Thursday, August 23, 2012

Will Another Study on Physician Burnout Finally Lead to Addressing its Causes?

The latest article on physician burnout has actually attracted some media attention.  e.g., here and here.

The Latest Article

The article was a survey of physicians in all specialties with over 7000 respondents (unfortunately a less than 27% response rate.)(1)  Its most notable findings were:
- The rate of burnout among physicians was 45.4%
-  Physician specialties with higher than average rates were emergency medicine, general internal medicine, neurology, and family medicine.
- The proportion of physicians who may have been depressed, (using the Primary Care Evaluation of Mental Disorders screening instrument,) was 37.8%

So almost half of all physicians, and more than half of the front-line physicians who treat adults appear to be burned out, while more than one-third of physicians may be clinically depressed.  So it is not surprising that the authors called the rate of burnout "alarming." 

They also commented on the implications of their data,
Unfortunately, little evidence exists about how to address this problem. Although extensive literature suggests that contributors include excessive workload, loss of autonomy, inefficiency due to excessive administrative burdens, a decline in the sense of meaning that physicians derive from work, and difficulty integrating personal and professional life, few interventions have been tested. Most of the available literature focuses on individual interventions centered on stress reduction training rather than organizational interventions designed to address the system factors that result in high burnout rates.
Previous Studies of Burnout and Dissatisfaction

This study, in fact, 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.(2)  In a 2001 survey of Massachusetts physicians, 62.3% were dissatisfied with the practice environment.(3)  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.(4)   In a survey of primary care physicians in 2007, 38.7% were somewhat or very dissatisfied.(5)  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.

The Causes of Dissatisfaction and Burnout

What is most remarkable about this voluminous literature is its relative lack of attention to the external forces and influences on physicians that are likely to be producing burnout, and the general aversion to promoting any interventions that could conceivably affect these external threats. Instead, burnout etc has been addressed as if it were some sort of psychiatric disease of physicians. This was noted above by Shanafelt et al.

In fact, the reason that we did the crude qualitative literature that lead to my articles on health care dysfunction (6), and to the establishment of Health Care Renewal was a 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 research suggested 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, bad governance and leadership of health care organizations, and the rise of various dishonest and unethical practices that affect physicians. We have found hundreds of cases and anecdotes supporting this viewpoint.

There is some corroboration of these assertions.  Some 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"(3)  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.(7)  (Also, see our comments on this paper)(8)  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.(9)   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.(10)

Yet at best studies of physicians' burnout, angst, or dissatisfaction only vaguely allude to "system factors" and not greedy, money-focused, self-interested, or corrupt leadership, etc at its causes.  And again as noted above, most interventions meant to improve burnout have treated it like a psychiatric illness, not a rational response to a badly lead, dysfunctional health care system.

Why Has Nothing Changed?

The real question is why so little has changed given this now 20 plus year history of the documentation of burnout, and why there has been such avoidance of what appears to be the real causes of the problem. One question worth raising again at this time is why the organizations one might think would be interested in helping physicians address causes of burnout have not done so.

One might think that medical societies, foundations interested in improving health and health care, bodies that accredit physicians, and academic medicine in general would all be interested in addressing the causes of physician burnout, dissatisfaction, and angst.  However, I am aware of no significant action on their part.  (There have bee some some marginal actions by the smallest of these organizations, e.g., the Society of General Internal Medicine's call to "chuck the RUC," see this post)

We should not be surprised, since most of these organizations have become more creatures of health care corporations than noble proponents of physicians' core values.  Most of these organizations have substantial institutional conflicts of interest, and are often lead by individuals with their own individual conflicts of interest.   

Medical societies, in particular, now often get significant financial support from industry (pharmaceutical, biotechnology, medical device and even health insurance companies).  The societies' leaders are often full-time executives, not necessarily physicians, who may look to their industry sponsors to continue to provide the funds that support nice salaries and luxurious offices.  The society's officers and boards are often dominated by physicians with their own conflicts of interest.  (Look here for more examples, and see, in particular, the case of the AAOS).

