Mark Jenkins, MD, Executive Director at the University of Washington’s Hall Health Center, primarily a student health center in Seattle, says physician burnout has been a problem for decades, starting in the 1980s and 1990s with the rise of HMOs.
“I saw it then in colleagues who were forced to take this ‘next, next, next’ approach and couldn’t spend the time they wanted to with patients,” he says. Since then, the problem has been magnified by electronic health record (EHR) systems and the financial pressures of keeping practices afloat.
Jenkins was among 65% of NEJM Catalyst Insights Council members who called physician burnout a serious problem in the industry, responding to the latest Council survey exploring this rising crisis. Although Jenkins’ administrator role has removed him from the “trenches” of seeing patients day-to-day, he feels burnout is an issue “even more so” today.
Michael Schneck, MD, Professor of Neurology and Neurosurgery at Loyola University Chicago Stritch School of Medicine, says fundamental changes in how physicians are asked to practice medicine have had a severe impact.
“We take people who are highly trained, highly educated individuals selected because of their motivations in terms of humanism and their ability to learn copious amounts of material, and we turn them into highly educated factory workers,” he says. “We ask them: ‘How many patients have you seen?’ ‘How many procedures have you done?’ ‘How have you met quality metrics?’”
These metrics do not translate to a good experience for physicians or patients, he says. “How is that being a physician where you’re supposed to relate to the individual and make things better?”
Because of these pressures, some of Schneck’s colleagues have opted out of clinical medicine, either to become administrators or medical educators, or to pursue business affairs. “But that’s only for a select amount — others who stay in clinical medicine as their primary daily activity generally have little opportunity to improve their situation,” he says.
As an example, he points to stroke code protocols that require neurologists, who tend to be at a higher risk of burnout than other specialties, to immediately respond within hospitals and emergency rooms when a stroke is suspected. “Half the time they are false alarms, they are very disruptive, and they require a large burden of documentation,” he says. “Ideas [like this] are good, but the process required to implement the idea is flawed. The devil is in the details and there are a lot of details.”
EHRs Need a Massive Overhaul
EHRs, considered a major part of the increased clerical burden — which respondents ranked as the top contributing factor to burnout — will improve in the future, Jenkins believes.
Getting there, though, will require a massive overhaul to address the lack of interoperability and to foster openness. He likens existing EHRs to trying to use a stethoscope with a big knot in it.
A redesign should be led by physicians, not software developers, he says. Important additions would be better voice recognition, artificial intelligence to aid documentation, and other capabilities that reduce clerical burden.
Schneck views proposed solutions such as scribes to help with documentation as a Band-Aid. “We need to fix the system so it doesn’t burn the physician out to begin with,” he says.
In addition to revamping EHRs, he sees a need for culture change. “Right now, burnout is treated as if there is something wrong with the physician rather than something wrong with the system,” he says. “The physician has lost stature as a team leader and is just another cog in the machine.”
Physician Input for Physician Engagement
Schneck feels a good place to start fixing burnout is to ask for physician input. “Nobody asks about how system processes impact the practicing physician,” he says. “None of the three top reasons we discussed to address physician burnout are physician-centric. However, if you improve physician satisfaction, you will improve patient quality of care and satisfaction.”
Physicians also must be fully engaged in the entire health system, not the microcosm of their own practice, he says. “You have to give the person an opportunity to grow, including defined career paths. Otherwise you perpetuate the day in, day out syndrome,” he says. He considers involvement in professional societies, which is a popular go-to in the industry, no more than a short-term solution. A better avenue is for medical schools to switch students from observers to active participants. “We could be teaching them how to engage in hospital activities or how to do quality assessments,” Schneck says.
Jenkins recommends that health care leaders and physicians identify individualized solutions. He warded off burnout at his previous post by mentoring a student-run cycling team. He tries to help his physicians by encouraging them to volunteer outside of the work environment with community health programs and student organizations that personally interest them.
Excessive metrics also drive burnout, as noted by 18% of NEJM Catalyst survey respondents. Jenkins calls for restructuring federal Meaningful Use requirements. “We’re collecting all this data, but it’s not useful. It’s more of a billing record, but doesn’t do anything to improve patient care or population health,” he says, adding that regulators should pump the brakes on tying reimbursements to this data. “They’re using a model that hasn’t been studied well enough. If a pharmaceutical company tried to release a drug without going through the double-blind studies, we’d never accept it.”
Multiple Sources of Support
Bart Hobson, MD, an urgent care physician at Marshfield Clinic, a health care system with over 50 locations in northern, central, and western Wisconsin, says fixing burnout will require leadership to consider it a top priority, which is difficult when there are competing interests for their time.
“If an organization wants to attract and keep the best people, they have to watch out for and have a plan to deal with burnout,” he says.
Physicians can help one another with burnout, Hobson says. He observed a practice partner not being able to keep up with charting because he was waiting until end of each day. Hobson encouraged the partner to do it after every few patients. “He made that change and was much happier,” he says.
Medical schools can be another source of support, Hobson says. They should put more emphasis on the emotional side of being a physician and give students tools they can use throughout their careers to cope with stress. “You want to develop a generation of physicians who understand burnout is part of life and can say, ‘I was told to expect this and now I need to do something about it.’”