Physician burnout: is there any one cause?

burnoutshotHealth care has received a rude wake-up call. With one of the highest rates of depression among professions – more than 45% across all specialties – physicians are burning out at a rapid rate. According to dermatology specialist and physician burnout coach Dr. Elizabeth Hughes, studies show that an average of 54% of physicians across all specialties have experienced burnout. As recently as 2005, it was 31%.

“Burnout,” says Hughes, “is the most significant challenge facing health care in the 21st century.” Left untreated, burnout can lead to dissatisfied and underserved patients. Worse, it can lead to medical errors, increased risk of litigation, patient mortality, and physician suicide.

“We are facing some powerful changes in medicine,” says internist and addiction specialist Dr. Michael Schiesser, “changes that are just bringing out the possibility of burnout that has been there all along.” Among the most obvious are the current administrative demands upon physicians alongside the downward pressure on compensation.

While surface causes of physician burnout are often readily seen, burnout remains difficult for physicians to admit. Theirs is an inherently and uniquely difficult work. Much scrutinized, they must treat illness and anxiety on a daily basis. It is a profession in which the stakes, and the level of expertise required to meet them, are high. Education and training is costly, hours long, and a personal life challenging to maintain.

To manage the demands of a medical career fosters the very individual traits that can lead to burnout: idealism, empathy, and a type-A personality. These traits very often form a kind of fire wall between the physician and his ability to recognize the signs of burnout and to seek the necessary help to prevent or treat it.

That reticence to be vulnerable and admit to ourselves that we are spiraling downward, says Hughes, leads to a deteriorating quality of life, including work overload, loss of control, lack of reward and community, feeling like a cog in the wheel, a diminished sense of personal accomplishment, and the sacrifice of family, hobbies, friendships, and other non-medical life goals.

Sadly, a habit of not having these life-invigorating resources to rely upon becomes ingrained and results in alienation from what was once a promising career choice. “Burnout leads to disengagement,” notes Hughes. “I see it as a real mismatch between the skills and expertise that physicians spent years honing and how they actually spend their time. This leads to frustration that physicians can’t do the jobs they’ve been trained to do.”

Though the cost for not doing so is great, physicians are notoriously hesitant to ask for help and sometimes with good cause. Burnout is often viewed as the physician’s fault, as if the reason a health care worker is burned out is because he or she is failing and not that the system is failing the physician. And physicians, as a group, can be their own worst critics.

“We want to see ourselves as always capable, not vulnerable, and that we don’t make mistakes” says Dr. Darcy Constans, a family physician at Seattle’s Polyclinic and a Leading WellTM team member at Physicians Insurance. “Because we are ultimately the ones responsible for everything, we must also be responsible for our own burnout.”

And yet, physicians experiencing burnout are not the most subjective observers of their medical issues. Says Dr. Mick Oreskovich, a Seattle psychiatrist and leading national researcher on burnout, “Those suffering from burnout or depression often have pretty delusional thinking. They are going to work thinking that they’re still doing a good job. They are often the last person in the room to know how depressed they are.”

Schiesser says that society nevertheless expects physicians to be flawless and on call to meet patient needs when, in fact, “physicians (also) have personal circumstances that need help and attention.”

Hughes calls for nothing less than a “culture of wellness” within the health care profession, because “when physicians aren’t well, the patients can’t be well either.” She quotes author Michael Scott, who said, “Put on your own oxygen mask before helping those around you.”

How ironic that the very traits that can make someone a quality doctor can also lead them to a predisposition for burnout. The key to helping patients be happy and healthy is to maintain the qualities that keep you connected to them and their care, while quite consciously fending off the pressures that prevent sharp focus and high touch healing from taking place.

Watch for Part 4 of our burnout series —  Physician burnout: solutions.

Meanwhile, read the rest of the burnout series:
– Part 1: Physician burnout: recognizing the signs
– Part 2: Physician burnout: impact on you, your team, and your patients

Physician burnout: impact on you, your team, and your patients

The Physician Burnout Series: Part 2 of 4

Stop burnout it before it stops youFive years into practicing family medicine, Dr. Marlene Costa (not her real name) had no control over the hours she worked or when she was on call. The organization that employed her increased its requirements for documentation, expecting her to write separate care plans for each chronic condition diagnosed. With some patients having three or four conditions, the paperwork became repetitive and overwhelming. Though Costa agreed it was important to have a plan of care, documentation was turning into a matter of checking the boxes. Not only was the process inefficient, it also frustrated her because her organization’s demands denied her the power to decide what was meaningful and effective in patient care.

A growing lack of control over her professional life and its encroachment on her personal life caused Costa to fall into the sinkhole of burnout.

