Summary week 4

198 https://doi.org/10.14503/THIJ-18-6842

© 2018 by the Texas Heart ® Institute, Houston

Texas Heart Institute Journal • August 2018, Vol. 45, No. 4

Physician Burnout: Causes, Consequences, and (?) Cures

“[D]issatisfaction among physicians with how their time and skills are used is widespread and growing.” 1

“The highly trained U.S. physician. . .has become a data-entry clerk, required to document not only diagno- ses, physician orders, and patient visit notes but also an increasing amount of low-value administrative data.” 2

“More than half of U.S. physicians are now experiencing professional burnout.” 3

“Physician burnout is reaching crisis proportions in the United States.” 2

B urnout in physicians is characterized by emotional exhaustion, f inding work no longer meaningful, feelings of ineffectiveness, and a tendency to view patients, students, and colleagues as objects rather than as human be- ings. Associated manifestations include headache, insomnia, tension, anger, narrow- mindedness, impaired memory, decreased attention, and thoughts of quitting.3-5 In certain situations, physical exhaustion and moral distress are prominent features.6,7 Career burnout is not limited to physicians.3,5 Results of studies in 2011 and 2014 showed that burnout indicators among the general United States working population remained steady at around 28%.3 During those years, however, the percentage of physicians suffering burnout increased from 45.5% to 54.4%.3 Because burnout by its nature is cumulative, that percentage is probably higher today. Physicians in specialties at the front line of care—emergency medicine, family medi- cine, and general internal medicine—are at greatest risk of burnout.5 And although higher levels of education and professional degrees seem to reduce the risk of burnout in workers outside the f ield of medicine, an MD or DO degree increases the risk.5

Causes

Aside from the often-mentioned external inf luences, the physician’s makeup always plays an important role: depth of commitment, upbringing, role models, expectations, moral values, level of stress tolerance, and resiliency. Nevertheless, in the current medical environment, even the best among us can be overwhelmed by the following external factors.

Loss of Autonomy Especially for physicians trained during the “high-touch” era (from approximately 1950 to the mid-1970s),8,9 the profession has lost much of its human context. Not too long ago, patient management required use of one’s brain and senses, sometimes followed by consultation with a colleague. Today, physicians have become microman- aged cogs in a machine:

Autonomy is the basic ability of individuals to exercise their judgment in terms of how to spend their time, attention, and resources. In the domain of medical care,

Special Report

Herbert L. Fred, MD, MACP Mark S. Scheid, PhD

Key words: Burnout, pro- fessional/epidemiology/ prevention & control; deliv- ery of health care/ history; documentation/methods; electronic health records/ organization & administra- tion; medical records sys- tems, computerized/trends/ utilization; patient-centered care/trends; physicians/ psychology; practice man- agement, medical/organiza- tion & administration; time management; workload/ psychology

Dr. Fred is an Associate Editor of the Texas Heart Institute Journal. Dr. Scheid is retired from Rice University, Houston.

Reprints will not be available from the authors.

E-mail: [email protected]

Texas Heart Institute Journal Physician Burnout 199

this could include the ability to decide when to see each patient, how much time to spend with each patient, what questions to ask them, when to see them next, what kinds of tests to perform, and what kinds of treatments to try out and for how long. This view of autonomy is almost in direct opposi- tion to the current practice of medicine. The cur- rent procedures in medical reimbursement policies and technological advances are constantly moving physicians in the direction of less time spent with each patient and greater f loods of information (for example, related to a given patient or general medi- cal information) to manage or master.10

In essence, the practice of medicine has become a “f ixing-people production line.”10

Treating the Data, Not the Patient Abraham Verghese recently wrote a telling vignette of his experience as a patient in the era of the electronic health record (EHR):

The nurse came in regularly, but not to visit me so much as the screen against the wall. Her back was to me as she asked, “On a scale of 1 to 10, with 10 being great diff iculty breathing…?” I saw her back 3 more times before I left. My visit recorded in the EHR would have exceeded all the “Quality Indi- cators,” measures that affect reimbursement and hospital ratings. As for my experience, it was OK, not great. I received care but did not feel cared for.11

Verghese’s experience illustrates the modern practice of focusing on the monitor rather than on the actual patient.

