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How the system works against you -and what to do about it.
Pediatrician Karen Ailsworth, MD, began her career with a multi-specialty practice in Baraboo, Wisc. She enjoyed the job at first, but a couple of years after she started an HMO bought the practice, and soon afterward conditions began to change for the worse.
“They wanted us to be more and more productive, like we had to see a patient every 15 minutes,” she recalls. It wasn’t long before she began experiencing a common symptom of burnout: anger at her patients. “I started feeling like, ‘don’t tell me your problems, I don’t have the time. Just make my life easy.’ And that wasn’t the way I wanted to practice.”
Ailsworth stuck it out for 16 years, finally quitting in 2010 and pursuing locum tenens work before landing a less stressful position at an Indian Health Center.
“It felt like the bean counters were in charge, and it wasn’t about patient care any longer,” she says of her former practice. “I didn’t feel like we got recognized for what we did. It wasn’t like I wanted an award, but more like recognizing not every patient fits into a 15-minute slot, and doctors aren’t just widgets in a factory.”
Ailsworth’s story would no doubt be familiar to many physicians, both for the feelings of burnout she experienced and the reasons behind them. Like her, doctors are reacting not just to the ordinary frustrations of workaday life but to obstacles produced by the healthcare system itself. These include, among others, the mounds of paperwork they must contend with, unhappiness over loss of professional autonomy and the ongoing decline in long-term relationships with patients.
“What we hear from doctors repeatedly is, ‘I went into healthcare to help people, but I spend my day typing into a computer or on the phone doing prior authorizations and I feel like my time is being wasted on all of these things instead of focusing on taking care of my patients,’ ” says Clif Knight, MD, FAAFP, a board member of the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience, a group fighting burnout in healthcare. “And over time doctors lose that connection of why they went into medicine and start wanting to do something else because they feel like they’re just wasting their time.”
Burnout on the rise
Whatever its source, there’s little doubt that feelings of burnout-which the AMA defines as “a stress reaction marked by depersonalization, emotional exhaustion, a feeling of decreased personal achievement and a lack of empathy for patients”-are widespread and growing. In the Physicians Foundation’s “2018 Survey of America’s Physicians: Practice Patterns and Perspectives,” 77.8 percent of respondents reported having feelings of professional burnout either sometimes, often or always-up from 74 percent in 2016.
Similarly, a 2016 study of the prevalence of burnout, published in the Mayo Clinic Proceedings, found that 54.4 percent of the physicians surveyed reported at least one symptom of burnout in 2014 compared with 45.5 percent in 2011.
The fact that so many doctors express similar feelings of frustration and alienation is itself evidence of deep-seated dysfunction in the nation’s healthcare system, according to many experts. “We feel caught between doing the work our patients need and the work we feel is mandatory in our environment,” says Christine Sinsky, MD, an internist and vice president of professional satisfaction for the AMA. “And when those competing demands are not aligned, it creates a situation that is simply unmanageable for many physicians and other health professionals.”
Some who have studied the problem believe “burnout” doesn’t accurately capture doctors’ reactions to the hurdles they face in trying to care for their patients. They describe it instead as “moral injury,” a term first coined to describe soldiers’ responses to the dilemmas they frequently face during wars. (See sidebar on page 23.)
The role of EHRs
Not surprisingly, a major culprit in creating unmanageable situations for many physicians are electronic health records. The technology’s shortcomings-lack of interoperability, poor user interface and interference with face-to-face patient care, among others-are well known by now, and a frequently cited cause of burnout. But their impact on doctors’ morale can extend beyond frustration with the technology itself by surfacing organizational dysfunction in hospitals and healthcare systems, says Mark Friedberg, MD, MPP, senior physician policy researcher with the RAND Corporation.
Friedberg notes that in large organizations, non-clinician executives often are the ones deciding which EHR system to purchase and how it will be configured with little input from the doctors who will be using it. That means patient care may not be an important part of the decision.
“If you’re a physician in a hospital telling management that this technology you use every day is inadequate, and you’re being told that [the EHR] isn’t for you but is for billing and complying with Medicare, that kind of response is a surefire path to burnout,” he says.
