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Physician Burnout: Why its not a Fair Fight

  
  
  

physician burnout article physician stress 150x150Physician Burnout vs. Fulfillment
Why it’s Not a Fair Fight

[CLICK HERE for the Physician Burnout Bibliography supporting this article]

Why does having a sense of satisfaction and fulfillment as a modern doctor seem like such a struggle at times? There is an invisible battle going on, day-by-day between our search for a Fulfilling Career in Medicine and the hidden forces of Physician Burnout.

In this article, originally published in the Sermo Speaker Series and on this physician burnout post on KevinMD.com,  I will outline why this is not a “fair fight” and the latest physician burnout research evidence on what you can do to even the odds.

What is Physician Burnout Anyway?

We each know what it feels like to be burned out, toast, fried and spent after a long weekend of call or a tough night in the hospital. If you are able to recover your drive and energy before you return to work, great job. I hope your resilience continues.

The difference between Stress and Physician Burnout is this ability to recover in your time off. Physician Burnout begins when you are NOT able to recharge your batteries between call nights or days in the office. You begin a downward spiral that has three distinct symptoms.

  • Physical and Emotional Exhaustion:
    • You are emotionally drained, depleted and worn out by work and not able to recover in your non-working hours
  • Depersonalization:
    • The Development of a negative, callous and cynical attitude toward patients and their concerns (“my patients are so #%*&!”)
    • The cardinal sign here is cynicism, sarcasm and feeling put upon by your patients.
  • Reduced Sense of Personal Accomplishment:
    • The tendency to see your work negatively, without value or meaningless (“what’s the use?”) and see ourselves as incompetent.

The standardized questionnaire measuring these three scales of physician burnout is called the Maslach Burnout Inventory (MBI). The inventors of the MBI described physician burnout as:

” … an erosion of the soul caused by a deterioration of one’s values, dignity, spirit and will.”

The Burnout – Engagement Continuum

Physician Burnout can be thought of as one extreme of a continuum with Career Engagement on its other end.

Physician Burnout < —————–> Physician Engagement

The feelings associated with full Engagement in your career are ones of fulfillment and satisfaction. You feel your work makes a positive difference in people’s lives and your career has true meaning. Engagement is the emotional gold standard for career success and at the opposite end of the  continuum with physician burnout.

It’s a Battle Out There – and it’s Not a Fair Fight

The forces of physician burnout and physician engagement are in daily conflict with each other. Much of the battle lies outside of our normal awareness.  While we focus on our patients and their issues, our practice environment is filled with invisible stresses that constantly pull us toward the physician burnout end of the continuum and actively block our experience of engagement.

Left to our own defenses, the average hard-working doctor is at a significant disadvantage in this battle. When we are dealing with physician burnout, it’s not a fair fight, plain and simple. Let me lay out some of these physician burnout building blocks so they are in plain view for all of us.

Please Note:
Each of these physician burnout supporters is a daily stress of practicing medicine that exists in addition to all the work you do to maintain your clinical skill set. I call these “invisible” because they are not WHAT you do at work, they are built into HOW you deliver your services.

To set the stage for this titanic struggle …

Imagine a boxing ring. Bright lights in your eyes. The noise of the crowd filling the stadium in anticipation of what is to come. You are sitting in your corner, gloves on, nervous, waiting for the bell to ring to start the match (your work day).

Physician Burnout is over in the opposite corner, smiling at you with a look of calm confidence. Burnout is a lot smaller than you thought … with a reputation for tenacity and powerful body punches. Suddenly you notice a whole host of trainers, coaches and support staff in the physician burnout corner. What the … ?

Here is a partial list of the invisible daily stresses who make up the team in burnout’s corner.

Being a Doctor is Stressful … Period

The “most stressful” professions are characterized as having a high level of responsibility and little control over the outcome. The practice of Medicine certainly fits that description and is consistently on the short list of professions with the highest inherent stress levels. This is a tough job that saps our energy every single day.

