Physician burnout

1. Physician burnout Thursday, November 20, 2014 Seth D Bilazarian, MD DrSeth@pmaonline.com

2. Physician burnout • Nearly 46% percent of 7288 surveyed physicians said they experienced at least one symptom of serious burnout, according to a study published in the Archives of Internal Medicine. • Compared with workers in the general population, physicians had an 8.6% higher risk of emotional exhaustion and 10% higher risk of overall burnout. Arch Intern Med 2012; DOI:10.1001/archinternmed.2012.3199.

3. Defining burnout • What is it? • Should we care? • As individuals? • As a profession? • As a society? • Why is it happening?

4. Burnout among physicians was measured using the Maslach Burnout Inventory (MBI) 45.8% of physicians reported at least one symptom of burnout The MBI has three subscales to evaluate each domain of burnout: Emotional exhaustion Depersonalization Low personal accomplishment Burnout and satisfaction with work/life balance among US physicians  Arch Intern Med 2012; DOI:10.1001/archinternmed.2012.3199.

5. Lay press articles The root of physician burnout - The Atlantic The physician burnout epidemic: What it means for patients and reform - The Atlantic The widespread problem of doctor burnout - NYTimes.com Doctor burnout: Nearly half of physicians report symptoms –USA Today Is your doctor burned out? Nearly half of US physicians say they're exhausted – Time Healthland

6. Shortage of physicians? • "By 2015, the US will be 62 900 doctors short, and the future looks even worse," Archambault said. "By 2025, the estimated shortage of doctors will more than double, as baby boomers require more care and Obamacare grants more insurance cards. Seeing a doctor in a reasonable amount of time may be a thing of the past, unless meaningful consumer-directed reform is passed soon." Romneycare hints at future doc shortage. BostonHerald.com

7. Six in 10 physicians would quit today • Doctors are working less, seeing fewer patients, and many would quit if they could, a sweeping survey of 13 575 physicians from across the nation shows. • A Survey of America's Physicians: Practice Patterns and Perspectives was commissioned by the Physicians Foundation. It is the latest and perhaps the largest and most comprehensive of a number of surveys that have identified wide, deep, and increasing discontent among the nation's physicians regardless of their age, gender, specialty, location, or employment status. A Survey of America's Physicians

8. Changes in patient-physician interaction • EMR • Patient autonomy: Can a patient demand care the doctor feels is inappropriate? • Patient satisfaction? • Appropriate-use criteria and Choosing Wisely • Patient-centric care

9. Changes in the law • ACA or Obamacare • Romneycare • Physicians' reaction to it • Physicians being blamed for the inefficiencies and inadequacies of the healthcare system

10. Cardiologists speaking after SCOTUS upholds ACA • Almost universally praised aspects of it (universal coverage) • Almost universal in expressing uneasiness, poorly articulated views about • Impact on societal costs • Practice and delivery of medicine • Impact on American medical innovation—drugs and devices • Clumsy

11. The Anti-ACA view • This bureaucratization will amplify everything patients and businesses despise about the current system: the unintelligible $103 234.61 bill for a turned ankle, the doctor who can't take a phone call because of how the hospital schedules shift. • Why aren't mom's eight specialists aware of each other's existence? Why is healthcare mostly conducted via a pad and pen and beepers and fax machines in the iPhone era? Why are there so few geriatricians when the first wave of baby boomers is already turning 65? Why is it still so hard to find usable information about quality and prices? Cheesecake Factory Medicine WSJ August 27, 2012

12. Doctors who view medicine as a calling are more satisfied (part 1) • They feel better about caring for patients with complex conditions such as obesity and alcohol addiction than other physicians, research shows. • The reasons that drive doctors to practice medicine can have an impact on how satisfied they are caring for patients with challenging conditions, says an Archives of Internal Medicine research letter published online August 27. • Researchers analyzed data from a national survey of 1504 primary-care physicians. They found that doctors who see medicine as a calling are more likely than other physicians to be satisfied treating patients who are obese or addicted to nicotine or alcohol. Doctors who view medicine as a calling are more satisfied. amednews.com