A second underlying source of burnout for many doctors, experts say, is loss of autonomy, as more physicians leave independent practice for employment with hospitals and health systems. While this relieves them of the administrative responsibilities that come with owning a practice, it also means they have less control over working conditions, says Robert McLean, MD, FACP, president-elect of the American College of Physicians.
“When you become part of a large system, you’re no longer a self-employed person who can determine their own work or call schedule,” he says. “A lot of those little decisions you used to make [as a practice owner] while they could become headaches, they also contribute to the feeling that you’re a self-actualized person, and that gets lost as an employee.”
But even doctors in independent practice no longer enjoy the degree of autonomy they once had in caring for patients, McLean notes, thanks to the proliferation of payer-imposed requirements such as prior authorizations and quality metrics. Meeting these requirements is not only time-consuming but runs counter to the emphasis on decision-making doctors receive during their training.
“Now a lot of those decisions can’t proceed the way the doctor thinks they should because there’s the ever-present middleman who’s following the golden rule, meaning he or she with the gold makes the rules,” he says. “So when someone else is paying the bill, to some extent they’re going to insert themselves in the process by determining how much they’re going to pay for treatment.”
Another underlying factor leading to feelings of burnout among doctors is the decline in long-term relationships with patients, according to the AMA’s Sinsky.
“I think we have come to conceptualize healthcare as a series of independent transactions that can be distributed among providers willy-nilly, so that we have lost sight of the value that’s derived from relationships,” she says. That value comes both from the emotional satisfaction doctors derive from their relationships with patients, and the quality of care they are able to provide.
“I can help guide my patients and make better diagnoses if I know them better,” she says. “And not every bit of knowing a patient is captured in the EHR or can be transferred from one physician to another.”
An additional cause of burnout has been an erosion in the belief that everyone in the healthcare industry is acting in the best interest of patients, rather than their own bottom line.
Knight cites the example of the extensive documentation that now accompanies evaluation and management codes, a widespread source of frustration among primary care doctors who are the main users of the codes.
“The coding documentations don’t really result in improved value from a clinical standpoint,” he says. “I think it boils down to a lack of trust that physicians won’t overbill.” The same logic applies to payers who require step therapy and prior authorizations before agreeing to pay for expensive treatments and medications.
“I think all these strategies have some degree of validity to them, but they’ve resulted in stealing time from physicians that they’d rather spend focusing on the clinical aspects of taking care of their patients,” he says.
At the root of these and many other sources of physician burnout is the tension resulting from the drive to hold down costs while improving patient outcomes and efficiency, says Bryan Bohman, MD, founder and former director of the Stanford Medicine WellMD Center, and chief medical officer for University HealthCare Alliance, a network of medical practices affiliated with Stanford University.
“Because of the increasing share of GDP we (healthcare) chew up, we’re under tremendous pressure to cut costs at the same time we’re trying to become more reliable, to provide better patient experiences, to show that quality processes are being implemented,” he says.
“It’s a confluence of forces that stresses the whole industry and doctors tend to blame ourselves for the fact that the system is inefficient and it creates a cycle of stress, overwork and negative self-judgment. And I think that’s a big part of what’s producing burnout.”
Looking for solutions
Despite the seeming intractability of the problems behind burnout, there are signs that healthcare institutions and policymakers are beginning to address them.
Among these are CMS’ “Patients Over Paperwork” initiative and the AMA’s STEPS Forward program, and the detailed recommendations for combatting burnout contained in the Institute for Healthcare Improvement’s “Framework for Improving Joy in Work” and the ACP’s “Putting Patients First By Reducing Administrative Tasks in Health Care” papers.
Along with these is a growing recognition of the responsibility hospital systems and other healthcare institutions have in alleviating burnout, since they now employ a large percentage of the nation’s healthcare providers.
Experts say that role extends beyond just offering wellness classes or helping doctors become more resilient. The ACP’s McLean notes that while such initiatives have a role in combatting burnout, they don’t get at the underlying causes.
