As a follow-up to last week’s post I thought that it would be interesting to point out a discussion by our Surgeon General. He is concerned as I am regarding the health and happiness of those who care for our sick and injured. Medicine is a profession in which emotional well-being is sorely lacking Surgeon General Vivek Murthy, MD, MBA, told MedPage editor Joyce Frieden in an exclusive interview at the annual meeting of the Association of Health Care Journalists.
“The suicide and burnout rate is very high, and this is concerning to me because we’re at a point in our country where we need more physicians, not fewer; we need more people entering our profession, not fewer,” he said. “If we have people burning out, it really goes against our needs.”
“As I think about the emotional well-being for our country, I am particularly interested in how to cultivate emotional well-being for healthcare providers. If healthcare providers aren’t well, it’s hard for them to heal the people for whom they are they caring.”
Murthy talked to MedPage Today before delivering a keynote address to the journalists’ group. A press representative from Murthy’s office was not present during the interview, but he did insist that he be permitted to leave his recorder running during the interview.
Emotional well-being was one of two healthcare areas that the Surgeon General’s office has targeted for this year, Murthy explained, noting that before he became Surgeon General, it was not a topic he thought would be high priority.
But in the months since he has taken office, a growing concern about emotional well-being emerged “from conversations I had with community members, and it is based on the science developed over the years that tells us emotional well-being is an important driver of health.”
“People think that emotional well-being is something that happens to you — things line up in your life, you have the right job, and your health is good, and [you are in] a happy family and in a good relationship and you’re happy in your emotional life,” he said. “But there’s a growing body of science that tells us there are things we can do to develop our emotional well-being proactively, and that in turn can have a positive impact on our health.”
Murthy noting that promoting well-being doesn’t require reinventing the wheel as there are already programs focused on emotional well-being that have significant outcomes for health and education, but people just don’t know about them.
“Sharing success stories is going to be an important part of expanding our prevention efforts,” he said.
Is physician burnout real and how significant is it? Some wondered, is discussing burnout causing more of it?
J. Duncan Moore wrote, if you talk to doctors about burnout, you might hear that it is a phenomenon tied to the age of the doctor or his or her decades in practice. “Physician burnout in my definition is a phenomenon of the physician who is older, above the age of 50 or 55, who has lived through the transition in medicine from the science to the business,” said David May, MD, 60, a cardiologist in Dallas. The pressure for cost reductions, the increased oversight, the convoluted rules imposed by Medicare for quality of care and meaningful use — “for many physicians of my generation, it’s not part of our DNA to think of it in those terms. That makes it less fun. There’s less excitement, less engagement.”
As plausible as it sounds, that theory is not really correct. It turns out there is a science of burnout, and it has been developed for the most part at Mayo in Rochester, Minn. The truth about burnout is that there is a U-shaped relationship between age and career satisfaction. Younger and older doctors suffer less burnout than mid-career doctors.
Lotte N. Dyrbye, MD, is not burned out on medicine, but she remembers what it felt like when she was. As a resident at the University of Washington Medical School in the late 1990s, she experienced emotional exhaustion, depersonalization, and dissatisfaction — the symptoms commonly labeled “burnout.”
It came back to her some years later when she heard a grand rounds presentation on burnout in residents by a colleague at the Mayo Clinic, Tait D. Shanafelt, MD. Intrigued, she took part in a study of burnout among medical students in Minnesota. She has been researching the topic ever since.
Dyrbye, Shanafelt, and Colin P. West, MD, are co-directors of the Mayo Clinic Department of Medicine Physician Well-Being Program, which has produced a series of studies published in medical journals looking at the phenomenon of burnout across the continuum of medicine.
Rates of burnout vary markedly by specialty. The highest rates were found among front-line physicians: family medicine, general internal medicine, neurology, and emergency medicine. The lowest rates were found among pathology, dermatology, general pediatrics, and preventive medicine.
“It matters to patients that physicians are burnt out; they deliver suboptimal care,” she told MedPage Today. “They are also more likely to cut back on clinical work hours, and more likely to leave current clinical practice. That impacts access and continuity.”
The Mayo research team has learned that:
- Burnout among physicians is real, and can be documented using standard measures.
- Physicians are significantly more exhausted by their work than other professionals or the population at large.
- Consequences of burnout play out in many dimensions, including worse patient care, premature retirement, unhappy family lives, uncivil collegial relations, dysfunctional care teams, loss of empathy, and medical errors.