A World of Rules Physicians from the “high-touch” era8 aren’t the only ones stressed by today’s high-tech emphasis. Young physicians, taught in medical school the traditional Oslerian philosophy of focusing on the patient, often experience stress as they adjust to a new environment and learn the business aspects of medicine,12 which in- clude rules from government, insurance companies, and hospitals that limit the time physicians can spend with a patient. Those rules also require that the visit comply with the Health Information Portability and Account- ability Act (HIPAA), Accountable Care Organizations (ACOs), quality indicators, and other standards.13 An adverse effect of another absolute rule merits at- tention. Compliance with the mandated work-hour limits for trainees across all specialties necessitates re- lentless monitoring and diligent enforcement by pro- gram directors. This intense pressure, along with the associated fear of losing accreditation, puts these direc- tors at substantially increased risk of early burnout.14

The hospital and other medical-practice owners also pressure physicians to remember that clicking the cor- rect boxes on the EHR will enable “upcoding”—billing at the highest level for each encounter.11 For all these reasons, internal and external, more than 50% of medical students, residents/fellows, and early- career physicians are already burned out.12

Asymmetric Rewards Because physicians have chosen a life of service, they don’t necessarily think of “insuff icient reward” as an important factor in career satisfaction.4 Ariely and La- nier, however, highlight this stressor’s special impact on the practice of medicine:

In our personal and professional lives, when we do what is expected of us, we receive, at most, a bit of praise. But, when we make a mistake, we are likely to be punished strongly. And although this asymmetry is true across the globe, it is particularly substantial in the medical profession…. As if the asymmetry of reward and punishment is not suff i- ciently harmful by itself, the explosion of informa- tion about each patient, each treatment, and each disease exacerbates this harm.10

Sense of Powerlessness Especially for physicians who work with populations in poor socioeconomic situations,6,7 the inability to do anything about the root causes of their patients’ medi- cal issues leads to a different cause of burnout: futility.

To many people, the white coat and the prescrip- tion pad represent the highest form of individual agency, the very picture of social power. But, even- tually, a physician will encounter patients whose health problems derive from a wicked, multigen- erational knot of poverty and marginalization, and even the most astute, excellent physician may well f ind herself outmatched. Facing patients’ adverse social circumstances as an individual clinician is a recipe for disillusionment: the physician who be- lieved she was maximizing her individual agency comes to feel utter ly powerless. No longer the lone hero—just alone.7

Electronic Health Record Woes “There is building resentment against the shackles of the present EHR; every additional click inf licts a nick on physicians’ morale.”15 For many physicians, the EHR has become the final straw. Although intended to overcome the f laws inherent in a paper-based system, the EHR has produced its own set of problems, perhaps the most important of which is the absence of social and behavioral factors fundamental to a patient’s treatment response and health outcomes.15

200 Physician Burnout August 2018, Vol. 45, No. 4

Instead of being a mere replacement for paper re- cords, EHRs have evolved into data-collection devices for HIPAA and other government regulations.13 Con- sequently, they focus more on processes than on out- comes, adding to the physician’s workload while not improving patient care.13 In that light, 2 recent studies are noteworthy. One study involved ambulatory care in 4 specialties (family medicine, internal medicine, cardiology, and orthopedics) in 4 states (Illinois, New Hampshire, Vir- ginia, and Washington). For every hour the physicians spent facing their patients, they spent nearly 2 addi- tional hours facing the computer, entering data. They also spent one to 2 hours working at home each night to “keep up.”1 The other study involved 142 family medicine physi- cians in Wisconsin who spent more than half their workday, nearly 6 hours, interacting with the EHR. Two thirds of that time was spent on clerical and inbox work.16 Worse, most EHRs are designed to facilitate billing, not patient care, leading the National Academy of Med- icine to request that social determinants of health be included in future versions of EHRs.17 And, almost 10 years after the passage of the Health Information Tech- nology for Economic and Clinical Health (HITECH) Act, health information technology (IT) developers still use hundreds of different communication and nomen- clature standards,18 preventing a substantial percentage of records from being shared across the various compet- ing EHR platforms. In fact, the very point-and-click design of the EHR prompts the physician to click more boxes, even when they’re not completely accurate. Thus, a one-legged pa- tient can have a chart reading “pulses intact in both feet.”11 The ease of making a point-and-click error should be obvious to anyone who has ever used a computer. One of us, for example, has been urged by his insurer to consult with a specialist about his COPD (chronic ob- structive pulmonary disease)—which he doesn’t have— and to schedule his routine mammogram—which, as a male, he doesn’t need. Clearly someone, somewhere, is clicking the wrong boxes.

