Physicians face tremendous work-related stresses that can lead to depression and burnout. Healthcare finance leaders can play a role in ensuring they have the support and resources they need to deal with these stresses.
With today’s veritable tsunami of change in health care, physicians face unprecedented and unrelenting challenges that have left many of them overwhelmed, and sapped of the energy and stamina needed to weather transitions and emerge intact. Simply expressed, many U.S. physicians are burned out, and recent reports suggest they are burning out in record numbers. Given the critical importance of these professionals to the very functioning of the nation’s healthcare system, this phenomenon demands the attention of every stakeholder in health care who might be in the position to help, including finance leaders of hospitals and health systems. Having the ability to address this problem meaningfully and effectively, however, requires first an understanding of the root causes of physician burnout.
Effects and Prevalence of Physician Burnout
Burnout is a syndrome characterized by emotional exhaustion or a loss of enthusiasm for work and feelings of depersonalization and low personal accomplishment. Physicians experiencing burnout are more prone to divorce, depression, drug addiction, and suicidal ideation. The impact on an individual can be devastating.
Although the costs of burnout for a physician’s employer or practice may not be immediately evident, the total financial impact can be considerable. As dysfunction spills over into the workplace, burnout may manifest as decreased productivity, disruptive or antisocial physician behavior, low staff morale, declining patient satisfaction scores, and damage to reputation—all of which directly or indirectly effect the healthcare bottom line. Further, when a physician decides to give up practicing medicine and leave, finding a replacement can cost as much as $250,000 in signing and recruiting fees, orientation costs, and lost productivity during onboarding and training. a
Perhaps most concerning, research solidly correlates physician burnout with subpar clinical performance, an unsatisfactory patient experience, and increased malpractice risk. In a study of 7,900 surgeons, major medical errors were strongly related to the surgeon’s degree of burnout. b The same study found that incremental increases in self-reported symptoms of burnout correlated with increases in self-reported errors from 5 to 11 percent. It follows that an increased potential for making major medical errors, coupled with reduced patient satisfaction scores, places burned-out physicians at higher risk for malpractice.
Currently, rates of burnout among physicians are alarmingly high—and notably higher than in the general population. Among more than 7,000 physicians responding to a survey published in the Archives of Internal Medicine, almost half reported at least one symptom of burnout. c Across physician specialties, burnout is most prevalent in physicians on the front line of care, with those in the fields of emergency medicine, family medicine, and general internal medicine being at greatest risk.
Burnout in Response to Adverse Events and Litigation
One of the most difficult career challenges for physicians—and a unique brand of professional stress—is coping in the aftermath of an adverse event and managing litigation stress. In addition to everything else, the threat of making a mistake and being sued factors prominently.
Elizabeth Galton, MD, assistant professor of psychiatry at the David Geffen School of Medicine at UCLA, suggests that the effects of such an event can be devastating to a physician’s professional identity. d “Physicians devote themselves to the health and well-being of their patients: Allegations of substandard care call into question the physician’s clinical judgment, competence, and even his or her commitment and dedication,” Galton says. For the past seven years in practice, Galton has specialized in caring for the caregiver, treating physicians suffering from litigation stress, and helping those who are reeling in the aftermath of an adverse event. Galton has identified a triad of symptoms, common in many of her physician patients, that make them susceptible to experiencing burnout. Although these symptoms are of a personal nature, and therefore difficult for others to help the physician address, it is important to understand their impact to begin to grasp the scope to the challenge that confronts many physicians.
Sleep disruption. According to Galton, during times of stress, sleep often is the first thing that’s affected. “The importance of sleep in order to cope cannot be overstated,” Galton says. “Sleep and dreams are absolutely essential to one’s ability to recover or ‘reboot’ from daily stressors and emotional trauma.”
Galton explains that sleep deprivation can worsen emotional instability and lead to reliance on alcohol and prescription medications that may work temporarily but can lead to abuse. During these difficult times, restoring restful sleep and supporting the body with adequate nutrition and exercise become top priorities, she suggests.
Erosion of personal confidence. The second symptom Galton frequently observes in physicians facing litigation is an erosion of professional confidence or the tendency to “second-guess” themselves. “Physicians are trained to be precise and detail-oriented, and to make tough decisions,” Galton says. “Stress can seriously hamper their ability to think clearly and to confidently make clinical decisions.” She also asserts that the fear of being sued again can undermine the trust that’s vital to the physician-patient relationship—and to career fulfillment in general.
Shame. Galton finds that physicians who are blamed for patient injury often have a deep sense of shame. “The physician’s sense of shame often unconsciously attaches to earlier experiences of shame that exist as emotional ‘hot spots’ in one’s psyche,” she explains. Galton believes that the current experience reactivates those earlier experiences and everything escalates; the physician becomes overwhelmed with feelings of shame and inadequacy that can consume his or her personal and professional life.
