Background - Physician Burnout
However, physician burnout is hardly new. As we wrote in 2012 about the predecessor the 2012 Shaneyfelt article, this is just the latest in a long series of studies showing physicians' growing angst, dissatisfaction, burnout, or whatever one calls it. In 1987, in an AMA survey of physicians over 40, 44% replied that were they given chances to do it all over again, they would not go into medicine.(3) In a 2001 survey of Massachusetts physicians, 62.3% were dissatisfied with the practice environment.(4) In 2002, a national survey by the Kaiser Family Foundation showed that 45% of physicians would not recommend that a young person should go into medicine.(5) In a survey of primary care physicians in 2007, 38.7% were somewhat or very dissatisfied.(6) I have a 6 inch thick set of paper files containing articles on the subject, although it is remarkable how many research studies reported only average scores on instruments, and hence did not report proportions of physicians who were burned out or dissatisfied. Yet the 2017 Health Affairs post garnered headlines declaring physician burnout to now be a crisis.
Whether the current attention to burnout will lead to any real improvements is doubtful. In particular, I am concerned that the Health Affairs blog post that sparked all the attention was at best misdirected. It avoided discussing more than a few of the most immediate, proximate causes of burnout. It seemed more motivated more by concerns about money than about patients and the physicians that try to serve them. It read like a top down diktat uninfomed by the concerns of physicians or patients, maybe because all of its authors were CEOs of large health care organizations, all but one large hospital systems.
I will venture to go through the issues point by point in the hope of sparking a discussion more focused on the physicians subject to or at risk of burnout, and ultimately the effects of their burnout on their patients.
For the Love of Money
While the blog post began with a nod towards improving the quality of, lowering the cost of, and improving access to health care, there was a subtext. Consider some quotes, first, stating that one cause of burnout is,
profound inefficiencies in the practice environment
The experience from Atrius Health suggests that replacing a physician who retires early or leaves to pursue other career opportunities can cost between $500,000 and $1 million due to recruitment, training, and lost revenue during this time.
Professional satisfaction for physicians is primarily driven by the ability to provide high-quality care to patients in an efficient manner.
As leaders, we must recognize burnout in physicians and other health care workers as a serious problem and respond vigorously. This is especially true if we want to maximize the effectiveness, productivity, and longevity of clinicians.
More than words are needed. Leaders of health care delivery organizations must embrace physician well-being as a critical factor in the long-term clinical and financial success of our organizations. We must make both the prevention of burnout and the restoration of the joy of a career in medicine core priorities, and address this issue with the same urgent methods we would use to solve any other important business problem: commit to measurement, develop strategy and tactics, and allocate the resources necessary to achieve success.
To interpret these passages, note that the authors of the blog post were John Noseworthy, James Madara, Delos Cosgrove, Mitchell Edgeworth, Ed Ellison, Sarah Krevans, Paul Rothman, Kevin Sowers, Steven Strongwater, David Torchiana, and Dean Harrison (links are those supplied by the post.) All but Dr Madara are CEOs of large, nominally non-profit corporate hospital systems. Dr Madara is the CEO of the American Medical Association (AMA).
I would suggest that to a business CEO, efficiency refers to a state in which goods and services are produced with a minimum of costs. Furthermore, many business managers follow the business dogma first called the shareholder value theory, which seems mainly to be interpreted to mean managers should maximize short-term revenue as their first priority (look here). This is part of the larger financialization of all spheres of life, including hospital systems.
The focus on relentless revenue maximization may be reinforced by large incentives for top managers, particularly CEOs, based on revenue and other financial, not clinical outcomes. Such perverse incentives have resulted in huge increases in executive compensation for hospital CEOs. For example, as we recently discussed, author Dr John Noseworthy, CEO of the Mayo Clinic, received more than $2.3 million in total compensation in 2013, and was just reported to have received more than $2.5 million in 2015. Author Dr Delos (Toby) Cosgrove, CEO of the Cleveland Clinic, received more than $4.8 million in 2015 (look here).