Consequences

Physician burnout is not only expensive in monetary terms, but also leads to a constellation of other costs, including physical, spiritual, and emotional.

Leaving Medicine Investigators estimate that, when physicians leave the f ield, the practice loses $500,000 to $1,000,000 of rev- enue. This loss is even greater in high-paying specialties. To recruit a replacement costs an additional $90,000.11

And the costs of college and medical school often leave physicians themselves with sizable debts, which can be harder to pay off in a nonmedical job. Physicians who quit because of burnout have spent a substantial percentage of their lives in premedical courses, medical school, residencies, and practice. Those years are not entirely wasted, of course, but the specif ic curricula that prepare physicians to practice medicine do not necessarily train them to do anything else well. Every physician who leaves the field adds to the work- load of other physicians. This has a cascading effect— causing more stress, leading to more burnout.

Remaining in Practice Even when a burned-out physician continues to practice medicine, negative consequences can follow, such as the misuse of alcohol and drugs, broken relationships, and suicidal ideation.5,14 These repercussions, in turn, clearly diminish the quality of care delivered.5,14 Moreover, the fact that roughly half of U.S. physicians have symptoms of burnout suggests that the problem stems from en- vironmental factors and the care-delivery system, not from elements within the individual.5 The litany of burnout characteristics—especially closed thinking, impaired memory, decreased attention, and viewing people as objects—can easily lead to medi- cal error. And every year, about 250,000 patients die in the U.S. because of medical error: “the rough equivalent of, say, a jumbo jet’s crashing every day.”11

(?) Cures

Because of burnout’s variable nature, there is no consen- sus for preventing, treating, or curing it. Most “cures” focus on stress-reduction training rather than on the systemic factors that produce burnout.5 Methods suggested to help physicians in their strug- gles against burnout include organizing a community of practice for mutual support4 or for political action7 and the use of cognitive behavioral therapy.4 Scribes may reduce the data-entry workload of physicians, increase physician satisfaction with patient visits, improve chart quality and accuracy, and not detract from patient sat- isfaction.19 Clearly, changes to the EHR are necessary. The EHR was created almost 10 years ago (an eon in computer time) to satisfy the requirements of hospitals and insur- ers rather than physicians.2,11 There was no associated nationwide directory or regulatory infrastructure.13 In addition, the EHR has not “kept pace with technology widely used to track, synthesize, and visualize informa- tion in many other domains of modern life.”15 Re-engineering current EHRs will be diff icult. In fact, Zulman and colleagues15 concluded that, in many clinical situations, patient care could be improved sim- ply by “deimplementing” the EHR.

Texas Heart Institute Journal Physician Burnout 201

Most authors point out that EHRs can never live up to their potential without true cross-platform compatibil- ity: the capability for medical data to be shared widely across the many competing versions of the EHR.13,16,18 However, the for-profit IT developers who create and sell the current EHRs operate in a highly competitive field and are usually reluctant to cooperate in areas where pro- prietary information might be shared with a competi- tor. And it is not just a matter of getting 2 or 3 to work together. According to the U.S. government, in 2017 no fewer than 186 different certif ied health-IT developers were supplying heathcare software to non-Federal acute care hospitals alone, and 684 developers were supplying EHRs to ambulatory care professionals.20 And because a hospital or insurer usually requests alterations of an off-the-shelf software platform to con- form with business practices already in use, it’s not un- usual for physicians to f ind that they “can’t reliably get a patient record from across town, let alone from a hos- pital in the same state, even if both places use the same brand of EHR.”11 Some argue—hopefully, perhaps—that inter-EHR data-sharing could be encouraged by asking the gov- ernment to streamline its EHR certif ication standards to focus more on outcomes, to tie EHR certif ication to interoperability, and to provide f inancial incentives to the private sector to develop standard interfaces for all aspects of patient care.13 Others argue, however, that the time has come for a total rethinking of the EHR, beginning with the underlying principles of patient care rather than with compliance and f inances.2 The creation of a new physician- and patient-cen- tered EHR would be a great improvement. But would the government, the insurers, and the medical com- munity be willing to admit that the f irst attempt was a failure and simply write off the hundreds of millions of dollars spent on it? We doubt it.