Similar conflicts may affect accrediting organizations, health care foundations, and especially academic medical institutions, as we have profusely discussed.  (Look at our posts on conflicts of interest, and institutional conflicts of interest.)

So if physicians really want to address what is making them burned out and dissatisfied, they will have to regain control of their own societies, organizations, and academic institutions, and ensure that these organizations put core values, not revenue generation and providing cushy compensation to their executives, first.  


1.  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.
2.    cited in Schroeder SA. The troubled profession: is medicine's glass half full or half empty? Ann Intern Med 1992; 116:583-592.
3. Massachusetts Medical Society. Physician satisfaction survey (2001). Link here.
4.  Kaiser Family Foundation. National survey of physicians - part III: doctors' opinions about their profession.  Link here.
5.  Merritt Hawkins & Associates. 2007 survey of primary care physicians.  Link here.
6. Poses MD. A cautionary tale: the dysfunction of American health care.  Eur J Int Med 2003; 14: 123-130.  Link here.
7.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.
8.  Poses RM, Smith WR. Faculty values. J Gen Intern Med 2010; 25: 646. Link here.
9. Pololi L, Ash A, Krupat E. Faculty values in the culture of academic medicine: findings of a national faculty survey. Link here.
10.  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.


Judy B said...

Bravo, Dr. Poses! Until docters regain control of their profession, nothing will change with regard to medical care reform or addressing problems within the profession such as burnout. Unfortunately, the vested interests will fight this tooth and nail!

Anonymous said...

One of the problems with this issue is it is viewed as a doctor only problem My reality is it impacts the doctor/patient relationship to such a point as to be a patient problem that we are ill equipped and unable to solve.

Doctors are trained to take every problem and break them down into the smallest parts and then solve those parts. This breath, bleed, broken approach may work well in the ER, but does nothing to solve the problems of the patient as a whole. Add to this the continuing abusive nature of medical training (1) and we have a person who is set up to fail as we all tend to revert to our training when faced with a large problem.

Doctors increase patient counts or testing to achieve the financial goals of the practice or of the practice owners. This increases stress as even the slights problem causes a backup and a loss of productivity. Phone calls and forms become something to dread. Patient interactions are stripped to the bare minimums. I have spoken to doctors who view patients as an unnecessary part of their practice as all they need is the paperwork to complete a diagnosis.

Doctors then treat their patients in the abusive manner they were treated in medical school, or worse, inflicting unnecessary pain on their patients. I have spoken with doctors who will state that injections and blood draws cause no pain or discomfort, and then break down injections to their individual parts to maximize profits.

Blood draws are such a part of the medical culture that even when not ordered they are done by staff. (2) We can now add imagining studies which impart large doses of radiation because it drives the bottom line, but will certainly have an impact on patient health in the future.

The curt tone in the office, the lack of eye contact, the insults, multiple injections and blood draws, or worse invasive test based on the excuse “we need to be sure” leave the patient as the one suffering the physical and mental results of the doctor’s burnout.



Steve Lucas

Roy M. Poses MD said...

Steve Lucas,
I completely agree that burnout may have bad effects on patient care, and that is another very big reason it needs to be honestly addressed.

Afraid said...

Administrators see MDs as whiners.

Roy M. Poses MD said...

I'm sure you are correct. I, for one, have been called a "whiner and complainer," and worse by administrators.

On the other hand, as noted above, many physicians call adminstrators clueless, greedy, uncaring, and sometimes dishonest or criminal. There is plenty of evidence that they may be right.

For example, look at some of what we have written on
executive compensation
executive lifestyle
golden parachutes
ill-informed management
imperial CEO
mission-hostile management
etc, etc, etc

Dike Drummond MD CPC said...

The doctors are the canary in the coal mine of medicine and we simply cannot allow them to drop at this rate.

The literature on burnout over the last 20 years is completely consistent with this study. 1 in 3 doctors on average are suffering from symptomatic burnout on any given office day. These statistics are worldwide, regardless of the docotor's specialty OR the type of healthcare delivery system.

The biggest cause is the conditioning of our healthcare educational system which effectively installs a survival mechanism in all doctors that has four key components.
Emotion Free
Lone Ranger

This is a key set of skills we all must use to survive training and NOT a great way to live a life.