We work with sick people all day long (duh!)

Our days are filled with intense encounters with sick, scared or hurting people … with all the emotional needs that come with an illness. This naturally draining environment is compounded by our typical lack of training on how to  create and maintain boundaries with our patients.

Balance, What Balance?

Medicine has a powerful tendency to become the “career that ate my brain”, pushing all other life priorities to the side. Our training reinforces our innate workaholic tendencies. As we get older, with more family responsibilities, the tension between work and our larger life is a major stressor for many. Lack of training in how to create and maintain boundaries – this time between work and life – is a part of this perfect recipe for physician burnout.

A Leadership Role You are Not Trained For

You graduate into the position as leader of a healthcare delivery team without receiving any formal leadership skills training. By default we learn a dysfunctional “Top Down” leadership style. Medicine and the military are the only professions where the leaders “give orders”.  This adds additional stress. (burnout’s smile just got a little bigger)

The Doctor as Rate Limiting Step in the System

We are the “bottleneck” in the provision of services on this same healthcare team,. The team can only go as fast as we can – and we are often behind schedule. Pressure mounts to perform at full steam all day long. This non-stop pressure is a key factor in physician burnout once you are in practice.

The Closed Door Creates a Black Box

We are isolated from the rest of the patient care team by the exam room door. We don’t know what they are doing and they don’t understand our situation simply because the majority of care occurs behind that closed door – when we are one-on-one with our patients.

Who’s Paying for This?

The financial incentives are confusing at best. The patient is often not the one paying for our services and many of them receive their care with no personal investment on their part. You may have to deal with over a dozen health plans with different formularies and referral and authorization procedures … of which the patient is blissfully unaware.

A Lawsuit Waiting to Happen

The hostile legal environment causes many us to see each patient as a potential lawsuit. This fear factor adds to the stress of all the points above.

The Job Isn’t Over Until the Paperwork is Done

Documentation requirements are a constant work overload. What you have to do – and document – to get paid is a game where the rules are always changing.

Who am I Working for This Week?

The ongoing wave of practice consolidation in many metro areas means you could be solo this week and working for the hospital the next. These shifting organizational structures can destroy years of effort invested in building your work team and profitability.

Politics and “Reform”

Political debate drives uncertainty about what your career will look and feel like in the future. All the pundits share the same complete lack of understanding about our day to day experience as providers in the trenches of patient care. There is no track record of common sense. We simply don’t know what to expect. (burnout LOVES that !)

Things Eventually Get Stale

The ten year threshold when your practice suddenly seems to become much more of a “mindless routine”, losing its ability to stimulate your creative juices each week. All of a sudden it seems as if medicine is “no fun any more”. Physician burnout can quickly grab the upper hand.

WOW, that is a  long list – and I am just getting started.
Most of these factors are clear to us when I state them out loud, yet they operate invisibly, beneath the surface of our awareness in a normal office or hospital work day. Each is a member of the corner labeled physician burnout. Which begs the question …

 

Who is in Your Corner?

What are we bringing to this fight? What is our personal motivation to take on this opponent and think we can hold physician burnout at bay?

  • We are extremely intelligent, quick learning, hard working with a drive to do our best. Once we know the tactics to defeat burnout, no one will work harder at putting them into action
  • Our connection to “WHY” we are a doctor – to our Purpose. The quality of this connection varies day-by-day, however it is a source of immense power and endurance when the connection is clear
  • We have invested over a decade of our lives in our medical training and are not going to give up easily
  • We get paid well enough to be in “the 5%”
  • We are a respected member of the community
  • Our families love and support us. We can draw strength from them
  • We have a life outside medicine where we can recharge and recuperate. You might think of this as “resting between rounds”

Most Importantly: Just like Rocky Balboa, we can take a huge amount of punishment – take a lickin’ and keep on tickin’. Our ability to simply “take it on the chin” and just keep comin’ is our tactic of last resort. (read on and I will show you some more skillful ways to put the hurt on physician burnout)

Who‘s winning so far?