“When docs have been experiencing death by a thousand cuts, we can’t just give them a bandage, we have to try to remove the knife,” he says. “You can’t yoga yourself out of burnout.”
Moreover, offering wellness programs without acknowledging the systemic causes of burnout can wind up being counterproductive, says Bohman. “Often the doctor’s attitude is, ‘you’re telling me one more thing I have to do. When am I going to exercise or meditate when I’m already doing medical records for three hours at home every night?’”
Instead, Bohman says, hospital systems need to focus more on getting input from “frontline workers”-clinicians-in
decisions and policies that affect how they do their jobs. He cites the example of how University HealthCare Alliance sought to come up with a universal set of quality metrics for its primary care providers.
“There are hundreds of different things you can measure to assess quality,” says Bohman. “So we asked our physicians, ‘what do you think are the things that have the most impact on patients, that improve clinical outcomes the most?’”
UHA is starting with 11 quality metrics that include common ones such as smoking cessation, depression screening and blood pressure control.
“It’s a small number of the ones that we need to ultimately take care of but we’re building the systems and the processes to do that in a way that doesn’t rely on doctors putting sticky notes on their computers to remember things,” Bohman says.
In addition, he says, institutions can reduce burnout by focusing on physician engagement, which requires developing a culture of trust and mutual respect.
“Assuming good intent on the part of every clinician is the key to improving engagement and wellness overall,” he says. “I’ve been an administrator for 10 years and I can’t remember getting burned by assuming a physician is trying to take good care of a patient. People don’t go into medicine with any other intent.”
Is it burnout-or moral injury?
“Burnout” is the word most commonly used to define the feelings of exhaustion, frustration and cynicism prevalent among growing numbers of American doctors. But some experts who have studied burnout think the term doesn’t accurately capture these doctors’ emotions or the situations from which they arise, preferring instead the term “moral injury.”
Wendy Dean, MD, formerly a psychiatrist and now senior medical officer at the Henry M. Jackson Foundation for the Advancement of Military Medicine, says moral injury occurs when doctors feel they are impeded from doing what is best for their patients. Impediments can take a variety of forms, such as an insurer’s unwillingness to pay for a medication or procedure, limits on appointment times set by the doctor’s employer, or the need to score highly on patient satisfaction surveys.
“How do you answer to all those masters and do what you pledged under the Hippocratic oath, which is always to work in the best interests of the patient?” Dean asks. “With every patient encounter you’re in a bind and not able to do what you were trained to do. You can tolerate that if it’s an occasional event, but when it happens every day it becomes a crushing burden.”
Moreover, she says, labeling a doctor burned out implies a condition that it’s the doctor’s responsibility to fix, rather than the result of a systemic failure. “The way I think of it is that physicians are very, very eager to take care of their patients. But sometimes we can’t do it. We’re not allowed.”
Adam Schwarz, MD, an internist in Hanover, N.H., spends a great deal of time talking with unhappy physicians in his role as a “well-being champion,” part of the American College of Physicians’ Physician Well-being and Professional Satisfaction” initiative, designed to combat burnout among ACP members. But the majority of doctors he encounters “identify more with the moral injury mindset than they do burnout,” he says.
The difference, he says, is that burnout implies feelings of being overwhelmed by the demands of being a physician, whereas “moral injury speaks to the sense that they have fallen below what they think standards should be or they’re cutting corners due to productivity requirements in ways that make them feel uncomfortable.
“It’s not that these docs aren’t working really hard. It’s that they’re having to make decisions that go against their core beliefs” he says. “It’s that alteration of the moral compass that makes docs feel like they’re betraying their patients.”
Dean believes the growing popularity of direct primary care models stems in part from doctors’ desire to avoid feelings of moral injury. She cites her own decision to adopt the DPC model when she was in practice. “The only way you could make a living taking insurance was to run people through at 12 an hour,” she recalls. “And I wasn’t going to do that because it’s not good patient care.”
“What physicians are saying is, ‘take the insurer out from between us and the patient,’” she adds. “Take the EHR out. Allow us the time to get to know who my patient is and what they want.”