How physician 'burnout' gets the real problem wrong

March 17, 2020

Wendy Dean, MD, the founder of Fix Moral Injury, discusses why the term "burnout" does not encompass the full scope of the problem, and what can be done to address physician career dissatisfaction.

Wendy Dean, MD, the founder of Fix Moral Injury, discusses why the term "burnout" does not encompass the full scope of the problem, and what can be done to address physician career dissatisfaction.

Medical Economics: Do we have a burnout crisis in medicine today?

Wendy Dean, MD: So we have a crisis of distress. Clinicians across the board have told us that they are struggling with their jobs. They love their patients. They love medicine in general, but they're struggling with the day to day challenges that they face as they try to do those jobs and take care of the patients.

Whether or not it's burnout, that's debatable.

Medical Economics: Can you expand on that a little bit? Because I think burnout is sort of the catch all that a lot of physicians use to describe the way they're feeling. If it's not burnout, then what is it?

Dean: Several years ago, I started noticing that a lot of my friends were struggling more. And what they said to me was: ‘I love my job; I love medicine. I love what I'm what I'm trying to do. But all these other things that get in the way and challenge me.’,

So I would ask them: ‘Okay, so you're burned out?’ And they'd say, ‘that does not strike me as really what my experience is.’

And so I started thinking about it more and more with a co-author, a colleague of mine that I'd worked with for several years. And we started thinking about it in a different way.

And what we thought about is: Every physician takes an oath to put their patient first as a priority. It comes before lunch, it comes before sleep. And so what we found was the challenge is that when there's some barrier in the way between us being able to take care of our patients, according to that oath we took to put them first. That’s where we struggle.

We framed it as moral injury, which means transgressing a deeply held belief. And in healthcare, that belief is the oath that you take to put your patient as the priority.

Medical Economics: Can you talk a little bit about sort of the difference between how you perceive the term burnout and how you perceive this term moral injury? Because I think a lot of physicians are still thinking in the burnout mentality. And so, what is actual burnout and what is actual moral injury?

Dean: Right. We're not trying to say that burnout doesn't exist, because there are some physicians who truly struggle and really do meet the criteria for burnout. What we think is that burnout is a constellation of symptoms, which are emotional exhaustion, feeling ineffective and depersonalizing. So that can come from a number of different places. But what we found as we talked to physicians across the country is that moral injury may be the primary cause of those symptoms. And what we believe is when we're trying to get our patients that care and routinely struggle to make that happen, it's exhausting. It makes you feel very ineffective. And then eventually, as you do that time after time after time, and you can sort of anticipate that it's going to happen again, you start to separate yourself from your patients, because it's painful to watch them go through the difficulty of not getting the care they need. And so that's the depersonalization point.

Medical Economics: You briefly mentioned before some of the causes of this moral injury, but if you can you expand on that and talk about what the challenges that physicians are dealing with day in and day out that compound and lead to these issues?

Dean: So with moral injury, what we're struggling with are the double binds that we’re put in. We want to take the best care of our patients. That's what we promised to do.

And yet, we're also being asked to take care of the bottom line of the organization by seeing more patients, and therefore not having as much time with each one. We are being asked to take care of the EHR as we're in sitting with a patient, but we can't make eye contact. We're being asked to do any number of things that get between us and our patients that break down that physician-patient relationship, and that tie our hands so that if we take care of the patient, we're not taking care of our system. And so we're getting good measures on our patient satisfaction. But maybe not good measures on what our volume metrics are. And it seems like the further we go, the more double binds we're getting into. And when you can't escape those double binds, that's really where the challenge comes.

Medical Economics: How does this affect patient care and patient outcomes?

Dean: When we're taking care of the EHR, or when we're taking care of the regulations that say, in order to maximize your billing, you need to ask about vaccinations, and tobacco use, and healthy lifestyle. All of those regulations are good, each individually. But when you put them all together, and you have to ask about them at every visit, you may go through half of the year, a lot of time, just doing the checkboxes that you need to check.