Let’s look at the scorecard. And before I show you the statistics, let’s just say … it aint looking so good.

Round One:
Medical School

50% of medical students experience burnout and 10% experience suicidal ideation during medical school

Round Two:
Residency

27-75% of residents are burned out at any given time, depending on specialty

Round Three:
Private Practice

Numerous global studies involving nearly every medical and surgical specialty indicate that approximately 1 in 3 doctors are experiencing physician burnout at any given time with some studies showing physician burnout prevalence as high as 60%.

Everyone Pays a Price in this Fight — Unfortunately

The presence of physician burnout has been shown to

  • Decrease physician’s professionalism and the quality of medical care they provide
  • Increase medical errors and malpractice rates
  • Lower patient compliance and satisfaction with medical care
  • Increase rates of physician substance abuse, suicide and intent to leave practice

 

How can you tip the odds in your favor and Beat Physician Burnout?

What can be done? Is physician burnout an inevitable consequence of the choice to become a doctor … immutable, like gravity? Not by any means. The day-to-day nature of the battle between Physician Engagement and Physician Burnout mandates a role for active prevention, regular monitoring and aggressive treatment. Recent research shows  the efficacy of specific burnout prevention and treatment measures on both the personal and organizational level .

Personal Burnout Prevention Measures

  • Self awareness and mindfulness training
  • Appreciative Inquiry
  • Narrative Medicine
  • Work Life Balance and healthy boundaries between work and non-work life areas
  • Lowering stress by
    • Learning effective leadership skills
    • Exerting control where possible over your work hours (women physicians are leading the way here
    • Creating focus where possible on work activities that provide the most meaning

Organizational Prevention Measures

Many of the negative consequences of physician burnout have direct bottom-line implications for provider organizations. Any decrease in physician burnout should produce measurable increases in quality of care and patient satisfaction in addition to lower malpractice rates and physician and staff turnover.  Each of these effects of physician burnout reduction would be expected to create sizeable increases in profits. There is a natural place for physician burnout prevention at the organizational level.Recent research shows us what that might look like.

  • State an organizational intention to value, track and support Physician Wellbeing
  • Institute regular monitoring for physician burnout amongst providers (MBI)
  • Create CME programs teaching the Personal Burnout Measures above
  • Provide time and funding for physician support meetings
  • Provide leadership skills training
  • Support flexibility in work hours
  • Create specific programs to support physicians suffering from symptomatic burnout

Burnout is waging a constant, invisible, soul eroding battle with our healthcare providers. Physicians engage this enemy every single day and research shows one third of us end up among the walking wounded. It is time to share the research proven tools to tip the odds in the favor of Engagement, Fulfillment and Career Satisfaction for our men and women “in the trenches” of modern medical practice.

Victory in this Burnout Battle would make everyone a winner

  • The Physician
  • Their Patients
  • Their Family
  • Their Staff and wider organization
  • Even the Payor

 

PLEASE LEAVE A COMMENT:
What are your thoughts on, and personal experience with, physician burnout?

keywords:
physician burnout, physician burnout symptoms, physician burnout treatment, physician burnout prevention, physician burnout not a fair fight

Comments

Have written and am revising a book called dealing with exactly this issue. It is endemic to the health care profession. Having been in health administration for over 35 years, I find this article particularly pertinent
Posted @ Tuesday, July 16, 2013 1:24 PM by Geoffrey Zamboni
Helpful article
Posted @ Tuesday, October 08, 2013 10:03 AM by Dr.Zahoor
Very comprehensive article, thank you for posting it. I wrote an article about employees and med students alike and how our medical education system needs a massive overhaul.  
 
I would like to connect with you soon to chat and learn more about you and potentially featuring you on our blog from time to time. 
 
Here is an example of an article we wrote on the topic.  
 