To help her clients, Galton employs a form of psychoanalysis called psychodynamic therapy, which involves examining unresolved prior traumatic experiences and understanding their influence on current experience and behavior.
“It’s very important to explore our earlier experiences of shame and loss, which we tend to bury or compartmentalize, and to bring those experiences to light,” Galton says. “Just talking about a prior traumatic experience and being able to describe what happened, and how it made one feel, makes the experience less painful, and helps [physician] patients eventually achieve resolution. The ultimate goal of therapy is not only to help physicians cope with the current challenge, but to help them move forward as healthier, happier, and better integrated professionals.”
Other Factors Contributing to Burnout
Medical errors and malpractice litigation are not the only factors that can cause a physician to succumb to burnout. As a career, medicine has never been easy. Long hours, making life or death decisions, and working under unimaginable stress while maintaining the highest professional standards are but a few of the traditional career stressors that place physicians at high risk for burnout. Simply earning the degree attests to years of self-sacrifice and discipline.
But in addition to the stress that comes with the job, recent changes in health care including increased regulatory pressures, changes in healthcare delivery, and changing payment models have imposed unprecedented administrative burdens on physicians. In 2015, respondents to a survey of more than 20,000 U.S. physicians (the
Medscape Physician Lifestyle Report) identified the following stressors and ranked them in order of significance on a 1-5 scale:
e
- Too many bureaucratic tasks (4.74)
- Spending too many hours at work (3.99)
- Insufficient income (3.71)
- Increasing computerization of practice (3.68)
- The impact of the Affordable Care Act (3.68)
Administrative overload, bureaucracy, financial pressures, a loss of autonomy, and the frustrations associated with increased computerization all are well-known sources of stress. Spending too many hours at work and not being able to control work hours compounds the problem by further disrupting the work-life balance needed to modulate stress.
Ann Whitehead, vice president of risk management & patient safety for CAPAssurance, a hospital and medical group professional liability insurer, isn’t surprised by these findings. f “Healthcare reform has profoundly changed the way medicine is delivered, and we’re all in the process of transformation,” Whitehead says. “Today’s physicians are being asked to do so much more. In the past, physicians would call risk management with basic questions related to professional liability. Now, we receive calls with questions on a range of compliance and regulatory issues—MACRA, ICD-10, HIPAA, EHR, reimbursement issues, telehealth, CDS, and many more. It is inevitable that this increase in responsibilities would detract from time spent with patients and career fulfillment.”
The Impact of Cultural Factors
Risk managers understand that truly fixing a problem, and achieving sustainable improvement requires understanding of its root causes. And often, for the most intractable problems, deficiencies in culture are at issue. Critics of the culture of medicine regard burnout as the inevitable byproduct of an educational system and profession that has long rewarded self-denial, perseverance, and expert performance in the face of enormous pressure. Medicine is charged with perpetuating an unhealthy “myth of invulnerability” and a doctrine of “survival of the fittest” among its recruits. Anthony Montgomery, organizational psychologist and expert in physician burnout, further argues that the educational system is largely responsible for perpetuating burnout by neglecting to cultivate an essential set of skills in its learners. g Montgomery asserts that medical education is almost exclusively aimed at perfecting students’ clinical and technical abilities—with little to no attention given to the development of the social, leadership, and teamwork skills desperately needed to successfully interact with patients and colleagues.
Barriers to Help and Treatment
It is both sad and ironic that those most directly responsible for health and healing may be in the greatest need of assistance. Unfortunately, admission of vulnerability doesn’t come easily for a group of professionals defined by self-sacrifice and perfectionism. The stigma associated with seeking help for mental illness—as well as concerns about the potential professional and licensing repercussions from having a mental health history—has likely made many physicians suffering depression and other mental health issues reluctant to reach out and resistant to being reached.
But one way or another, these physicians must be reached. Statistics on physician suicide tragically show the consequences of delayed treatment for such issues. Suicide among physicians is disproportionately higher than in the general population—with as many as 400 physicians committing suicide each year in the United States. h
A 2015 article in TIME cites findings of research by Srijan Sen, MD, PhD, a psychiatrist at the University of Michigan who is widely considered the leading expert on physician depression, that only 22 percent of internists who are depressed get help. i Sen notes that the physicians who are most predisposed to depression often possess the very traits of sensitivity and empathy that we look for in our physicians.
A Call to Action
Although the root causes of physician burnout are many, and improvement likely will require intensive and long-term systemic and cultural change, physicians need help, now. Organizations, and their finance leaders in particular, can do a lot to promote wellness and prevent burnout among their physicians, while improving physician retention and quality of care. A good place to start is by raising awareness of the issue, educating staff, and providing resource information. Here are some recommendations for promoting physician well-being and empowerment to thrive in the face of their many stresses.