13. Doctors who view medicine as a calling are more satisfied (part 2) • Of the three conditions, physicians were most satisfied treating nicotine dependence (62%), followed by obesity (57%) and alcoholism (50%). • Physicians who are unhappy with their career choice are less likely to be satisfied treating those disorders, and they often blame patients for their conditions. • The findings are significant, given high rates of burnout in the profession, said study coauthor Dr John D Yoon, an assistant professor in the University of Chicago's Section of Hospital Medicine and associate faculty member at the MacLean Center for Clinical Medical Ethics. http://www.ama-assn.org/amednews/2012/09/10/prsc0910.htm

14. Changes in response to legal and financial pressures by the healthcare system • Family farm vs ADM • A1 Deli vs Cheesecake Factory http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande

15. Political counterpoint to the Big Medicine piece of Dr Atul Gawande in the New Yorker The highlighted aspects are the corporatization of medical practices and the payment advisory board. "The 'most important institutional change' after ObamaCare passed in 2010: the independent payment advisory board composed of 15 philosopher kings who will rule over US healthcare." The unknown aspects of who, what, and why and perceived hazards of this decision-making process are discussed. "The longer-run danger is . . . cost board starts to decide what types of care 'work' for society at large and thus what individual patients are allowed to receive."' "The Cheesecake Factory is a great place to eat but you probably wouldn't want to be operated on there—especially if it's run by the government." Anti-Cheesecake view Cheesecake Factory Medicine. Wall Street Journal

16. Big medicine–Cheesecake Factory: Where they fall short • No discussion on inelasticity of pricing (high-end restaurants don't cost the same as fast-food restaurants) • Not responsible for patient's care before and after interactions • Restaurants are incentivized to capture as much business as possible but are not required legally or expected ethically to serve all comers • There is no defensive-medicine equivalent in the dining industry • The problem of poor coordination as described is real and serious but this has been foisted on doctors ("Too many cooks spoil the pot") but we are complicit • I didn't have as good a meal as Dr Gawande did

17. Should we care about burnout? "Ultimately resistance that is not addressed creatively can frazzle nerves . . . and overly burden. . . . Prolonged contact with conflict and criticism wears them down, robs them of joy. Many . . . simply want out" Leadership Essentials by Greg Ogden and Daniel Meyer p 154

18. What's frustrating • EMR has several advantages but reviewing it is time consuming—"Where's the beef?" • Oversight in the office ICAEL, ICANL 48-hr turnaround • Hospital—appropriate-use criteria, malpractice, public reporting • Daily practice hospital computer systems—not ready for prime time order preop antibiotic, nine signatures prior to cath • Post hoc scrutiny

19. Is life is easier? • Night float, hospitalists, nocturnists Exclusive: Nocturnists on hand for the critical hours. news-press.com

20. Relevant articles in the Atlantic • The Physician Burnout Epidemic: What it means for patients and reform • The Root of Physician Burnout

21. Reducing dissatisfiers Reduce stressors by cutting back on working hours, relaxing intrusive oversight, and finding ways to lift the burden of "busywork" from the shoulders of physicians. Fair pay Enhance fulfillment Focus on the work itself. Do physicians recognize what they find most fulfilling? What does their best work look like? Are they making full use of their knowledge, skills, and innate abilities? Are they growing and developing as human beings? Do they feel that they are making a real difference in the lives of their patients and communities? The root of physician burnout"Incentivizing with money is a self-fulfilling prophecy of cynicism. We must promote compassion, courage, and wisdom among our physicians before we "make a sordid business of this high and sacred calling."