7 Surprising Reasons Why Your Medical Staff is Unhappy - See more at: http://getreferralmd.com/2013/09/medical-staff-employment-tips
Posted @ Tuesday, October 15, 2013 11:36 AM by Jonathan Govette
Excellent 
Thanks so much.
Posted @ Monday, November 04, 2013 12:30 AM by Andrew Opfell MD
Most physicians lack control over almost every aspect of their work environment. They are often victims of exploitation by their employers, who promise the moon when trying to recruit a physician, then constantly change work policies to extract more work for less compensation and less physician control over staff and office policies and subsequently over patient outcomes. Given the high cost of obtaining a medical education and the low compensation given primary care physicians, added to the stress is constant financial worries. But the worst of all stressors is seeing the end results of cost-cutting measures by administrators such as understaffing and hiring poorly trained and poorly paid staff: poor patient outcomes due to ordered consults or tests never being scheduled and recommended follow up appointments never being made, etc. And let's not forget the insurance companies, who obstruct every test, consult or therapy we order. How would a physician who actually cares about patient outcomes not get burned out? And what does a physician do when they become burned out and still owe hundreds of thousands of dollars in student loans?
Posted @ Thursday, December 12, 2013 9:47 PM by Kathy Clarke MD
I agree with everything you say here Kathy AND the way out is Physician Leadership. Get your department organized and focused on what they need from administration ... so you can negotiate toe to toe with administration rather than feeling like they are ordering around. 
 
If your department is acting like a "herd of cats" with no leadership ... that is when your administration is in total control of operations. It does not have to be that way ... but only about 5% of groups/departments understand this. 
 
~ Dike
Posted @ Friday, December 13, 2013 11:45 AM by Dike Drummond MD
You have amazing insight into this problem. As a delegate for our state medical association, I attended our recent annual meeting and learned that these Healthcare systems don't always honor the demands of individual physicians. In the past, a physician could walk into a hospital and threaten to leave if the the administrator didn't work with them. However, now that HealthCare Systems view the physicians as employees who are replaceable, it becomes more like the Japanese saying ... 'the tallest blade of grass gets cut'. There were stories of seasoned physicians making certain demands to the administrators who were then fired and replaced by a new, fresh-from-training doctor. This currently employed physicians - particularly when these towns have but one hospital to work at and being fired would mean relocating. I think the solution would be forming Physician Burnout Measures and creating committees that institute policies, etc. One would have to operate slowly - and as a committee - within the Healthcare system. Keep up the blogs - I have enjoyed them all!
Posted @ Wednesday, January 22, 2014 9:57 AM by Bjorn Krane, MD
Thanks for the comment Bjorn. Here is a post that will help doctors give input without being labeled disruptive or fired  
http://www.thehappymd.com/blog/bid/285327/Disruptive-Physician-Toolkit 
 
Enjoy, 
 
~ Dike
Posted @ Wednesday, January 22, 2014 11:52 AM by Dike Drummond MD
Burnout is such a big problem, the expectation from physicians is really high when it comes to patient care, being a leader and keeping up with the constantly changing medical practices, it can be overwhelming. I have not completed fellowship in pulm cc yet and I believe I have burned out multiple times already. Most of it has been from unrealistic expectations from the patients and their families to be able to cure anything, the broken system that causes patients to fall through the cracks regardless of how much effort is made to get better follow up and most of all the insurance companies that have never seen a patient dictating, creating rules/options on what can or can not be ordered or prescribed. Its a big problem that people outside the medical community need to be made aware of.
Posted @ Sunday, February 02, 2014 12:48 PM by Burnout
Thanks for the comment Mona. In my experience, burnout is always multifactorial ... and the most important thing you can do for yourself is in this blog post  
http://www.thehappymd.com/blog/bid/290254/Happiest-Doctors-build-this-Venn-Diagram 
 
Keep Breathing, 
 
~ Dike
Posted @ Sunday, February 02, 2014 1:10 PM by Dike Drummond MD
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