Burnout is multifactorial

September 24, 2018

Multiple changes in the healthcare field are working synergistically to pull an increasing number of physicians into the bitter swirl of burnout.

Editor’s Note:Physicians Practice’s blog features contributions from members of the medical community. These blogs are an opportunity for professionals to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions are that of the writers and do not necessarily reflect the opinions of Physicians Practice or UBM.

recent commentary on work-life balance and the EHR discussed the major changes in medicine that parallel the rise in burnout rates among physicians. These include hospital/health-system employment for medical groups, increasing pharmaceutical rates, Obamacare, pay for performance metrics, and the EHR. While I agree that the EHR plays a large role in burnout – indeed I am writing this blog before bedtime and have incomplete charts from clinic today – I disagree with the authors’ contention that the other four medical transformations play only a minor role.

Loss of autonomy (or perceived loss) is a major contributor to burnout. Consider moving from an independent practice to hospital employment. While this move may resolve some financial concerns and provide tools to meet billing regulations, it is not without stress. Aligning with a hospital system can be a big challenge for physicians who have become so accustomed to making independent decisions about staff roles and compensation, office hours, scope of practice, and clinic workflows that they no longer recognize these as choices that may be lost. Even when the buyout of your medical practice is a relief, the transition from independent to employed can be tough. 

The lack of control over the optimal treatment for patients is a major contributor to burnout. Medication costs can be outrageous, making great pharmaceutical breakthroughs inaccessible for all but the well-insured and financially solid patient. In clinic today, I spent several minutes trying to figure out the most affordable option for generic medications at local pharmacies. Even generics can be out of reach for patients, many of whom may be on numerous medications. In an average clinic day, at least a third to a half of my patients have financial barriers to obtaining some or all of their medications. This requires extreme creativity and harsh prioritization. 

Poor leadership can contribute to burnout; and our government is not leading for the good of patients. The Affordable Care Act (a.k.a. Obamacare) has been a blessing and a curse. I support many provisions and feel that it was both necessary and a reasonable first step in health care reform. However, it has introduced interesting contradictions and challenges. For example, it is great that almost all of my patients have coverage of preventive health screenings, such as mammograms. It is difficult that so many have high deductibles that preclude them from going for the follow up testing when a screening test is abnormal. I’ve traded my role as healer, in many cases, for a health insurance navigator as I coach patients through the labyrinth of what is covered, what is not, and what may be. 

Perceived unfairness is a major contributor to burnout. I’ve been heavily involved in quality metrics and performance for the last decade. I understand the appeal of quantifying the relative value of the work done by caregivers and healthcare teams. In theory, this will enhance patient outcomes and raise everyone’s performance as we continuously improve. In some cases, this has successfully driven the right type of care. In other cases, this has driven the wrong type of behavior – cherry picking “compliant” patients, adjusting documentation to move someone from category A to category B, fulfilling the letter but not the spirit of care guidelines. An internist who is financially penalized for patients who do not take their medication or an emergency medicine physician whose door-to-doc times are impeded by staffing ratios outside of her control feel the unfairness of these measures. 

Multiple changes, including the EHR, have worked synergistically to create a perfect storm of loss of autonomy, a deficit of visionary healthcare leadership, unfairness, loss of respect for professional judgment, and an overall sense of frustration that is pulling an increasing number of our colleagues into the bitter swirl of burnout. 

Jennifer Frank, MD, is a family physician and physician leader in Northeastern Wisconsin and finds medicine still to be the best gig out there. Married with four kids, she is engaged in intensive study and pursuit of work-life balance.