22. The widespread problem of doctor burnout (NY Times and the Atlantic) • Almost half complained of being emotionally exhausted, feeling detached from their patients and work, or suffering from a low sense of accomplishment. • She feels increasingly frustrated with what she calls the "bureaucratization" of medicine and resents spending "more time filling out forms than caring for patients."  The widespread problem of doctor burnout. New York Times

23. Dave Scott (Cornwall Bridge, CT) • Burned-out doctors will not question or fight the system. They will cheat to survive. And those who profit from the system as it is will want to leave burned-out doctors as they are. Unburned-out doctors would try to change things. • If you want to find out why doctors are burned out, figure out who benefits from burned-out doctors. Those who benefit from burned-out doctors would be those whose routines and practices would be disrupted by doctors who weren't burned out, who were still trying and caring. Burning people out gets rid of their idealism, and medicine is one of the fields (teaching is another) that uses idealism and service to attract people.

24. Weak? Entitled (I've worked really hard and got all As)? Anxiety from transition, change, and uncertainty? "Broken contract" Addicted to affirmation—less appreciation shown by patients Frustrated with blame for ills of the system (especially cost) More deep rooted? This is not what I signed up for, this is not my calling, these are not my values. Is it because physicians' values are being compromised? My comment: Why are physicians frustrated and burning out?

25. Systemic American healthcare system values are in evolution • ACA • MA referendum on physician-assisted suicide • Impact of declining small group practices and rise of Big Medicine=HCA (family farm=ADM) • Geographic variability (Dartmouth Atlas) and recent reports of grotesque fraudulent care (HCA in NY Times)

26. Physician values • Largely comes during training: internship, residency, and fellowship • Messages I heard: • "Did you sleep?" • "Trust no one" • Things I saw: • Meticulous review of every lab and imaging value prior to discharge • Want everything at discharge to be tied up in a neat package—"put a bow on it"

27. Ethical concerns: Always put the patient first • Not treat (therapeutic nihilism) • Treat • Treat if the patient wants treatment (patient centric) • Treatment if guidelines and evidence warrant treatment • Avoid treatment if uncertain (nonagenarians, PFO, renal stenosis, atherogenic dyslipidemia, vitamin D) • What would you do if I were your mother?

28. Studies question P4P (part 1) • Programs that reward doctors and hospitals for hitting certain quality targets are being rolled out in Massachusetts and across the country. A major focus is that doctors should be paid for keeping patients healthy rather than for the volume of tests or treatments they order. • A review of seven studies of primary-care programs that paid doctors extra for meeting certain targets, published by the Cochrane Collaboration in September, was inconclusive about the effect on quality of care. "Implementation should proceed with caution," the authors wrote. • Published in March (NEJM) a large Medicare pilot program that paid providers more if they met certain process targets—and docked those who did poorly—did not reduce short-term patient mortality rates. A version of the program is being rolled out nationally. The authors of the paper called the results "sobering." Studies question medical rewards. Boston.com

29. Studies question P4P (part 2) • In BMJ editorial 8/14/2012 • Explains why they think paying doctors more based on quality metrics is inherently problematic • Hospitals and doctors can easily change their reporting practices to improve their quality scores • Financial incentives can undermine doctors' intrinsic desire to help their patients. The idea that people will be motivated to do better if they are paid more as a result may seem like common sense, but medicine is complex. Often the measures used to determine success do not match the conditions of care or patient outcomes the program is meant to address • Other fields have struggled with pay-for-performance programs. Under national education policy, schools that score poorly on standardized tests receive less funding. "They're the ones who need it most," he said. "Is the right reaction to poor quality that those institutions need fewer resources, not more?" Studies question medical rewards. Boston.com

30. Conclusions • Burnout is real and has both qualitative and quantitative risks for healthcare delivery and our profession • My take: Physicians are dealing with a time of transition—like it or not we are becoming more like tradespersons than professionals with a calling • The systemic changes that contributed to this had noble intent—(eg, physician work-hour limitation) but have diminished physician autonomy to such an extent that following the rules and feeling "excessively scrutinized" and avoiding criticism is becoming the chief professional motivation • Aspiring to conduct oneself in a profession as a career with a calling is a noble intent and may have benefits for both patients and physicians