- Burnout may increase or decrease according to stage of life or years in practice.
- Health reform is twisting the knot even tighter.
- The contributors to eventual burnout have their origins in medical school.
- In the absence of interventions and countermeasures, rates of burnout appear to be increasing.
The definition of burnout used in the literature has three components: emotional exhaustion (feeling overextended and exhausted by patient-care responsibilities); depersonalization (an unfeeling and impersonal response toward patients); and a low sense of personal accomplishment (feelings of competence and successful achievement from work).
The standard tool used to evaluate rates of burnout is the Maslach Burnout Inventory, developed in the 1980s by Christina Maslach, PhD, a psychologist at the University of California Berkeley. Using the Maslach Burnout Inventory, the Mayo group conducted a survey of 7,288 physicians in 2011. They found 45.8% reported at least one symptom of burnout. That included 37.9% who had high emotional exhaustion, 29.4% with high depersonalization, and 12.4% with a low sense of personal accomplishment.
More than one-third (37.8%) screened positive for depression, and 6.4% had experienced suicidal ideation in the past 12 months. Almost 37% reported their work schedules did not leave enough time for personal and family life.
What the Mayo researchers really wanted to know was whether doctors have the same rate of burnout as the rest of the general population. They compared 6,179 nonretired physicians ages 29 to 65 with 3,442 employed nonphysicians in the same age bracket.
The results, published in the Archives of Internal Medicine, were startling:
- Physicians were at higher risk for emotional exhaustion (32.1% versus 23.5%)
- Physicians have a higher level of depersonalization (19.4% versus 15.0%)
- Physicians are at higher risk for overall burnout (37.9% versus 27.8%)
- Physicians worked 10 hours more per week on average than the general population (50 hours versus 40 hours)
Further, 40.1% of doctors thought they didn’t have enough time left over for family and personal life, compared to 23.1% of the general public. Female physicians were markedly more dissatisfied with their work-life balance than female nonphysicians (43.1% versus 23.0%).
The authors conclude, “After adjusting for hours worked per week, higher levels of education and professional degrees seem to reduce the risk for burnout in fields outside of medicine, whereas a degree in medicine increases the risk.” (Emphasis added).
Thus the experience of burnout among physicians “does not simply mirror larger societal trends.”
“I think the majority of us are dissatisfied,” said Julie Lyons, MD, 40, a family practitioner in Idaho. “Medicine is becoming more corporate. The responsibilities of the physician double each year depending on the new requirements. Powerless is how a lot of my group feels.”
In her practice, preauthorizing medications and imaging, and additional noncompensated work is taking at least an hour every day, she said. “Not to mention we are now expected to be available to our patients by email. You’re not compensated for that, either.”
The computer system requires her to function as a data entry clerk. She has to enter tests, results, imaging orders herself. Plus she has to write all her own correspondence to insurance companies, patients, businesses, and schools.
“Previously, you’d have nursing support for that. Previously, they were forms you could check off, but our new forms are not prepopulated,” she said. It all takes a lot of extra time.
“Burnout is the symptom. The causes are multifactorial,” said Tim Lee, MD, a pediatrician who is an associate medical director for quality at the Palo Alto Medical Foundation in California. “The electronic medical record, all the requirements … A lot of physicians aren’t great with computers. The administrative work has reached 40 percent of your time. It goes to the question of meaning in medicine. Doctors say, ‘I didn’t go into medicine for this. I am charting all day. It’s ludicrous.'”
Many physicians feel so overwhelmed with the amount of work that is expected of them that they’re not receptive to any new initiatives, he said. They just don’t have the bandwidth. That presents a problem for the organization, which must constantly introduce new projects or ways of doing things to respond to external pressures from regulators, insurance companies, the government, or patients themselves. Physicians who feel overwhelmed, Lee added, aren’t going to engage. “We can’t think. We can’t make progress.”
It’s commonly believed that doctors have a certain kind of personality — a perfectionism, an emotional detachment, with sense of themselves as solo flyers who have to always be right — that predisposes them to a vulnerability to burnout. The solution might then come from teaching doctors to take better care of themselves.
While physician self-help may be a worthy goal in its own right, Dyrbye said, it is not sufficient. Burnout “has its origins in the work environment. It’s related to the type of work we do,” not to the personal characteristics of a few susceptible individuals.
