Author: Dr. Emily Darby
At the risk of sounding cynical right off the bat, the very idea of needing an approximate financial cost of physician burnout to motivate action seems a bit absurd. To be clear, I am not criticizing Han et al, authors of Estimating the Attributable Cost of Physician Burnout in the United States. We live in a world motivated by money, and keeping physicians employed and happy only “sells” when there are clear financial consequences. Nevertheless, the non-financial consequences of burnout can be so much more devastating and heart-wrenching because it involves real-life people— friends, colleagues, parents, and spouses. I left medicine on my own terms, but I’ve known fellow physicians who have suffered drug or alcohol misuse, divorce, depression, and suicide. How much of a role burnout played in these outcomes is unclear, but with most struggling physicians, it is always there at the edges.
A lot has been written about the sources of burnout, and I don’t want to reiterate too many of the technical aspects. What I find fascinating is to note that the current environment of medicine may pit the typical detail-oriented, feedback-responsive, and socially motivated physician (née professional student) up against an almost perfect “enemy” in the current medical system. Throughout her education and training, the physician-to-be must excel—through intelligence, eagerness, and in many cases putting in just a little more time and effort than her peers. Most physicians also enter medicine with some concept of contributing to a greater social good. These very traits which can produce great healthcare providers can also become a working physician’s downfall: when the feedback loops becomes negative, there is literally no more time in the day for that extra effort, and the vision of social good is clouded by medical bureaucracy.
The business environment in which physicians work is unlike any other. Charges and payments are set, neither by physicians and practices nor by the patient/consumer, but by the government and insurance companies. Facility expenses, staffing, and EMR’s (electronic medical records), however, steadily increase the cost of practice. Thus, physicians have very little choice but to try to increase volume in order to keep income stable (much less make more over time). Whether all physicians “deserve” some of the salaries they have come to expect may be a matter of public debate. Still, I find it interesting that society does not impose the same judgement on other careers that involve rigorous education, deferred income potential, stressful and demanding hours, and a looming threat of liability. In addition, recent decades have seen a monumental increase in the “paperwork” of medicine. Charting used to be for internal documentation of what occurred within a patient visit to serve as a memory jog for a provider at subsequent visits. Now, with payor requirements for charting in order to meet criteria for payment, meaningful use requirements for documentation in order to achieve some small reimbursement of the large cost of the EMR, and the need to keep track of the medical information of increasingly complex patients over time, the secretarial work-load of medicine is an immense burden. Moreover, in the era of cost-cutting, much of what used to be delegated to staff, now falls on the physician. Just falling behind in this documentation can trigger a cycle of internal feedback and consequences from clinic administrators and employers—a major source of physician stress.
With the above factors depleting a physicians’ energy and morale, ideally, he would have time to replete himself through physical exercise, relationships, avocations, spiritual practice, or simply quiet reflection. In reality, physicians are often expected to be available within busy workdays and evenings for phone calls with patients, colleagues, home health companies, insurance companies, and emergency rooms, usually with minimal if any compensation. Even the well-meaning call from a neighbor can intrude upon what be the only hour with a child at night. The work can creep in subconsciously as well. I remember during one particularly stressful period when we were restructuring our practice and I was in charge of strategizing scheduling, I would wake up in the middle of the night several nights a week with calendar permutations on my brain! Unfortunately, looking for meaningful friendship and support from physician colleagues can also be difficult. The work ethic and survival focus cultivated in training can prevent at-risk physicians from reaching out. Likewise, the lack of time and that singular focus on getting through the day, can make physician colleagues seem unapproachable for issues that seem too personal or not able to be relegated to a 2-minute elevator chat.
So, physician burnout is both a tangible issue affecting real lives and a cost to the healthcare system. The question remains: what to do about it? I, like many physicians, during my worst moments in practice, scoffed about mindfulness for burnout as being akin to using a band-aid for hemorrhage. How was mindfulness going solve the need to see 30-40 inpatients a day when we were unable to hire replacement physicians and were not allowed to utilize a locums provider? There is a lot wrong with many physician current practice environments, and physicians, first and foremost, need to learn to be advocates for themselves, both as individuals and as a professional group. In regard to having a voice in public policy, I have actually heard physicians say “We don’t want to seem selfish—we need to advocate for the patient first.” I am pretty sure those words have rarely been uttered by any other lobbying group! Furthermore, patients are the major beneficiaries of a healthy physician workforce. To circle back to mindfulness, though, I do feel that attention to mindfulness and physician wellness can play an important role in physician health and career longevity. While mindfulness can’t tackle crisis management alone, it can help a physician focus on right now and the immediate pleasures of her job (yes, there are many), the privilege of her role, and the good she is doing at any given moment. It can also help train the brain, so that “off time,” however brief, is really off—enabling the physician as person to fully focus on moments such as dinner with the kids, a walk with a spouse, or even a good book without the constant interruption of a thought loop of day’s perceived failures or the imagined ones of the day ahead.
Hopefully, the loss of 4.6 billion dollars will offer adequate financial motivation for employers to set aside both time and funding for physician wellness. Nevertheless, we also need more publically available resources for solo and small physician groups who are also at risk of burnout but may have minimal ability to access help. County, state, and national medical societies could play an important role in galvanizing this effort. Moreover, rather than accepting burnout as the current state of medicine, physicians need to work to change the culture. “Physician heal thyself” needs to evolve into a group effort.