A new patient of mine said that he was switching physicians because he was unhappy with his prior family doctor. I asked why. “After a while, she stopped listening.” What was that like?, I asked. “I’d come into the office. She used to look me in the eye and put her hand on my shoulder. Now her eye is on the screen and her hand is on the mouse.” My new patient has severe arthritis, chronic pain, heart disease, depression and asthma. “She used to pay attention to everything, But now, once there’s a diagnosis and a treatment, she’s out of there. She used to ask how I was feeling, now it’s just about numbers. I’ve lost a friend.” Six months later, this doctor left practice. Turns out that this doctor had been a student of mine, bright, caring and skilled. She met all of her hospital’s productivity and quality benchmarks. But she was burned out.
Buried in the news earlier this year was a report that Dr. Vivek Murthy, the Surgeon General of the United States, considered the well-being of physicians be the nation’s number one health priority. Number two was prescription drug abuse. With obesity, diabetes, cancer and depression affecting large segments of the population, why the focus on doctors?
The magnitude of the problem is staggering. Burnout — emotional exhaustion, often accompanied by cynicism and feeling ineffective — affects more than half of practicing physicians and is on the rise. Seen as a problem of “well-being” — affecting physicians’ personal lives and work satisfaction — it garnered little public sympathy, dismissed as the whining of a privileged class. But now patients have reason to worry. Drs. Tait Shanafelt, Colin West and Lotte Dyrbye at the Mayo Clinic have been studying physician burnout for twenty years. They have shown how burnout starts early in training, and — for most — doesn’t get better. It compromises not only physicians’ own health and happiness; it also leads to unsafe prescribing practices, overuse of diagnostic tests, compromised patient safety and poor communication with patients and colleagues. The public is only beginning to wake up to the fact that the next physician they see might be burned out and their own health might suffer.
Burnout isn’t the same as depression; it tends to get better when you’re away from the work setting. Unchecked, though, burnout can lead to depression, even suicide. Physicians kill themselves at twice the rate of other Americans; there was another casualty at our hospital just this week. In the early stages of emotional exhaustion, physicians can still be caring and empathic and derive satisfaction for their work. But over time burnout grinds us down; satisfaction and empathy become unsustainable and we stop caring. Burnout is not an acute illness from which physicians bounce back quickly; it is, in burnout researcher Christina Maslach’s words, an “erosion of the soul.” When doctors experience a loss of meaning, high responsibility with low control, and isolating and unsupportive work environments, they can crumble and quit.
While burnout is common to all human services professions — doctors, social workers, teachers — in medicine it is even more prevalent. In August, the Lancet, one of the two top medical journals in the world, published a comprehensive review of interventions to address physician burnout. Colin West and his colleagues reviewed dozens of studies in which physicians learned mindfulness techniques, engaged in deep discussions about what matters in medicine and learned to recognize and respond to stress before it got out of hand. Other studies showed how changing the work environment — giving physicians more control over workflow and adopting a team-based approach to care — can help. Individual and organizational approaches produced equally large improvements in burnout — a 30% reduction. The cost pales in comparison to the cost — over $250,000 — of replacing a physician who leaves practice.
Healthcare organizations can no longer ignore the problem now that solutions are at hand. Awareness of stress and its consequences is the first step. In its early phases, stress manifests as bodily sensations (for example as headaches or loss of appetite), negative emotions (anger or irritability) or negative thoughts (failure or blame). Doctors are generally stoical and therefore not particularly good at recognizing the early warning signs of stress, before it has taken its toll. Equally important is awareness of positive qualities — resilience, perspective-taking, cognitive reappraisal and resolve — which can mitigate burnout. Just as individuals can learn to monitor their level of burnout and engagement, so can organizations. Psychologist Jean Wallace has called on health care organizations to monitor clinician wellness as a quality indicator and muster the resolve to disseminate findings and take action; and family physician Christine Sinsky has suggested that health care organizations take a careful look at what promotes joy in practice and act to increase it. But the response from health care organizations has been lacking.
It is tempting to treat burnout as a “disease” or adaptive failure of individual doctors, yet that approach is unlikely to be effective. It’s true that people who are over-critical, fixed in their ways and who have difficulty with ambiguity and setting boundaries are at greater risk for burnout. Perhaps those traits should be identified early in training so that physicians can be aware of them. For the past ten years, I’ve offered “mindful practice” workshops (along with my colleague Mick Krasner) which focus on physician mindfulness, self-awareness, and communication. We’ve shown reductions in burnout, and also an increase in well-being, empathy and patient-centered care. Through greater awareness, physicians learn to be more emotionally accessible, attentive and resilient. Because burnout is due in part to professional isolation, we incorporate discussion groups and community building.
Yet, promoting individual mindfulness and communication will not be enough in the current health care environment. Physicians, disillusioned by the productivity orientation of administrators and lack of affirmation for the human relationships that sustain clinicians’ sense of purpose and meaning in their work, need enlightened leaders — leaders who recognize that, fundamentally, medicine is a human endeavor and not an assembly line. And patients in the twenty-first century are no longer content being passive recipients of care (appropriately so), which requires more communication with physicians yet no time to do it; we need more help with coordination, outreach and patient education.
New electronic health records systems are partly to blame for the surge in burnout. Primarily designed to maximize billing, they are often unwieldy when it comes to clinical care. Learning a new “language,” hours of data entry, relentless error messages, and displacing of attentional focus from the patient’s face to the exigencies of the screen all take physicians away from what provides meaning and purpose in clinical care. With resolve on the part of health care organizations and the involvement of front-line clinicians, intelligent design of health information systems should no longer be an oxymoron. The hours physicians spend doing meaningless documentation must stop; health care organizations, insurers and the government need to carefully re-examine the intention of these tasks and excise those that are worsening the problems they were designed to solve. Scribes who take notes and navigate the electronic health record for physicians can combat the physical fatigue from completing electronic documentation.
Advances in medicine include new drugs, devices and procedures. Equally important is how and by whom health care is delivered. Burnout is often blamed on a broken health care system; yet the fix involves more than achieving the “triple aim”– addressing health, patients’ experience of care and costs. Burnout is eroding the social capital of medicine — the caring human beings willing to take on difficult problems and engage with patients and colleagues. Yet organizational inertia prevails, unacceptable now that effective means of combating physician burnout are at hand. While research might eventually suggest which of the many programs is superior, we cannot afford to wait before acting; too much is at stake. Family physician Tom Bodenheimer now calls for a “fourth aim” — the well-being of the healthcare workforce. I think — and apparently the Surgeon General agrees — that the fourth aim should come first.