“It can’t just be, the physician is responsible for his or her own self care, mindfulness, stress relaxation. A lot of factors are beyond an individual’s control,” she said. “There is also a very large organizational responsibility” to address the factors in the work environment that cause burnout.
Medical students don’t start out with a propensity toward dissatisfaction. Quite the contrary they actually come into medical training with lower levels of depression and a higher quality of life than their peer group. Something happens along the way that turns them, Dyrbye said.
There are indications that burnout may be getting worse. The Mayo group conducted an experiment in its own clinic from 2010 to 2012 looking at an intervention to help doctors reflect and talk about meaning in work, personal and professional balance, community, and caring for patients. The intervention was successful: depersonalization, emotional exhaustion, and overall burnout decreased substantially.
But there was a cohort of nonparticipants — doctors who didn’t want to be part of the study, even in the control group — that didn’t get any of the interventions. Their scores tanked on all measures across the yearlong study period: The percent who found their work meaningful plummeted. Rates of emotional exhaustion went up. Rates of high depersonalization rose, and so did overall burnout. It is perhaps worth noting that the study period coincided with the rollout of parts of the health reform law and the federal government’s push toward installing electronic medical records in doctors’ practices and mandating “meaningful use” of the devices.
The American Medical Association, which contributed funding to the Mayo research project, has invested considerable resources in understanding the causes and possible solutions to burnout. The AMA doesn’t like to use the word “burnout;” it prefers to talk about “enhancing physician satisfaction and efficiency.”
“We want to restore the joy of medicine,” said AMA President Steven J. Stack, MD, in June when the organization unveiled a web site designed to help physicians “revitalize your practice and improve patient care.” Stack has a unique perspective on the risk for burnout: he is an emergency physician, the specialty with the highest rate of burnout according to a Mayo survey of specialists.
In 2012, the AMA commissioned an exhaustive research study by the RAND Corp. to look at all the factors that influence physician professional satisfaction, and identify potential targets for interventions to improve it.
“People are feeling frustrated,” said James L. Madara, MD, the AMA’s executive vice president and CEO. “There’s a lot of administrative requirements burdening the practice of medicine. We were getting a meta-signal that there were problems in running physician practices.”
The RAND study examined “dissatisfiers and satisfiers” that physicians found in practice. The most important “satisfier,” Madara reported, was “having enough face time one-on-one with patients.”
The leading “dissatisfiers” were the increased busyness of the practice and the electronic medical record. “In their current state they are pretty dysfunctional for entry and extraction of clinically important data,” Madara said. The AMA has come up with some ideas for improving the internal flow in physicians’ offices, which it is publishing on its STEPSForward.org web site. “Every physician has access to this,” Stack said, not just AMA members.
Still, there are burnout skeptics, as I pointed out. Martin Love is one of them.”I’m not sure that I believe in physician burnout,” he said. “The word burnout strikes me as being classist. Do janitors working two jobs burn out? They don’t use the word, they just get tired and anxious and frustrated. But docs get to have burnout.”
Love, 70, has been CEO of the Humboldt-Del Norte Independent Practice Association in Eureka, Calif., for 15 years. Before that he was a clinical laboratory director and later a hospital CEO. He has been in healthcare since 1971.
His long years of experience have delivered him into a decidedly unglamorous view of medicine. “There is some sort of mismatch between what people think their careers are going to provide them, and what their careers provide them. That mismatch has been true for 40 years or so.”
Practicing medicine, he said, is “very boring work. You sit in a little room, and people come and whine. There’s only 20 or 30 things they whine about. They do that over and over again for years. That’s a medical career.”
And primary care patients are the worst whiners. “Primary care has got to be one of the most boring things in the world to do.” Love has had conversations with doctors who tell him it’s not boring at all. “But my observation is that it is boring. And people in midcareer or later will do almost anything to avoid seeing the next patient. But they can’t. Because they need the money. So they complain.”
He thinks a huge dissatisfier for physicians is their expectation for professional autonomy. Indeed, when MedPage Today surveyed a sample of health care professionals and asked them to choose among 10 factors contributing to professional burnout, the No. 1 rated factor, cited by 26% of respondents, was “loss of autonomy and control over content of clinical work.” And this is only getting worse with health care reform. Autonomy is “one of the most addictive things there is,” Love said. “You are always running out.”
