I've just been to see my doctor. He's fed up.
I never would have guessed it. He bustled into the room with the same polite smile and soft handshake with which he's greeted me for years. And when the brief checkup was over, he bade me a friendly goodbye — the epitome, it seemed to me, of unruffled competence and efficiency: a veteran at the zenith of professional life, fit and fully at ease in his white coat.
That was his professionalism. A few minutes later, passing a doorway behind which he sat scowling at his computer screen, I asked if he had a moment and explained that I was working on an article about physician burnout. "Do you see much of that among your own colleagues?" I inquired.
Absolutely, he declared. "It's a tremendous problem!"
I asked if his large medical group and their affiliated hospitals have programs in place to combat it.
They do, he affirmed. There's a physician wellness committee (mandated since 2001 by the Joint Commission). There are regular talks and presentations on healthy lifestyles, maintaining work-life balance, programs to promote access to leisure-time activities and so on. But in his opinion, he confided (pardon the indelicate quotation), "It's just pissing into the wind."
That wind, he explained, is the high-velocity change the health care system is undergoing and the exhausting demands being placed on physicians. "And their families," he added. He enumerated the 15-minute visits, one after another, day in and day out, that he's expected to tick off, punctuated only by a 30- or a 60-minute surgery a couple of times a week, and hectic clinics when he may treat 50 patients in two hours. Then there are the times he's on call for the whole department.
He cited with sympathy the primary care physicians who are paid for eight hours a day but consistently put in 12. And while some relief is promised them, he acknowledged, as more and more routine care is being handed over to nonphysician providers, that leaves only the toughest, most demanding cases for senior doctors — whose overworked numbers are dwindling under the pressure.
"It's only going to get worse," he fretted. "You and I are getting older. We're going to need more health care. And I'm afraid the doctors just won't be there for us."
"So how about you?" I asked. "What do you do to keep from burn … ?"
"Me!" he exclaimed with a bitter laugh. "I'm out of here! Six months more and I'm gone. I've had it. I'm going to find a situation where I've got some control."
I was astonished. "Really! You're quitting?"
"But will you still practice medicine?"
"Oh, yes," he said.
"What you want is increasingly hard to find, though, isn't it?" I observed.
He shrugged. "Yeah. I'm looking around at what's out there. You can only take this step if you're not totally dependent on salary and benefits. If you're young and you're still paying off $200,000 in student loans, you're stuck."
If that's anecdotal evidence — in the most literal sense — for the pervasiveness of burnout among today's physicians, there are plenty of formal studies to back it up.
In a 2006 survey of members by the American College of Physician Executives, fully 90 percent of respondents in health care leadership roles affirmed that they'd personally witnessed severe emotional distress, fatigue, family disruption, depression, substance abuse, suicidal thoughts and even suicide among their confreres. Reliable numbers don't exist, but it's estimated that about 400 doctors kill themselves each year in the United States, a rate well above that of most other occupations. Three-quarters admitted to having suffered many of those symptoms personally. Sixtypercent said they'd seriously contemplated leaving medicine because of the toll.
In September 2011, the medical staffing company Cejka Search and Minneapolis-based Physician Wellness Services, a subsidiary of the employee assistance provider Workplace Behavioral Solutions Inc., reported that 86 percent of a representative sample of 2,069 doctors who took part in a nationwide survey described themselves as "moderately to severely stressed or burned out on an average day."
Two-thirds agreed that the stress had worsened significantly over the previous three years. More than one in 10 — 14 percent — had taken the same step my doctor has planned: They'd walked out on their existing practices in search of relief.
Although the numbers would seem to be better, the most recent academic examination of physician burnout — a survey of more than 7,000 U.S. doctors reported in the Archives of Internal Medicine last October — showed conditions still dire. Almost half, 48.5 percent, of respondents complained of at least one symptom of burnout — a far greater proportion than in the general population.
One in three respondents, according to the assessment tool used, were diagnosable as emotionally exhausted; one in five showed clear signs of "depersonalization" — cynicism, negativity, coldness or antipathy to patients and others in the care team; two in five were disgruntled because work was eating away at too much personal or family time. Those most prone to burnout, the study concluded, were physicians "at the front line of care access (family medicine, general internal medicine and emergency medicine)."
Lead researcher Tait Shanafelt, M.D., a professor at Mayo Medical School in Rochester, Minn., has embarked with his co-authors on a follow-up study to analyze the effects of workplace initiatives designed to alleviate the conditions doctors find most stressful. According to the Cejka/PWS survey, those are, in descending order: "administrative demands of the job, long work hours, on-call schedules and concerns about medical malpractice lawsuits."
Wrist Slap or Sanction
Unfortunately, too few U.S. hospitals and health care organizations are paying more than lip service to policies that would make life easier for their most precious resource. Cejka warns that for every doctor who quits a medical group (about 35,000 do each year), the ledger takes a hit totaling $1,262,297. That was the average cost of the turnover of a single physician in 2011, Cejka calculated, when lost downstream revenue ($990,034), recruitment expenses ($61,200) and investment in bringing a replacement doc up-to-speed ($211,063) were taken into account.
Yet, Cejka and PWS found that only 15 percent of respondents to its burnout survey credited their employer with doing anything at all to help them cope.
