Why is physician burnout an urgent issue in so many health care organizations, seeming to worsen every time it is measured? Explanations abound, including crushing workloads, loss of autonomy, and pressures to improve patient experience along with other components of quality.
A sense of the history of medicine suggests that the conventional wisdom is wrong, and that these issues are not the drivers of physician burnout. They are flip sides of the same coin. The same forces that are causing physician burnout also make the physicians’ job more and more demanding, increasingly complex, and often annoying. And they create a sense of chaos for patients, which makes improvement of patient experience an imperative.
The implication is that the solution to physician burnout is not to wind back the clock, or ignore the need for coordination and compassion in care. These issues can only be taken on together. In other words, physician burnout can only be improved with better patient experience — and the other way around.
The reason: the root cause of our challenges is medical progress, which is, of course, wonderful in so many ways. But the price of progress goes beyond the costs of new tests and treatments. To take advantage of these advances requires increasing numbers of clinicians, with narrower and narrower expertise. Most patients have to come in contact with dozens, sometimes even more than a hundred personnel important to their care during a hospitalization.
The experience can be chaos — for patients and for the clinicians themselves. To master their areas of expertise and get their work done, physicians circumscribe their work and their scope of activities. They focus on one organ, or one disease process, or just perform one type of procedure. The outpatient physicians do not go to the hospital, and the hospital-based physicians may not interact with their patients or other colleagues outside their disciplines.
For patients, the experience of being ill and receiving care from a large number of personnel — who, despite their hard work and good intentions, are not always perfectly coordinated — is nothing less than frightening. When it is obvious that clinicians do not actually know each other, are giving slightly different answers to questions, and may not even trust each other, it is hard for patients to feel confident that they are getting good care.
But these dynamics are no fun for physicians either. With all those clinicians involved in any patients’ care, the work of staying in touch with each other becomes close to a full-time job. Entering information into the electronic medical record so other clinicians know what is happening is one type of burden — but even worse is having to digest information about one’s patients from those clinicians. I am a part-time clinician, but whenever I open my “inbox” in my electronic medical record, I feel like a fire hose is blasting me against the wall.
And here is one of the sadder secrets of modern medicine: even though physicians interact with more clinicians in the course of their day, it is a lonelier type of work than a generation ago. Physicians struggle just to get through their day, and walk by other clinicians trying to do the same thing. They may walk down the hall of a hospital where they have worked for decades, and no one says hello.
It is not reasonable to hope that these side effects of medical progress can be eliminated the way we address side effects of a drug — by stopping the offending agent. We cannot turn back progress, and wouldn’t want to if we could. Instead, we have to recognize that 21st-century medicine is different, and change health care delivery so that it reduces the suffering of patients but clinicians as well.
To do that requires coordination. No one can deliver state-of-the-science care on their own anymore, so embracing teamwork — rather than grudging acceptance of it — is the right path forward for organizations and for individual physicians. Real teams are more than a group of non-physicians who increase the number of patients a doctor can see. Real teams have more than complementary job descriptions. Real teams are actually greater than the sums of their parts.
In real teams, the members know one another, feel loyalty to one another, trust one another, and would not want to disappoint one another. The reinforcement that comes from earning the respect of colleagues that surround physicians goes beyond what financial incentives can ever achieve.
So what is the path forward? First, physicians and their organizations should commit to organizing their care around reducing the suffering of patients. That is the noble goal that resonates with the motivations of every clinician, and trumps all other concerns.
Second, physicians and their organizations should focus on how they are going to achieve that goal. What their patients want, and what will bring pride to physicians, is to deliver care that is safe, compassionate, and coordinated.
Third, organizations should assess and manage their progress, by measuring and learning and creating systems for accountability for improvement.
With clarity on those goals, physicians and their organizations can organize care so that it does not harm patients and meets their patients’ needs. Beyond pride, such work will bring business success through greater market share, more effective collaboration with patients, and enhanced ability to recruit and retain colleagues.
The bottom line: the answer to physician burnout is not reducing our aspirations for the care that we deliver to our patients. It is, in fact, becoming more ambitious. There is only one way out of our problems, and it is to move forward.