And so rather than having 10 minutes or 20 minutes to talk to a patient about the problem that they actually came in with, we now have half of that time, because the other half is dedicated to these routine questions. And that, for patients, is very frustrating. And for physicians, it's also frustrating, because we want to get to the problem that the patient has. We don't want to have these speed bumps along the way.

Medical Economics: It seems like there's a disconnect between what physicians need and what, hospital administrators, insurance company, executives goals’ are. How do we bridge that divide between the business side of healthcare and the clinical side of healthcare?

Dean: I think that is the crux of this matter.

Over the last 30 years, we've kind of diverged on our paths and physicians have been quite happy to leave the business of medicine to the MBAs and to the executives. Executives have been happy to kind of ignore the clinical side and let the physicians take care of that.

The problem is that has caused us to not consider what the clinical impact of some of our financial or business decisions have been. So what really needs to happen is physicians need to understand, on some level, what the incentives are and what the concerns are for the administrators. And the opposite is true, as well. Administrators need to be very clear about what the clinical challenges are. The best systems do a dyad where there's an administrator paired with a physician leader, they make those decisions together, they negotiate what progress should be, what the next steps look like. And the patient is still at the center. It's not the business side that's at the center. We all need to come together to make sure that patient gets the care they need.

Medical Economics: It's an election year. And one of the big things we're talking about is healthcare reform. And I'm wondering what way could we kind of fix the healthcare system in a way that makes it healthier for doctors?

Dean: This is not a red problem, it's not a blue problem. Everybody needs healthcare. And one of the challenges that we've seen is that across the world, no matter what kind of system somebody is in, they have said we're struggling with this problem. So just changing how we do the reimbursement may not fix the problem.

What we need to think about is: How do we align all the incentives for the stakeholders in the same direction? And we need to put the patient at the center of that alignment. So that all of the stakeholders are pointing to the best care for the patient and are supporting the physician-patient relationship.

Medical Economics: A lot of these problems are systemic. And I'm wondering what can individual physicians do to make their own career more satisfying and more healthy and also to chip in and try to help the system change for the better?

Dean: Every one of these problems can be mitigated to some degree at the local level. And for every problem, you can find a local, personal immediate solution to. They may not fix everything. But if you know there's a particular issue that you find most problematic, the best thing to do is to educate yourself about it, to follow how the incentives drive that process, and then work with other people who also have the same problem. And who be driving that pattern, because of their incentives, and all can work together to try to change that pattern of decision making.

It does mean partnering with people that we may not typically partner with. It may be that we need to be much more in contact with the coders, or with the billing department, or with the safety officer, and asking for them to engage with us and thinking through a different way to approach a problem.

Medical Economics: Physicians often feel that there's a stigma about talking about how they're feeling about their career. They worry that there will be sort of blacklist, that they will be known as a weak physician. Is this changing? What can we do to make it easier for physicians to open up and talk amongst each other about these issues?

Dean: Those concerns, on some level, are real. Physicians are very highly regulated, very highly monitored for what their mental health issues are. Every year when you renew your license, you have to fill out a questionnaire. And so we can't take it lightly, that acknowledging that you're struggling doesn't pose some serious questions.

At the same time, I think when we're talking about moral injury, we're not talking about a personal problem with resilience or a personal mental health issue. What we're saying is we're caught in a broken system. And so allowing physicians to say: ‘it's not me it's the broken system’ is part of the solution. Being able to have some sort of forum where physicians can come together and talk about common challenges that they face every day and about taking care of their patients. How can we, across the board-from anesthesiologists to surgeons, to primary care physicians to pediatricians-how can we all work together to fix this common problem that we all have? It needs to be in a somewhat protected environment.

But, also, we need to stand up for each other.

Medical Economics: What would you like to say to physicians out there who may be watching this, who may be finally why they are feeling this way. What message do you have for physicians?

Dean: I would say, ‘it's not about you, it is about the system that we're working in.’ And so reach out to your colleagues and band together with them. Find some camaraderie, find some collaboration, and also reach out across institutions, across the country. There are lots of like-minded people out there that we can find support from. The more of us that come together, the more powerful will be.