Survey physicians and make physician wellness a key quality indicator. Understanding the profound influence of physician wellness on everything from professional liability exposure to healthcare outcomes, it seems prudent that physician wellness should be consistently monitored along with other improvement metrics. The American Medical Association has developed an educational module titled Preventing Physician Burnout to provide insight into cultivating a culture of wellness in the workplace, including establishing provider wellness as a key quality indicator. j The resource includes a simple 11-question wellness survey, developed by one of the module’s authors, Mark Linzer, MD, at Hennepin County Medical Center, which the authors recommend be administered to physicians at least annually. The survey asks physicians whether they have the tools and resources needed to successfully perform at work. Respondents also are asked to pinpoint the specific causes of workplace stress and to recommend possible improvements.
Establish a wellness committee. A hospital or medical group also can promote wellness by offering resource information and staff education through a physician health and well-being committee, whose charter should be to assist physicians with all matters related to maintaining their health and well-being, with special attention to behavioral issues, substance abuse, addiction, and mental illness. Wellness committees, ideally, comprise professionals of various disciplines and ideally include clinical staff and administrators who can review data from physician wellness surveys and collaborate on making improvements. Typical activities of such a committee would be to offer educational programs, sponsor stress-reduction workshops, identify physician support resources, and simply raise awareness of the issue.
Identify burnout prevention and support resources. There are many resources across the industry aimed at preventing physician burnout and maintaining physicians’ well-being. As a noteworthy example, Stanford University, known for its progressive approach to burnout prevention, has developed an elaborate and neatly organized online resource library for their physicians, WellMD, that offers health and lifestyle assessments, classes, and other information to support wellness and address myriad mental health needs among physician staff. Resources include information on physician-peer support programs and guidance on issues such as dealing with crises, coping with grief and loss, and addressing concerns about a colleague.
Be responsive and make necessary workflow changes. Invariably, improving physician wellness will require changes in workflow to lighten or streamline physician workload. When the physician’s direct participation isn’t possible, appointing a “physician champion” to guide improvement can ensure that physician interests are well represented. Further, physician leaders should be sensitive to the destabilizing impact of change on physician workload and morale.
For example, the emergency department (ED) chief in one hospital recently became aware that his staff physicians were struggling with the steps required to document care in the electronic health record (EHR) system, to the detriment of their workflow. The physicians complained that, added to the essential duties of caring for patients in the ED, the EHR documentation requirements were burdensome, heaping extra hours and stress onto an already demanding shift. This issue was especially frustrating for older physicians. The ED chief explored and implemented the use of scribes in the ED to free up physicians to focus on their patients. This case example underscores how being responsive to factors affecting physician job satisfaction, and identifying improvement opportunities, is just one important way to advocate for staff and help prevent burnout.
It is imperative that all healthcare stakeholders understand the importance of “caring for the caregiver.” Physician burnout affects not only the individual physicians, but also their employers, practices, and patients. By providing guidance and executing well-thought-out tactics, healthcare leaders can best position their organizations to address and remedy physician burnout, thereby improving overall physician satisfaction while also contributing to a culture of collaboration and engagement between physicians and health system leadership.
Catherine Miller, RN, JD, is risk management and patient safety specialist, Cooperative of American Physicians, Inc., Los Angeles.
Footnotes
a. Buchbinder, S.B., Wilson, M., Melick, C.F., Powe, N.R., “Estimates of Costs of Primary Care Physician Turnover,” American Journal of Managed Care, November 1999.
b. Shanafelt, T.D., Balch C.M., Bechamps, G., Russell, T., Dyrbye, L., Satele, D., Collicott, P., Novotny, P.J., Sloan, J., Freischlag, J.., “Burnout and Medical Errors Among American Surgeons, Annals of Surgery, 2010.
c. Shanafelt, T., Boone, S., Litjen, T., Dyrbye, L., Sotile, W., Satele, D., West, C., Sloan, J., Oreskovich, M., Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General US Population,” Archives of Internal Medicine, 2012.
d. Galton’s comments are from an interview.
e. Peckham, C., “Physician Burnout: It Just Keeps Getting Worse,” Medscape, Jan. 26, 2015.
f. Whitehead’s comments are from an interview.
g. Montgomery, A. “The Inevitability of Physician Burnout: Implications for Interventions,” Burnout Research, June 2014.
h. Andrew, L.B., and Brenner, B.E., “Physician Suicide,” Medscape, May 6, 2011.
i. Oaklander, M., “(2015). Life Support: Inside the Movement to Save the Mental Health of America’s Doctors,” TIME, Sept. 7-14, 2015.
j. Linzer, M., Guzman Corrales, L., and Hennepin, S.P., Preventing Physician Burnout , StepsForward, In partnership with Hennepin County Medical Center and the American College of Physicians, 2017.