It is this programming that is primarily responsible for the epidemic of burnout we see in medicine. The additional post-graduation stresses of "the business of medicine", our complete lack of functional leadership skills and the uncertainties of political "reform" and the changing practice landscape - 75% of doctors are projected to be employees by 2013 - not to mention raising a family with this #800 gorilla of a career. It is a recipe for this dysfunction.

Where do we go from here? It is a multifactorial answer. The doctors need the skills to lower stress and prevent burnout as individuals. That is why I created my website. We know what works to create a more resilent doctor and prevent burnout and it is rarely taught in the standard medical school and residency curriculum. And organizations bear a large responsibility because it is so darn easy to focus on the patient .... and not see that - in healthcare especially - the health and wellbeing of the provider has a direct impact on the quality and healing at the level of the patient.

We have a moral, ethical and business imperative to support the wellness of the providers and not treat doctors like piece workers on a production line.

These are immensely important topics that deserve more than a blog comment to do them justice. If you REALLY want to explore this issue in a way that has a chance to create meaningful change. Please contact me through my website.

The doctors are the canary in the coal mine of modern healthcare ... unfortunately that same canary is the one coordinating the care of everone in your system... and we cannot afford to let them drop.

My two cents,

Dike Drummmond MD
TheHappyMD (dot) com

Anonymous said...

Excellent post.

After 30 years in medicine, I've managed to largely avoid burnout by, 20 years ago, moving from an employed position to private practice. I like having SOME degree of control over my work environment.

That said, there is nothing in medicine I find more infuriating, more depressing, more stressful than the lack of a professional society that represents my interests. My society, the AAFP, has very clearly decided to align itself with the interests of CMS and the large insurers, to the detriment of family physicians and their patients.

The leadership of the AAFP is either completely corrupt, or so deeply stupid as to be almost incomprehensible. I'll be charitable, and pick the first option.

M. George, M.D. said...

I am a solo F.P., and I too am very frustrated by what is going on in our profession. I seems that the powers that be are hell bent on driving private practice out of existence. AAFP states they are concerned about the burnout rate, which is mostly due to the added burden of PCMH and meaningful use requirments. Then they go on to praise FPs for being willing to participate in the new Comprehensive Primary Care initiative. This program is designed to see how much money medicare can save based on a capitated model that is heavily incentive driven.
AAFP President Glen Stream, M.D. states that its success is crucial so that the model can be expanded to the rest of the country. This seems very odd to me considering that millions of newly insured patients will be seeking healhcare from burned out and over worked physicans.
By the way has anyone noted the drop in the passing rate for Family Medicine recertifiers. Please take a look at the numbers since 2010 to the present. I am just thinking that if you are not board certified, then you have to work for some entity that will not pay what the pivate sector does. Just my thoughts, thanks.
M. George, M.D.

Anonymous said...

Super article, Dr. Poses. I saw it because it was (probably auto-posted) in my Medscape account.

I also posted to Sermo and got some responses:

I would like to ask you and your readers to look at those responses. These ideas need to spread, and yours is the best articulation.

PS - Your comment verification is really difficult; I'm already on my 5th try. Maybe just letters, not numbers.

Roy M. Poses MD said...

Anonymous of 23 November, 2012

Thanks for your comments.

I do not have access to Sermo. Can you put those comments in another comment on this post, or send them to me?

Sorry about the verification. It is what is available on the Blogger site, which kindly hosts this blog without requiring payment from me.

Anonymous said...

No worries on the comment verification.

Sermo is worthwhile. There is a mix of postings some very thoughtful, and some angry or sarcastic (no surprise). But I think that your ideas deserve more readers.

I have been on Sermo for years, and it looks to me like the signon is simple, quick and free.

BUT, I think that you have to fax them a copy of your license (or maybe diploma), and I don't know how quick they are to respond. AND, they have strong user agreement rules about reposting and sharing outside, so I am going to respect that.

Good post; best wishes.

Anonymous said...

72 comments on Sermo post about your article. Quality is good.