“Medicine was my calling, my passion,” Costa said. “It was what I was meant to do—and it was killing me. I felt like everything I had spent my entire life working for was evaporating in front of me. I felt stuck. My work was making me so depressed and anxious that I wasn’t functional anymore, but I had no way out because I had hundreds of thousands of dollars in student loans to pay. When you look at the numbers out there of depression and suicide among physicians, having gone through that depression and the shame it brings, it doesn’t surprise me.”

For Costa, climbing out of the hole of burnout meant taking a year off and then reestablishing herself with a new group of physicians that values teamwork and allows her more autonomy. She is happy again in her profession, and thankful.

“I feel really lucky that I had the resources and wherewithal to take time away and figure it out—to change my situation. It would have been so easy for that to turn out differently,” she said.

The dehumanizing work environment Costa experienced is one of the primary causes of burnout, according to Dr. Charles Meredith, a board certified addiction and general psychiatry professional who was medical director of the Washington Physicians Health Program for a decade and recently went into private practice.

Correlations have been made between burnout and depression, substance abuse, emotional disengagement, and increased medical errors. Though errors may increase because of burnout, they may also be the cause of it to some degree. Errors that cause harm to a patient are devastating to the physician as well as the patient.

Albert Wu, MD, MPH, professor of health policy and management at Johns Hopkins Bloomberg School of Public Health, has coined the term “second victim” to describe the effect of medical errors on physicians. In an interview for Patient Safety Network, he said, “Over the years, we gradually began to realize that most things are at least partly the responsibility of the system: things are built into the system that allow other things to go wrong. But even though individuals are often not responsible at all for things that go wrong, they still feel responsible.”1

Dr. Darcy Constans of Seattle’s Polyclinic agrees. According to the 36-year-old family physician, mistakes are not considered acceptable in the medical profession. “Physicians hold themselves to a ridiculously high standard—perfection.” Constans said. “Medicine is different than a lot of other careers. Take baseball for example: one home run out of 20 hits is doing really well. But if you’re a doctor, you feel you have to make 20 out of 20 or you’re really screwing up. When a physician makes a mistake, especially a big one, it’s devastating in a core way that may cause him or her to question whether or not he or she should be doing this.”

Experts agree that recovery from a medical error is dependent on the support a physician receives. The emotional aftermath is not something that can be swept under a rug.

“It’s different for each person in how it plays out, but physicians can have a deep sense of shame over any kind of mistake, as well as intense fear that they could do it again and hurt someone,” Constans said. “That isn’t something you can live with every day if you are practicing. You might be able to hang on for a couple months or even years, but not for an extended period of time. A lot of times people suffer significant depression and anxiety and then stop practicing, or leave clinical practice and find something else that doesn’t involve patients and feels safer.”

Of 10 colleagues who graduated from residency with Constans six years ago, two are not practicing any longer and many others have experienced severe sadness in their work, she said.

Dr. Ron Hofeldt, psychiatrist and Director of Physician Affairs for Physicians Insurance since 1994, has helped hundreds of physicians work through the ramifications of medical errors, both emotionally and in litigation. In recent years, he has partnered with Carolyn McManus, a teacher of Mindfulness-Based Stress Reduction at the Outpatient Rehabilitation Department at Swedish Medical Center in Seattle, to lead workshops on mindfulness meditation, a practice known to help doctors recover from and prevent burnout.

“Anecdotally, at the level of state and county medical societies and leadership, people are seeing a bit of a crisis in the medical field,” Hofeldt said. “Over the last five to eight years there are increasing rates of dissatisfaction among physicians in general, leading to attrition in the field. When I was in medical school, my professors would complain that they couldn’t get their children to go into medicine and it was the only field worth going into. Now I hear doctors say they would counsel children against going into medicine. They are looking for ways to get out of the profession.”

In response to the crisis of physician burnout, Physicians Insurance is multiplying the efforts of Hofeldt and McManus with a program called Leading WellTM, which consists of a team of 10 physicians who will offer consultation to organizations and groups in order to both lessen the burnout experienced by physicians and also enable those who are burned out to recover. Hofeldt is hopeful that the work of Leading Well and other groups will renew a passion for the field of medicine by giving current and future practitioners a new set of tools they can use to tackle the stresses of health care in the 21st century.

1 Robert Wachter, “In Conversation with…Albert Wu, MD, MPH,” PSNet, May 2011, accessed August 5, 2016, https://psnet.ahrq.gov/perspectives/perspective/101/in-conversation-with-albert-wu-md-mph.

Next: Watch for our upcoming blog article titled Physician Burnout: Is There Any One Cause? (Part 3 of a 4-part series on Physician Burnout)

Physician burnout: recognizing the signs

The Physician Burnout Series: Part 1 of 4

Recognizing burnout in yourself or others

Recognize the signs of burnout in yourself and others

Sarah: An oncology nurse for 30 years, Sarah has such great bedside manner she’s taught seminars on the subject. But following a recent annual review, statements like “lacking in compassion,” “not listening well,” and “staring blankly when confronted by grief” are bouncing around in her mind. She wanted to argue with her supervisor, to point out the commendations she has received in years past, but truthfully, she knows that the needs of her patients that used to arouse empathy in her now only seem to sap her energy. It’s enough for her to complete the physical work of nursing these days, and she wonders where her passion for people has gone.

