make workflows more efficient. Physician burnout is a “precondition to patient safety” that has been “neglected,” she added.
In this tempest of different views, the lone area of consensus seems to be that burnout is getting worse. In 2011, a survey of nearly 7,000 physicians by the American Medical Association and the Mayo Clinic found that just over 45% met criteria for burnout. Three years later, a follow-up survey found signs of burnout among nearly 55% of physicians.
Burnout is also intensifying, the Medscape Lifestyle Report 2016 found when it asked physicians to rate the severity of their exhaustion. “Too many bureaucratic tasks,” “spending too many hours at work” and “increased computerization of practice” were the top three causes; other culprits included compassion fatigue, too many difficult patients and “feeling like just a cog in a wheel.”
Some sources of burnout are simply inherent in modern healthcare. Doctors and administrators alike suggest a fundamental disconnect between healthcare as a business and the altruism enticing many doctors to medicine.
Others stem from U.S. government efforts to convert its healthcare payments into a system based on value rather than volume. In order to avoid reductions in Medicare reimbursements under several of these initiatives, doctors have to submit quality data from EHRs that many find timeconsuming and confusing.
The health IT factor
When doctors are required to use health IT more, some adapt seamlessly. Others find their workflow interrupted, said Julie Taylor, CEO of Alaska Regional Hospital, Anchorage.
A recent study published in the Annals of Internal Medicine observed 57 physicians. The study found that they spent nearly 50% of their time on EHR and desk work, and just 27% of their time with patients. Even in the examination room, physicians spent 37% of their time on EHR and desk work.
At its most extreme, burnout is a matter of life and death. Every year, 300 to 400 physicians in the U.S. commit suicide. Female physicians are 2.3 times more likely to die by their own hand than women in the general population; male physicians are 1.4 times more likely.
The problem is well-defined, but solutions are not. Addressing burnout at various levels carries with it a host of barriers that coalesce into a single tidy conundrum: If elements of healthcare that drive burnout are inevitable, is burnout inevitable too? After all, EHRs are not going away.
Yes and no, doctors say. “There are contributors to burnout that we can’t modify,” said Dr. Allison Ludwig, assistant dean for student affairs at the Albert Einstein College of Medicine in New York and an expert on medical student burnout.
For instance, a doctor might have to tell one patient they have cancer, then step into the next room to see another patient and quickly don a cheery face. “That’s never going to go away in medicine,” Ludwig said.
Medical culture is problematic too. When doctors stand up for themselves, the interpretation is often, “That person’s a problem,” Morris, the geriatrician, said. “I think our profession needs to get off of that and understand that people are setting boundaries they need to set for themselves.”
Medical schools should help students cultivate resilience early on, Ludwig said. Its student wellness program, WellMed, aims to help students develop healthy, balanced habits and attitudes to make them “better healers and role models for their patients.”
In several health systems in Colorado, not-for-profit Lumunos has been rolling out its colleagues program, which fosters relationships between physicians. Through a compilation of weekly emails, monthly conversations led by a facilitator and occasional retreats, it guides them in healthy reflection.
Morris, who is now at Centura Health Physician Group and is involved in the Lumunos program, said she found the program highly supportive since it helped doctors develop relationships with each other. Ultimately, she said, it also benefits patients to have happier doctors.
Ludwig acknowledged that the jury is still out on which programs work. “We don’t know what the success of any of this is. We just keep trying stuff,” she said. “It’s a lot of trial and error at this point.”
Anti-burnout programs are neither widespread nor robust. When Modern Healthcare asked 93 healthcare CEOs as part of its third-quarter Power Panel survey whether their organizations had programs to address physician burnout, just less than 36% said yes. Nearly 28% had not, while slightly more than 36% said such programs were “under development.”
Of those who did have programs, 81% said their effectiveness “remained to be seen.”
The C-suite perspective holds that a lack of control induces burnout. Some executives advocate an approach to addressing burnout that emphasizes physician empowerment rather than coping mechanisms.
“I believe that that feeling of helplessness is really at the root of burnout,” said Dr. Mark Keroack, CEO of Baystate Health, a not-for-profit, integrated healthcare system based in Springfield, Mass.
To give physicians a greater sense of control, Baystate offers a physician leadership academy that trains them in communication and other management skills. “It basically empowers doctors to be part of shaping the way care is delivered,” Keroack said. “The least burnt-out physicians are the ones who are most involved in making the changes happen.”
Other CEOs voice similar views. “It’s a question about, ‘Do I have control over my environment?’ ” said Mary Brainerd, CEO of HealthPartners, a not-for-profit healthcare organization based in Minnesota. She said HealthPartners has specific programs to engage physicians and allow them to have an impact on the organization, as well as simplify technology use.
Drawing comfort from art
Tapping into the power of art—especially words—is the basis for yet another approach to shore up doctors’ spirits.
Pulse: Voices from the Heart of Medicine is an online magazine “focused on the experience of medicine as told by the people experiencing it,” said Dr. Paul Gross, Pulse’s founder and editor-in-chief. Doctors, nurses, patients and students alike can contribute.
Writing and sharing are not meant to be merely cathartic, explained Gross, who is also an assistant professor in the family and social medicine department at Montefiore Health System in New York.
“Policymakers read stories like this,” Gross said, naming a former CMS administrator as an example. “It makes people who are making decisions about legislation and policy to think … ‘Oh, we’ve got a problem.’ ” Pulse stories with policy implications have been reprinted by established mainstream outlets such as the Wall Street Journal, as well as the popular medical site KevinMD, Gross said.
“We look for stories that have systemic implications,” Gross said. “It’s not just fixing individuals.”
If anything about the future of healthcare is certain, it’s that the list of payment reform initiatives will grow, and they will tie physicians more closely to EHRs, which remain far from user-friendly. As of 2014, only 74% of physicians in the U.S. had adopted certified EHRs, meaning that EHR-related burnout still awaits a quarter of physicians.
In many ways these changes will lead to a better healthcare system, said Dr. Darrell Kirch, CEO of the Association of American Medical Colleges. At the same time, some physicians feel these changes “are taking the heart or the soul out of medicine,” he added. And until more systematic solutions arise, the consequences of those frustrations can be devastating.
“Our biggest challenge is to help the workforce come through it and get to the other side,” Kirch said. “We can’t afford to lose them.”