Thus, too a hospital CEO, efficiency might mean the ability to provide services as cheaply as possible, and such efficiency is likely to be a top priority. The quotes above suggest that hospital CEOs mainly want to combat burnout to increase efficiency. One quote above refers directly to the monetary costs, again presumably to the hospital, of losing physicians to burnout. One quote refers to burnout as hampering physician productivity, which to a hospital CEO might mean the ability to produce maximum billing, that is revenue, in the minimum amount of time. Finally, one quote suggests that to the authors, burnout is a business problem, not a human problem, or a clinical problem.
Even stranger, two quotes suggest that the CEO authors believe inefficiency might cause burnout. That would appear very strange to employed physicians who may be increasingly pressured by top management to be more efficient, and thus to increase revenue. I would guess that many employed physicians would attribute their burnout to this relentless push for productivity and efficiency by top management.
So reading not between the lines, but the lines themselves suggests that the CEO authors might be more interested in reducing burnout to increase hospital revenues, and thus their total compensation, rather than to make physicians happier or more fulfilled, much to less improve patient care. Such a focus on revenue might not be reassuring to burned out physicians, especially those who feel forced to shortchange time spent with individual patients to fuel revenue. The repetitive discussion of efficiency and productivity in the Health Affairs blog post should worry any physician who feels his or her first responsbility is to take the best care of each individual patient.
Hear No Evil,...
Proximal Versus Organizational, Leadership and Governance Causes of Burnout
Here is what the blog post said about the causes of burnout:
The spike in reported burnout is directly attributable to loss of control over work, increased performance measurement (quality, cost, patient experience), the increasing complexity of medical care, the implementation of electronic health records (EHRs), and profound inefficiencies in the practice environment, all of which have altered work flows and patient interactions.We dealt with the curious citation of inefficiencies as a cause of burnout above.
The rest of the items seem more plausible. However absent from the post is consideration of why physicians lost control over work, have been subject to performance measurement (often without good evidence that it improves performance, and particularly patients' outcomes), and have been forced to use often badly designed, poorly implemented EHRs. Particularly absent was any consideration of whether the nature or actions of large organizations, such as those led by the authors of the blog post, could have had anything to do with physician burnout.
Contrast this discusion with how we on Health Care Renewal have discussed burnout in the past. In 2012, we noted the first report on burnout by Shanefelt et al(2). At that time we observed that the already voluminous literature on burnout often did not attend to the external forces and influences on physicians that are likely to be producing burnout. Instead, burnout etc has been addressed as if it were lack of resilience, or even some sort of psychiatric disease of physicians.
In fact, we began the project that led to the establishment of Health Care Renewal because of our general perception that physician angst was worsening (in the first few years of the 21st century), and that no one was seriously addressing its causes. Our first crude qualitative research(8) suggested hypotheses that physicians' angst was due to perceived threats to their core values, and that these threats arose from the issues this blog discusses: concentration and abuse of power, leadership that is ill-informed, uncaring about or hostile to the values of health care professionals, incompetent, deceptive or dishonest, self-interested, conflicted, or outright corrupt, and governance that lacks accountability, and transparency, . We have found hundreds of cases and anecdotes supporting this viewpoint.
We found some corroboration of these hypotheses from other research. Written comments from the 2001 Massachusetts survey made similar points about the causes of dissatisfaction, for example: "too much emphasis on the bottom line. Taken over by large corporations. Quality of care and interaction now subsumed by productivity and profit," and "the once most noble profession has become a factory job with a facade of ethics"(4) Pololi and colleagues' qualitative interviews of young medical faculty included anecdotes of angst due to academic leaders who put revenues ahead of patient care, teaching, and research; and who allegedly used deception for personal gain.(9) (Also, see our comments on this paper.)(10) Pololi and colleagues' large survey of US medical faculty showed that over half thought that managers were only interested in them because of the money they brought in.(11) We were able to show in a preliminary analysis of data from a physician survey that an instrument meant to measure physicians' perception of the integrity of the leadership of their organizations, which incorporated questions about whether leaders supported core values, put patient care ahead of revenue, supported transparency about quality issues, put patient care ahead of self-interest, and displayed honesty strongly correlated (negatively) with stress, intention to leave the practice, and burnout.(12)
Yet at best most studies of physicians' burnout, angst, or dissatisfaction only vaguely allude to "system factors" and not greedy, money-focused, preversely incentivized, self-interested, or corrupt leadership, etc as its causes. "System factors" such as bad EHRs and performance measures suggested by the Health Affairs bloggers were more likely to have been imposed on physicians by bad organizational leadership than by the physicians themselves. Of course, the CEO authors of the post likely would be made very uncomfortable with the notion that bad health care leadership, including of hospital systems like their own, might be a major cause of burnout.