The dissatisfaction among physicians stems in part from their unrealistic expectation of how much freedom they will actually have to do as they please, Love said. “The training they get doesn’t prepare them for the work they’re going to do. It also distracts them, or misdirects them, in terms of those things they are interested in, which are around autonomy and money and importance.” A working physician is not really going to have much executive power to influence the flow of resources in medicine, much less in his or her own practice, Love said.
Today, the Mayo Clinic’s Dyrbye finds herself on the other side of the burnout wall. She is 46, a general internist at the Mayo Clinic, and full-time working mother of three.
“My practice definitely has changed over the past 10 years. Demands on my time are going up exponentially. We have more and more non-visit care. People are not coming into the office for face-to-face encounters.” Like every other doctor, she is swamped by paper work, medication refills, patient portals, meaningful use, and the EMR. “That can make for some very long days,” she said.
But she is very far from burned out. “I have been fortunate to be able to spend time on the aspects of medicine that I find the most meaning from. I love seeing my patients, and providing care to a primary-care panel. I love working with medical students. I love writing papers. It has helped me sustain and be resilient.”
Her personal experience is congruent with her research interest: “We found that physicians who spend at least 20% of their time in meaningful activities have lower rates of burnout,” she told MedPage Today.
How those meaningful activities are defined is a highly individualized preference, she said. “If you’re a hematologist and you really like to take care of people with a certain type of leukemia, that could be your 20%. Or if you like working with medical students.”
Allowing physicians to find the niche that floats their boat, and pursue it as part of their practice work output is one avenue to restore physician satisfaction. There are others that are being studied around the country.
It’s good that the risks of physician burnout are being brought fully into the spotlight, said Lee. “If the public doesn’t recognize burnout as an issue, it’s going to have serious consequences for health care. Physicians aren’t going to want to work, they’ll tune out. They won’t respond to your voice mail or take your email.
“People need to understand, there is a return on investment on addressing burnout. It’s going to cost money. Trust is a big issue. People have to believe that physicians want to be engaged, to do the best for their patients.”
Burnout is typically not a rapid onset condition and for many there are signs of the condition as early as medical school or post-graduate training.
In recognition of this, some medical schools and residency programs are taking steps to address burnout as an early career issue. “You might not be able to change the clinical environment, but you can change their response and the choices they make,” said Vineet Arora, MD, a faculty physician and assistant dean at the University of Chicago Pritzker School of Medicine.
One way to do this is to induce a greater resiliency in physicians in training. The Association of American Medical Colleges is now encouraging schools and residency programs to cultivate resilience in young physicians. Among its “intrapersonal competencies” for entering residents the AAMC includes “resilience and adaptability.” That is, a doctor who can demonstrate tolerance of stressful or changing environments or situations and adapt effectively to them.
“While most of us would say that medicine is the most gratifying, stimulating, and noble career a person can pursue, many of our colleagues are in genuine distress,” said AAMC President Darrell G. Kirch, MD, last year. “Resilience is what drives us forward and inspires us to take on difficult challenges and to keep trying in the face of doubt and failure.”
Studies show that about a quarter of medical students are depressed, half of them experience burnout, and most of them report quality of life substantially worse than the same-age general population. To screen for distress among medical students Lotte N. Dyrbye, MD, and colleagues at the Mayo Clinic developed a Medical Student Well-Being Index. The index correlates with quality of life, fatigue, recent suicidal ideation, burnout, and the likelihood of seriously considering dropping out of medical school.
It is easy and convenient to think that people who go into medicine have a certain kind of perfectionist personality that predisposes them toward burnout, Dyrbye said. Her research into what kind of person enters medical school convinced her the opposite was true. “When they come in the door, medical students have better or similar levels of mental health than others,” with lower prevalence of depression and a higher quality of life reported in most arenas, she said.
The University of Chicago has incorporated wellness and resilience into the undergraduate and graduate medical curricula. Wei Wei Lee, MD, is assistant dean of students and directs the wellness program at Pritzker. “One of the domains of competency is professionalism,” she told MedPage Today. Medical students need to recognize personal and professional development as a skill. That means they must acquire healthy coping mechanisms, become aware of stress, and learn to be flexible and mature and adjust to change.
She has assembled a student committee on wellness, with four representatives from each class, that meets monthly. The committee develops programs to address burnout and holds social events to build student camaraderie. The school is building a portfolio for the students on teamwork and leadership skills as well.
