by Steven Adelman, M.D.
A recent study* published in the Mayo Clinic Proceedings lends further evidence to what some are starting to refer to as the mounting occupational health crisis in health care. Between 2011 and 2014, an objective measure of burnout now registers 54% of practicing physicians as “burning out” (up from 46%). Physicians in high burnout specialties like family medicine, internal medicine and emergency medicine are experiencing burnout at a rate of approximately 60% ! As physician burnout increases, the work-life satisfaction of physicians has decreased from 49% to 41%.
This is a large study with a non-physician, general population control group. The burnout rate of other US adults is much lower and not increasing. As physician work-life satisfaction decreases, others in our society are becoming more satisfied. Physicians work an average of 55 hours per week as compared to 40 hours for non-physicians. And we are 75% more likely to experience suicidal ideation in the course of a year (7% vs. 4%).
Accompanying this eye-opening burnout study is a provocative editorial by William Lanier, MD, editor-in-chief of the Mayo Clinic Proceedings and Dan Ariely, Ph.D., a professor of psychology and behavioral economics at Duke. They hypothesize that the following 3 factors play a significant role in the burnout and dissatisfaction of practicing physicians:
- Asymmetrical Rewards
- Loss of Autonomy
- Cognitive Scarcity
Asymmetrical Rewards: In our industrialized “zero defect” environment, physicians are expected to deliver excellent and cost-effective care in a fashion that delights every single patient. In many systems, there is a relentless focus on the practicing physician’s imperfections. A busy internist may see 30-40 patients in the course of a day in the office. If a single patient complains that the doctor seemed rushed and unsympathetic, that complaint may become the focus of a time-consuming sit-down that may take on a life of its own. The positive care experiences of the overwhelming majority of the physician’s patients fade in comparison to the hassles and scrutiny brought on by a single patient complaint.
Loss of Autonomy: Practicing physicians, especially those who are employed and those who work in primary care, now answer to a coterie of masters. A bevy of metrics, initiatives, guidelines, prior authorization busy-work and required protocols now jockey with click after click on the electronic medical record to take up the majority of one’s time in the office. Although the doctor-patient clinical encounter remains at the heart of medical practice, non-value-added intrusions get in the way at every turn. Here in Massachusetts, some patients come to the office armed with an agenda that they expect their physician to follow. One internist I met last month was rather taken aback when he tried explaining to his patient why it was unwise for him to switch her to a new medication she had seen advertised on TV. The patient’s comment to her physician was a curt, “How dare you not listen to me? What are you – an idiot?” Along with a loss of autonomy, many of us also experience a troubling loss of respect and status.
This refers to the challenge of making complex decisions at a breakneck pace. ORs are tightly scheduled. Physicians in office practices are over-booked, with same day requests squeezed in to enhance satisfaction scores. Changes in coverage and societal ills like drug addiction have many emergency departments filled beyond capacity. To many physicians, the practice of medicine feels like a game of “Whack-a-Mole.” But patients are not moles; they are fellow human beings, with serious illnesses, complex problems, life and death concerns. After Captain Sully landed his plane on the Hudson River he was given 6 months off to recover from the trauma. Practicing physicians do not have the luxury to recharge their batteries – the onslaught of pain, suffering and rapid-fire decision making is incessant. The enormity of all of this requires us to reflect and recover, yet we lack time buffers to regain our footing and equanimity. This depletes us; hence, burnout.
Ariely and Lanier do not offer a concrete fix for a system that is dehumanizing the central figures upon whom it relies. The profession has changed around us, yet our macho culture and industrialized work environment have failed to accommodate to the reality of this occupational health crisis and the burnout it is producing. It’s time for us to step up, as individuals, groups, organizations and systems, to identify and address the root causes of a phenomenon that threatens the health and well-being of the best and the brightest.
*Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014.
Shanafelt TD et al. Mayo Clin Proc. 2015 Dec;90(12):1600-13.
Steven Adelman, M.D., is director of Physician Health Services, a non-profit corporation founded by the Massachusetts Medical Society.