In fact, it's only comparatively recently that health care organizations have taken an interest in their physicians' psychological well-being — that is, until the doctor's demons triggered what has been labeled "disruptive behavior."
Physicians who were wrestling with exhaustion, insomnia, irascibility, spousal conflicts, apathy, disdain for patients and subordinates, anxiety, bad temper, loneliness, depression, overeating, heavy drinking, drug abuse or despair — all red flags for incipient burnout — were allowed to stew in their own juices until they bullied or blew off their colleagues once too often, swore at nurses too vehemently, hurled scalpels, or committed some egregious procedural blunder and harmed a patient. Or themselves.
Depending on their seniority, their standing as income generators and the gravity of the breach, they would then be either politely admonished or referred to the state medical board, where they might be stripped of their license. The latter was a step so extreme that colleagues and administrators were loath to do anything that might invoke it. As psychiatrist Jody Foster, M.D., executive medical director of Penn Behavioral Health Corporate Services at the University of Pennsylvania, notes, "It used to be that there was almost nothing between a limp slap on the wrist and being sanctioned."
Decompensating doctors poison the workplace atmosphere — replacing a nurse burned out by abuse from a troubled physician has its own steep price tag for the hospital, figured at $88,000 on average last year. But they also pose a threat to quality of care and safety. Growing appreciation of this connection has led to a shift in institutional attitudes.
Rather than waiting for physicians to boil over and then reprimanding them — a career threat that actually dissuaded seething docs from admitting they might benefit from help — intervention has been decoupled from discipline. All health care organizations seeking accreditation by the Joint Commission now must establish through their bylaws a committee of physicians charged with providing confidential, repercussionless counseling and treatment to peers who ask for it or are referred because of actual or potential impairment.
On paper the committee is supposed to take a proactive role in heading off burnout. Its existence is meant to be publicized widely, and it should sponsor "educational programs to acquaint the medical staff with the nature of physician health issues and the purpose of the committee." But in practice, say observers, the emphasis at all too many hospitals remains on dealing with troubled docs after they've stumbled — often by steering them to counseling and rehab through the physician health services mechanism offered by most state medical societies.
"The goal should be to keep you happy, not to sanction you because you're a jerk and yell and scream and don't come to committee meetings," emphasizes Alan Rosenstein, M.D., medical director of PWS and a practicing internist in the San Francisco Bay area. But by his estimate — which he admits is superficial — fewer than 5 to 10 percent of U.S. health care organizations really have a grasp on what they can and ought to be doing to realize that goal.
The doctors who answered the Cejka/PWS survey made a few suggestions.
Almost two-thirds proposed that their groups and institutions provide more ancillary support for routine administrative tasks. Radiologist Richard Gunderman, M.D., a professor at the Indiana University School of Medicine and an occasional essayist for the Atlantic magazine, offers a practical example: When his Indianapolis hospital gave him an office assistant who could track down numbers, dial and connect the myriad telephone calls he has to make each day to outside physicians to discuss the patient films he's reading, life suddenly got much brighter. "I can spend a higher proportion of my time doing things I've been trained to do," he sighs, "and less doing things I'm frankly not very good at."
Almost 40 percent of survey respondents said having exercise facilities or classes for physicians conveniently on-site would go a long way toward keeping them vigorous and sane. That's commonplace among big employers outside the health care sector — not so much within. "I've always made sure to make exercise a part of my life, and I've created a schedule that allows me to do that," says Foster. Exercise and sleep, she advises, are key to avoiding burnout.
Other stress-relief initiatives the surveyed doctors urged hospitals and health systems to embrace include wellness promotion campaigns (cited by 28 percent), life management workshops (24 percent), concierge services (help running errands, getting event tickets, arranging family birthday parties and the like; 20 percent) and one-on-one coaching and mentoring by physician peers (19 percent). All, incidentally, are benefits PWS contracts to provide in its Employee Assistance Program for clients' doctors.
"Organizations need to give physicians a little bit of slack," summarizes Rosenstein — to which psychiatrist Foster chimes in with a hearty "Amen!"
"Physicians doing clinic work feel as though they're on a treadmill," she observes. (My doctor is certainly a case in point.) "At the end of the day, it's as if they've popped out of a whirlwind. They don't have the same sense of satisfaction physicians used to feel — they don't know their patients as well, and there's an increasing disparity between why they entered the profession and what they're actually doing."
A simple solution, she suggests: "Give them an afternoon off each week. For clinic doctors that's like a gift from heaven! They come back so grateful and refreshed and invigorated. … why wouldn't an organization want [and find it cost-effective] to give them that?"
To be sure, acknowledges Gunderman, "dealing with our external circumstances tends to dominate the discussion. But that can't be the whole story. Certainly there are things that burn us out. But there are also lots of things we can cultivate as individuals to make ourselves more resilient."
Next time: Temperament and training can make physicians their own worst enemies on the psychological firing line. But those might also be their best weapons for remaining happy warriors. Consider two ambitious academic medical center programs with contrasting approaches to sustaining physician wellness … plus a couple of remarkably cost-effective tools (cost: nothing) hospitals might champion to keep their doctors energized and productive.
David Ollier Weber is a principal of The Kila Springs Group in Placerville, Calif., and a regular contributor to H&HN Daily.