Burdens and Burnout

Writing and speaking about the changes in health care that have occurred in the last few decades have spawned a cottage industry online. On the social media website for physicians founded by Kevin Pho MD, we learn about what issues concern doctors and patients. The exchanges posted seem to foster a sense of group therapy—and for good cause. There is a lot of angst among physicians about their roles in this ever-changing health care landscape. Perhaps the most serious problem deals with the negative effects of increasing administrative burdens every practicing physician must face.

With his usual keen insight, in a series of two syndicated columns for The Washington Post in June 2015, Charles Krauthammer MD attempted to identify the reasons “Why Doctors Quit.” Although the columnist had not practiced psychiatry since finishing his medical training, he had observed how physicians felt the damaging effects of responsibility without autonomy. Responsibility for the care of patients, without commensurate autonomy to make medical decisions in the patient’s best interest, induces feelings of a lack of self-worth.

Today, physicians face many hurdles in doing what is right for their patients. Obtaining preauthorization for simple tests and lab work frustrates the physician and creates an atmosphere of constantly being kept “on hold” while waiting for permission to move forward with medically necessary orders. “Step-therapy,” defined here as progressively administering drugs or treatments if the simplest measures prove unsuccessful, may cause actual harm if a more complex (read expensive) treatment should have been chosen in the first place. Such decisions for care, micromanaged by the federal government and payers, remove from the physician the autonomy to make appropriate medical decisions. Then there is the burden of documentation, the filling out of computer codes denoting the level of all work done and every decision made. No longer is it considered acceptable to handwrite notes in the patient’s chart. In fact, unless medical records and claims are maintained and filed electronically, the doctor’s practice is fined by payers for noncompliance. A lot of doctors feel cornered, boxed in by their desire to continue serving their patients, yet unable to lighten the administrative burdens of modern medical practice.

Reports from physician surveys conducted nationwide paint a bleak picture of the mind-set of doctors. Medscape polled 15,000 in their most recent (2019) survey of all physicians, from family doctors to surgeons of all stripes. Nearly half the respondents reported symptoms of burnout, defined as feelings of job dissatisfaction with elements of hopelessness. One in seven respondents, according to the survey and sensationalized in the New York Post, have considered suicide. These findings should, indeed, raise alarms. The Band-Aid approach has been to foster “mindfulness,” increase exercise to promote endorphin release and to open up channels of communication among peers. However, those superficial measures remind me of the fable of the boy sticking his finger in the dike to prevent the flood. The boy stayed there all night, in spite of the cold, until the adults of the village find him and make the necessary repairs. But where are the necessary repairs for disaffected physicians? The New York Post article concludes with the cute reference to the happiest doctors—plastic surgeons—without explaining why they are happy in their jobs. It seems apparent that, with no one to answer to for insurance coverage for elective surgery, plastic surgeons engage their self-pay patients with fewer requirements for documentation. They can afford to spend quality time with their patients.

While some physician counselors talk about relieving doctors of the demands imposed by documentation requirements, there is little action on the part of Health and Human Services to lessen the burden. In fact, the entire fabric of reimbursement for physician services is made up of bullet points and quality measures that don’t really address quality. Too much emphasis has been placed on process rather than on outcomes. Further complicating the formula for physician payment is the notion that somehow federal government officials can determine accurately how exhaustive a doctor’s use of resources costs the system. How an individual doctor’s decisions cost the system are being used for “economic credentialing” by hospitals in attempts to “eliminate waste.” For surgeons, their graded “success” and reimbursement depend on hitting targets, such as the number of eyes in which a cataract surgeon achieves 20/40 or better vision, divided by the total number of cataract surgeries performed. It is simply naive to believe that a higher score for patient comorbidities, like glaucoma or macular degeneration, can be factored into worse outcomes for cataract surgery without creating disincentives for doctors to tackle patients with multiple medical problems. If reimbursement depends on the best possible outcomes, why would a doctor take on patients who have a higher risk of complications? Under the current system, it is easier, and more lucrative, to simply refer those patients elsewhere. And what does that imply for referral centers, such as academic institutions? They will get the most complicated, sickest patients, shipped out of their local communities.

Part of the symptom complex of burnout for doctors includes feelings of helplessness in a profession designed to help. When it seems like we are stymied in doing what we do best—that is, taking care of patients—either because of time constraints or administrative demands, doctors begin to question why they stay in the field. They wonder if all the sacrifices of time and sleep and the hundreds of hours of training have really been worth it. Pride of purpose is eroded by the grind of the insignificant, and doctors feel like they are drowning in a sea of minutia dictated by outside forces.

Enter Physician Speaking by Kevin MD, a boutique speakers bureau. For a fee, keynote speakers provide both context for the discomfort doctors feel and the inspiration to emerge from the funk. It helps the audience to have a hero, someone who has overcome professional and personal adversity to give a pep talk to the assembled. I have learned about the physical challenges of remaining in space, orbiting the earth for a year. I have digested the latest business approaches to forming successful work groups. But the most important features of keynote speakers, getting in the minds of the audience and calling them to action, come with practice and a personal sense of mission. As I reviewed the online accomplishments of the panel of speakers presented by Kevin MD, I noticed a common thread among suggested topics for keynote speeches: physician burnout. These speakers help doctors define what is bothering us and what we can do about it. They are not selling snake oil or an elixir to simply ease our minds. They are providing us with a road map to a better destination, a place in our responsibilities as doctors where we can once again do what we do best. They force us to come to grips with what doesn’t work and what we must do to change it.

For doctors, according to the surveys, the satisfaction derived from patient care is still the prime motivator to entering and staying in medicine. Finding ways to enhance our satisfaction in our work while minimizing the frustrations is our challenge. Recapturing our humanity as doctors can be achieved by focusing on the patient and by reducing or eliminating burnout through delegation of clerical tasks. Or perhaps, like me, doctors could retire from practicing medicine and write about the changes to come.