Furthermore, there clearly have been leadership problems at many of the blog post authors' institutions that could have made them more uncomfortable. Cases involving some of the authors' institutions have appeared on Health Care Renewal.
Most recently we noted that Mayo Clinic CEO Dr Noseworthy had raised questions of mission-hostile management by suggesting that the Mayo Clinic should give some patients with commercial health care insurance priority over those with less well paying government health insurance (look here). Not long ago we noted the controversy generated by Cleveland Clinic CEO Dr Cosgrove's lukewarm approach to the Trump administration's "Muslim ban," even though that ban had affected one of the Clinic's own house-staff, while the Clinic was planning a fund raising event at Mr Trump's Mar a Lago resort, raising yet more conflict of interest questions (look here).
We have also disccused issues occurring at the American Medical Assocation, and particularly its RBRVS Update Committee (RUC) (CEO Dr Madara), Sutter Health (CEO Ms Krevans), Johns Hopkins (CEO Dr Rothman), Duke (CEO Mr Sowers), Partners (CEO Dr Torchiana), and Northwestern (CEO Mr Harrison).
Finally, several of the Health Affairs authors have "board level" conflicts of interest. In 2006, we first blogged about a "new species of conflict of interest" which involved health care organizational leaders who were simultaneously members of the boards of directors of for-profit health care corporations or other corporations which could strongly influence health care. We posited these conflicts would be particularly important because being on the board of directors entails not just a financial incentive, but also requires board members to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]
Two Health Affairs blog authors have such conflicts. Dr Paul Rothman is on the boards of Merck and of Cancer Genetics, a biotechnology company specializing in DNA based testing. Dean M Harrison is on the board of Northern Trust, a wealth management firm. He was on the board of Ikaria Inc, a biotechnology company now part of Mallinckrodt, and incidentally is a special advisor to Merrick Ventures, a private equity firm (look here).
Thus, how can one regard as credible an article on physician burnout which ignores how large organizations' nature or actions might be the major cause of such burnout, and which was written by the top leaders of such organizations?
Corporate Employment as a Cause of Burnout
Finally, the Health Affairs post mention of "loss of control over work" deserves special attention. It could represent a catch-all of more "system factors" as noted above. However, the biggest cause of physicians' loss of control over work may be the rising power of large health care organizations, in particular the large hospital systems that now increasingly employ physicians, turning them into corporate physicians.
In the US, home of the most commercialized health care system among developed countries, physicians increasingly practice as employees of large organizations, usually hospitals and hospital systems, sometimes for-profit corporations. The leaders of such systems meanwhile are now often generic managers, people trained as managers without specific training or experience in medicine or health care, and "managerialists" who apply generic management theory and dogma to medicine and health care just as it might be applied to building widgets or selling soap.
We have also frequently posted about what we have called generic management, the manager's coup d'etat, and mission-hostile management. Managerialism wraps these concepts up into a single package. The idea is that all organizations, including health care organizations, ought to be run people with generic management training and background, not necessarily by people with specific backgrounds or training in the organizations' areas of operation. Thus, for example, hospitals ought to be run by MBAs, not doctors, nurses, or public health experts. Furthermore, all organizations ought to be run according to the same basic principles of business management. These principles in turn ought to be based on current neoliberal dogma, with the prime directive that short-term revenue is the primary goal.