Students do a self-assessment twice a year of their physical well-being, mental well-being, and health-seeking behaviors. They set specific goals they want to work on in the next 6 months. This becomes part of their personal and professional development portfolio. The committee then develops events around the themes that the students are interested in.
“Out of these self assessments, we’re now putting together mandatory session on mental health in the medical profession,” Lee said. The school wants to destigmatize issues around mental health, and talk about it in an open atmosphere. “We want to normalize that health seeking is not punitive, that there is a supportive community of faculty staff and peers out there.” Since the program started in the 2014-15 academic year, student engagement has been high, she said.
The program on resiliency for residents at Chicago was led by Amber-Nicole Bird, MD, now an assistant professor of medicine at the University of Pennsylvania Perelman School of Medicine. A survey of residents at the University of Chicago Medical Center revealed that all of them had experienced it in their training but the majority felt they had no outlet to discuss the issue.
“We felt like there were plenty of interventions available that focused on wellness: healthy eating, sleep management, taking care of yourself,” Bird said. But residents didn’t think those worked. “We thought, what if we could look at a different marker, say, resilience? Those individuals with lower resilience look at it in a different way, or have more downstream consequences. Maybe we could train them to be more resilient.”
The team leaders used the Connor-Davidson Resilience Scale to quantify resilience in residents. They divided the scores between low, intermediate, and high. The average was 70 out of 100. Those who scored lower than 40 were deemed to be at high risk in managing stress. A program was created emphasizing setting realistic goals, managing expectations, processing and letting go after stressful clinical events, and finding gratitude.
From August to March of the 2014-15 school year, small group sessions were held to introduce the main skill, for example, managing and letting go after stressful clinical events. Students were invited to discuss why it was stressful, what it felt like, how they managed it.
Then came a skill building exercise for letting go, including a systems analysis of medical error. “We would have the residents write a narrative of an episode they were involved in that was stressful,” Bird said. “We would then have them rewrite the story, remove the ‘I’, tell the story from the third person as it occurred. Then we asked them to identify where there were other actors at play that contributed to the error.”
A similar exercise was created around finding gratitude. Residents at first were skeptical of the program’s value, Bird recalled, but that evaporated as the year progressed. “At the end, we had great feedback. Just under 70 percent of the residents who went through the program wanted it to be continued,” she said.
The qualitative feedback showed that the program fostered a sense of shared experience. That was important for the residents, because it “gave them time to process an experience where they felt alone,” Bird said. “It was therapeutic.”
There is certainly much to be depressed about in medicine: stress, declining reimbursements, soul-sucking electronic medical records, long hours, arbitrary rules, and much more. All the training is not going to solve the problems of burnout and the unhappiness that more and more physicians are experiencing. We, physicians, need to find balance in our lives. With all the increasing pressures, administrative requirements and the treat of malpractice without any suggestion of tort reform the pressures will continue.
My solution was to find the right partner and decide not to follow my parents’ suggestion to come home to Westchester County to join a high power, lucrative practice. Choices!!
Still, I have had the same feelings related to burn out, but have a great family support group, a wonderful staff that looks out for me and other interests. Why is this topic of burn out and the health and happiness so important today? Because if the health care reform system accomplishes what it has planned, we will need all the physicians and more to manage the increase in the patient population in the healthcare system.
The fact of the matter is there are already so many regulations in medicine, without considering the Affordable Care Act, you also have different practice groups, nurses, nurse practitioners, PAs, different levels of doctors with different types of certification, zoning issues, and you have the FDA and DEA all with the complexities of interactions of all.
So, those of you out there already in medicine, give yourselves a break, power off the phone occasionally, get a hobby, pursue some outside interests, take vacations and if you don’t already have one…get someone to share your happiness with before you burn out. Find you life balance and enjoy or get out before it swallows you whole!
Those of you considering the profession of medicine, get a hobby, find an interest besides your goal of becoming a doctor and have someone to share it with! Again, find your balance in life.
Readers of this blog who are not involved in medicine know that burn out happens in other professions also. So, whether you are a CEO, hedge fund trader, professional athlete, etc… these suggestions for a balance in your life apply or pass them on to your friends who show the signs of burn out.
Next, a discussion of the abuses that we in medicine suffer and their effect on the health and happiness in our lives as physicians.