Physician burnout increases as more boomers require access to care
The state of our health care system depends, in part, on the state of our health care providers. But research over the last few years has shown that physician burnout is on the rise. Mark Linzer, director of the division of general internal medicine at Hennepin County Medical Center in Minneapolis, has been studying physician burnout since 1996. Burnout, he says, is a long-term stress reaction that includes emotional exhaustion, a sense of depersonalization, and a lack of a sense of personal accomplishment.
Linzer says burnout occurs in all medical specialties but is highest in physicians who practice on the front lines of medicine. That includes those in emergency medicine and primary care. “Burned-out doctors,” he says, “are more likely than other doctors to leave medicine.”
“When doctors become discouraged and leave medicine,” says Doris Gundersen, medical director of the Colorado Physician Health Program, “the problem of the current shortage of physicians is exacerbated.”
With 10,000 baby boomers turning 65 and becoming eligible for Medicare every day, and millions of new patients becoming insured through the Affordable Care Act, access to doctors is becoming increasingly difficult.
Every time a doctor leaves medicine, says Linzer, an interruption in continuity of care is created, and a cost of $250,000 is incurred to replace that physician.
Surveys by the AMA and the RAND Corp., the Mayo Clinic, the University of Rochester Medical Center, and Stanford University School of Medicine show that the hours and demands of the work, the requirements to interact regularly with insurance companies, the increase in clerical duties, inefficient electronic medical records, a loss of a sense of autonomy, and difficulty maintaining a work-life balance all contribute to the problem. “Burnout,” says Linzer, “results primarily from challenges within the system.”
When asked in separate studies by the Mayo Clinic and a RAND Corp./AMA collaboration what makes them satisfied in their work, physicians stressed the importance of a sense of autonomy that allows them to make the best decisions for their patients. As pressure mounts to treat patients quickly, and oversight by the government and insurance companies increases, these decisions can become compromised.
Physician surveys show that doctors report frustration with the pressures of daily practice that make it difficult to establish relationships with patients. Gundersen says doctors regularly spend hours dealing with insurance companies trying to get treatment approval and dealing with insurance denials and appeals of claims.
The amount of documentation required by insurers and government agencies takes up more staff time and requires too much physician involvement to resolve complicated billing and recordkeeping issues. Meeting required rules and regulations interferes with the time physicians can spend with patients.
While doctors overwhelmingly say in these ongoing surveys that they appreciate the theoretical usefulness of electronic records, those in use haven’t been properly streamlined. Current systems, says Russell Phillips, director of the Center for Primary Care at Harvard Medical School, are not well-designed for the field and interfere with the face-to-face doctor-patient experience. “Electronic records are burdensome and have made physicians into data entry clerks,” Phillips says.
Surveys also find that physicians cite respect by colleagues, patients and payers as being important to them. But as practices get bigger and workloads get heavier, many are feeling isolated and report a lack of support by the doctors and administrators they work with.
Colin West, a general internist and a lead researcher of physician well-being at the Mayo Clinic, says physician burnout is common and growing. “It’s not the exception,” he says, “but the rule, and the stigma of being burned out has to be eliminated so that we can move forward and create strategies to deal with it.”
On the cutting edge of research into physician burnout, the Mayo Clinic has done surveys and studies and is expected to come out with programs designed to promote physician satisfaction and well-being.
“We need to focus on the entire health care system, because we are all in this together,” says West, adding that first and foremost physicians need to be reminded about the importance and value of what they do.
At the University of Rochester Medical Center, Drs. Michael Krasner and Ronald Epstein have been researching burnout for years. They believe the cure lies in healthy encounters and relationships between health care workers, colleagues and patients. To engage effectively with patients, says Epstein, one has to be present and attentive, and with that in mind, workshops to promote mindfulness meditation and interpersonal communication are offered and have been found to reduce stress, burnout and enhance physician resilience and are now being taught all over the world.
The Stanford Committee on Professional Satisfaction and Support, co-chaired by Bryan Bohman, an internist and anesthesiologist, says physicians must learn how to take care of themselves. “Medicine,” he says, “used to revolve around the doctor, but that has changed, and now patients are better educated, more knowledgeable, and unafraid to ask questions.” At the same time, he adds, physicians are being constantly evaluated, scrutinized and pressured.
To take on the battle and explosion of complexity, Stanford is addressing wellness, work-life balance, satisfaction and support across its entire medical culture. Stanford’s satisfaction and wellness programs are geared to medical students, house staff (interns, residents and fellows), and medical staff (attending physicians) and are working at building adequate networks of support not just to prevent their physicians from burning out, but also to promote a high level of professional fulfillment.
Programs at Stanford include student counseling and mentoring. For residents, a 24-hour hotline is available for mental health consultation, and several departments have implemented their own wellness programs to help build resiliency. A resident peer support program has been set up to help the house staff when bad patient outcomes or other critical negative incidents occur.
“In each department,” says Bohman, “the chief resident will be trained to conduct one-on-one conversations to listen and guide their colleagues through the coping process and make suggestions on how residents should take care of themselves during stressful times.”
Other initiatives are also in place at Stanford, and research continues. Bohman says the medical center is hoping to build a center devoted to physician wellness. “We are completely aware,” he says, “that one of the greatest obstacles to improving patient care is burnout by doctors who practice on the front lines of medicine.”
At Harvard’s Center for Primary Care, another model is at work. About 20 percent of primary care physicians in the university’s hospitals and clinics are now working in teams that include nurses, community health workers, social workers, pharmacists and other professionals who can lend support. Primary care physicians have found that this prevents the burden from falling to just one person, and Phillips says morale has benefited enormously.
As programs to maximize physician well-being are implemented, patients will also be able to feel more confident that they, too, are getting the best care available.