Tom: Always the life of the party in medical school and residency, Tom could always be counted on to go clubbing and drink anyone under the table. Even now, after a decade in emergency medicine, colleagues who stopped partying hard to meet the demands of their profession notice that Tom’s energy seems to ramp up rather than diminish with age. Lately he’s not only been energetic, he’s also visibly agitated and unapproachable. Then, following a night shift, he drove his Porsche through a railing and off an embankment on his way home. When he was admitted to the ER, they found methamphetamine in his blood work.

Matt: Matt placed the central line during a code blue and did everything he could to save the 45-year-old man with a vfib cardiac arrest. When the patient died and everyone was clearing the room, it occurred to Matt that the guidewire was left in. He sat at his desk for the next half hour, not sure what to do or say. Did the guidewire have anything to do with the continued PEA arrest? How could he have missed it? How will he face his colleagues when they find out about it? What will he tell the family? Will there be a lawsuit? Is his home and children’s education fund at jeopardy? Head in his hands, Matt wondered for the thousandth time if he really should be practicing medicine.

Though Sarah, Tom and Matt are facing very different circumstances, they all have one thing in common—they are experiencing burnout. According to Dr. Mark Mariani, director of Multicare’s Physician Wellness Program, burnout is a syndrome of depersonalization, emotional exhaustion, and low personal accomplishment that leads to decreased effectiveness at work.

Though not a new phenomenon, the rates of burnout among physicians in the United States have risen dramatically. Ongoing research by Dr. Tait Shanafelt at Mayo Clinic shows the percentage of reported physician burnout in the United States has risen from 30% in 2011 to an alarming 54% in 2014. During the same time, burnout rates in other professional fields in the U.S. held steady in the high 20-percent range.

Specialties at highest risk for burnout include emergency, family and general internal medicine, but large increases were also seen between 2011 and 2014 in orthopedic surgeons, radiologists and rehabilitation.

The trend has many medical professionals understandably worried. In addition, the study shows that 39% of the doctors who took the survey screened positive for depression, the rate of suicidal ideation in the last 12 months jumped from 4 to 7.2%, self-medication and substance abuse is a problem, and burnout is causing many to consider early retirement or reduce their working hours.
“There are costs to the healthcare system as burnout directly affects quality of care, patient satisfaction, nurse turnover and financial performance of the healthcare system,” says Dr. Viral Shah. “There are also personal costs to the physicians that experience burnout—sleep problems, depression, anxiety, substance use, fatigue, and getting into conflicts at work and home.”

The Mayo Clinic will conduct another survey in 2017, but with more than half of the physicians in the United States reporting burnout, it’s past time to do something about this.

According to Dr. Shanafelt, five dimensions that contribute to burnout include excessive workload, inefficiencies in the practice environment, loss of flexibility and control for medical professionals, loss of meaning in work, and a loss of work/life balance (40% of physicians work more than 60 hours per week compared to 7 percent of the general public).

“This is a system-based problem,” says Dr. Shanafelt in a recent radio interview. “U.S. medicine is at a tipping point now, with over half of our physicians experiencing burnout. We need healthcare organizations to address this problem with strategies to focus on improving efficiency in practices … delegating clerical work to support staff, creating an environment that cultivates flexibility and control over work, a greater connection with colleagues, and where addressing the problem is the shared responsibility of both physicians and organizations.

“The current degree of burnout is alarming given the strong links between physician burnout and quality of care, as well as the connection between burnout and medical errors. Physicians who are burnt out are more likely to reduce their professional work effort or cut hours, which could compound the anticipated shortage of physicians in the U.S. during the next decade.”

For those experiencing burnout—a lack of self-efficacy, emotional exhaustion, and depersonalization—there is hope. Thought leaders such at Dr. Shanafelt are taking an academic approach to study the syndrome and come up with solutions; MultiCare’s Physician Wellness Program is in the process of developing an organized approach to addressing burnout; and Physicians Insurance has partnered with Leading Well and Vera University, a division of Vera Whole Health, to offer courses that teach physicians how to prevent and overcome burnout.

But first, the #1 need to be addressed, according to Dr. Mariani, is for physicians to recognize that they are experiencing burnout. They need to know there are solutions available, no matter how complex the situation may be.

“Like with anything cultural, it is not a quick answer or pill that will change this,” says Dr. Mariani. “It’s going to be a long road, but we need to start our journey now.”

 

Next: Watch for our upcoming blog article Burnout: Stop It before It Stops You (#2 in a 4-part series on burnout).