Again, the authors of the Health Affaris post included some generic managers: Mr Edgeworth, whose highest degree was an MBA, and who had a long career as a hospital manager; Ms Krevans, and MBA with an MPH, who also had a long career as a hospital manager; and Mr Harrison, an MBA, who also had a career in hospital management. Doubtless all of the authors lead organizations whose upper management is frequently generic and managerialist. It is likely that the hospital systems they lead increasingly employ physicians, who thus have become corporate. So the Health Affairs blog authors might not be comfortable with the notion that a major cause of burnout may physicians' new status as hired employees sometimes of their own hospital systems, rather than autonomous practitioners.
To repeat, how can one regard as credible an article on physician burnout which ignores how large organizations' nature or actions might be the major cause of such burnout, and which was written by the top leaders of such organizations?
I am glad that physician burnout is getting less anechoic. However, in my humble opinion, the last thing physicians at risk of or suffering burnout need is a top down diktat from CEOs of large health care organizations. The CEOs who wrote the Health Affairs post may not have any personal responsibility for any particular physician's burnout. However, the transformation of medical practice by the influence of large health care organizations run by the authors' fellow CEOs, particularly huge hospital systems, often resulting in physicians practicing as hired employees of such corporations likely is a major cause of burnout. If the leaders of such large organizations really want to reduce burnout, they should first listen to their own physicians. But this might lead them to realize that reducing burnout might require them to divest themselves of considerable authority, power, and hence remuneration. True health care reform in this sphere will require the breakup of concentrations of power, and the transformation of leadership to make it well-informed, supportive of and willing to be accountable for the health care mission, honest and unconflicted.
Physicians need to join up with other health care professionals and concerned member of the public to push for such reform, which may seem radical in our current era. Such reform may be made more difficult because it clearly would threaten the financial status of some people who have gotten very rich from the status quo, and can use their wealth and power to resist reform.
Despite the fact that the current US president has stated he is for the "forgotten people" rather than the elites, do not expect such reform from him. He has sought advice on health care policy from the same people who wrote the Health Affairs post, as per the Washington Post, December 28, 2016:
On Wednesday, his guests were health-care executives, many of whom represent companies or institutions that have a big stake in the outcome of Trump’s ambitions to dismantle the Affordable Care Act. According to a pool report, the group, all men, met with him at 11 a.m. at the Mar-a-Lago estate in Palm Beach, Fla. They included John Noseworthy of the Mayo Clinic, Paul Rothman of Johns Hopkins Medicine, David Torchiana of Partners HealthCare and Toby Cosgrove of the Cleveland Clinic.
We truly live in interesting times.
1. Shanafelt TD et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc 2015; 90: 1600-1613. Link here.
2. Shanafelt TD, Boone S, Tan et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012; available online here
3. cited in Schroeder SA. The troubled profession: is medicine's glass half full or half empty? Ann Intern Med 1992; 116:583-592.
4. Massachusetts Medical Society. Physician satisfaction survey (2001). Link here.
6. Kaiser Family Foundation. National survey of physicians - part III: doctors' opinions about their profession. Link here.
7. Merritt Hawkins & Associates. 2007 survey of primary care physicians. Link here.
8. Poses MD. A cautionary tale: the dysfunction of American health care. Eur J Int Med 2003; 14: 123-130. Link here.
9.Pololi L, Kern DE, Carr P, et al. The culture of academic medicine: faculty perceptions of the lack of alignment between individual and institutional values. J Gen Intern Med 2009; 24: 1289-95. Link here.
10. Poses RM, Smith WR. Faculty values. J Gen Intern Med 2010; 25: 646. Link here.
11. Pololi L, Ash A, Krupat E. Faculty values in the culture of academic medicine: findings of a national faculty survey. Link here.
12. Poses RM, Baier-Manwell L, Mundt M, Linzer M. Perceived leadership integrity and physicians’ stress, burnout, and intention to leave practice. J Gen Intern Med 2005; 20: S182. Link here.
"For the Love of Money" by the O'Jays, used as the opening theme for (now President) Donald Trump's Celebrity Apprentice