Conclusion

To sum up: a loss of autonomy, overreliance on comput- er data, onerous rules, an asymmetric reward system, a sense of powerlessness, and EHRs that are not designed primarily for patient care have produced a climate in which more than half of all members of the f ield, from medical students to senior practitioners, are burned out. As a result, physicians are quitting in large numbers, further increasing the stress on those still practicing. Those burned-out physicians who remain are less able to give appropriate patient care. There appears to be no easy solution to these problems. Sorry.

References 1. Sinsky C, Colligan L, Li L, Prgomet M, Reynolds S, Goeders

L, et al. Allocation of physician time in ambulatory practice: a

time and motion study in 4 specialties. Ann Intern Med 2016; 165(11):753-60.

2. Downing NL, Bates DW, Longhurst CA. Physician burnout in the electronic health record era: are we ignoring the real cause? Ann Intern Med 2018;169(1):50-1.

3. Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, West CP. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014 [published erratum ap- pears in Mayo Clin Proc 2016;91(2):276]. Mayo Clin Proc 2015;90(12):1600-13.

4. Byyny RL. The joy in caring. Pharos Alpha Omega Alpha Honor Med Soc 2018;81(2):2-8.

5. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012;172(18):1377-85.

6. Cervantes L, Richardson S, Raghavan R, Hou N, Hasnain- Wynia R, Wynia MK, et al. Clinicians’ perspectives on providing emergency-only hemodialysis to undocumented im- migrants: a qualitative study. Ann Intern Med 2018;169(2): 78-86.

7. Eisenstein L. To fight burnout, organize. N Engl J Med 2018; 379(6):509-11.

8. Fred HL. Medical education on the brink: 62 years of front- line observations and opinions. Tex Heart Inst J 2012;39(3): 322-9.

9. Fred HL. The late forties and early fifties: a memorable time in medicine. Tex Heart Inst J 2013;40(5):508-9.

10. Ariely D, Lanier WL. Disturbing trends in physician burnout and satisfaction with work-life balance: dealing with malady among the nation’s healers. Mayo Clin Proc 2015;90(12): 1593-6.

11. Verghese A. How tech can turn doctors into clerical work- ers [Internet]. Available from: https://www.nytimes.com/ interactive/2018/05/16/magazine/health-issue-what-we-lose- with-data-driven-medicine.html [2018 May 16; cited 2018 Sep 4].

12. Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, Shanafelt TD. Burnout among U.S. medical students, resi- dents, and early career physicians relative to the general U.S. population. Acad Med 2014;89(3):443-51.

13. Halamka JD, Tripathi M. The HITECH era in retrospect. N Engl J Med 2017;377(10):907-9.

14. De Oliveira GS Jr, Almeida MD, Ahmad S, Fitzgerald PC, McCarthy RJ. Anesthesiology residency program director burnout. J Clin Anesth 2011;23(3):176-82.

15. Zulman DM, Shah NH, Verghese A. Evolutionary pressures on the electronic health record: caring for complexity. JAMA 2016;316(9):923-4.

16. Arndt BG, Beasley JW, Watkinson MD, Temte JL, Tuan WJ, Sinsky CA, Gilchrist VJ. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med 2017;15(5):419-26.

17. Committee on the Recommended Social and Behavioral Do- mains and Measures for Electronic Health Records; Board on Population Health and Public Health Practice; Institute of Medicine. Capturing social and behavioral domains and mea- sures in electronic health records: phase 2. Washington (DC): National Academies Press (US); 2015 Jan.

18. Washington V, DeSalvo K, Mostashari F, Blumenthal D. The HITECH era and the path forward. N Engl J Med 2017;377 (10):904-6.

19. Gidwani R, Nguyen C, Kofoed A, Carragee C, Rydel T, Nelligan I, et al. Impact of scribes on physician satisfaction, patient satisfaction, and charting eff iciency: a randomized controlled trial. Ann Fam Med 2017;15(5):427-33.

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20. Off ice of the National Coordinator for Health Information Technology. ‘Certif ied health IT developers and editions re- ported by health care professionals participating in the Medi- care EHR incentive program,’ Health IT Quick-Stat #30. Available from: dashboard.healthit.gov/quickstats/pages/FIG- Vendors-of-EHRs-to-Participating-Professionals.php [2017 July; cited 2018 Sep 4].

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