The Doctor’s Advocate | Second Quarter 2018
Director's Forum

Physician Burnout: Defining the Problems, Revealing the Solutions

Howard Marcus, MD, FACP

Howard Marcus MD

Howard Marcus, MD, is a board certified internal medicine physician who practices in Austin, Texas. He is chair of the Texas Alliance for Patient Access (a tort reform organization) and a member of and consultant to The Doctors Company Texas Advisory Board.

Physicians are perfectionistic, hardworking, and trained to put the patient first. The practice of medicine has always been stressful: Physicians manage patients in a world of diagnostic uncertainty and frequently difficult decision making. These factors have always been a part of medical practice, but in the past few decades, and at an accelerating pace, increasingly burdensome nonclinical demands and requirements have been placed upon physicians, particularly in primary care, filling the day with barriers and frustrations, and making a challenging job even more difficult.

The following list represents some of these demands and requirements.1

  • Learn workarounds to maneuver through electronic medical record (EMR) user interfaces; perform data entry that could, and should, be done by others (e.g., scribes); demonstrate meaningful use (MU); answer questions coming in through the EMR patient portal; and manage EMR drug interaction warnings, which are often clinically irrelevant and/or incorrect.
  • Hassle with payers over prior authorization issues.
  • Pick the correct diagnostic code from the more than 69,000 choices in ICD-10.
  • Conform to and report multiple quality measures (MACRA).
  • Fulfill maintenance of certification (MOC) requirements and perform tasks and tests to demonstrate competency.
  • Conform to HIPAA and state medical board regulations.
  • Fulfill complex evaluation and management (E&M) coding requirements.

When physicians are unable to recover and rebound from the ever-increasing demands of their medical practices, the result is often burnout, a chronic condition that is a normal response to an abnormal situation, but that brings with it negative psychological, physical, and cognitive effects.

Recognized as a leading measure of burnout, the Maslach Burnout Inventory (MBI) lists three characteristics of burnout:2

  • Emotional exhaustion: the feeling of being overextended and exhausted by one’s work.
  • Depersonalization: the feeling of losing a compassionate approach to patient care, which may lead to cynicism.
  • Loss of personal accomplishment: the feeling of loss of efficacy and competence.

A seminal paper, “Burnout and Satisfaction with Work-Life Balance Among US Physicians Relative to the General US Population,” was published in the Archives of Internal Medicine in 2012.3 This paper generated response by the lay press, including the New York Times and The Atlantic, thus demonstrating public interest and concern. The authors analyzed over 7,000 survey assessments using the MBI, and found that 45.8 percent of physicians reported at least one symptom of burnout, with the highest rates in family practice, general internal medicine, and emergency medicine. A further finding was that high levels of education and professional degrees seem to reduce the risk for burnout in fields outside of medicine, whereas a degree in medicine increases the risk of burnout. The authors concluded that “the fact that almost 1 in 2 US physicians has symptoms of burnout implies that the origins of this problem are rooted in the environment and care delivery system rather than the personal characteristics of a few susceptible individuals.”

Given the expansion in practice reporting requirements and increasing EMR use and complexity, it should be no surprise that a 2015 survey published by Mayo Clinic Proceedings 4 found that nearly 55 percent of 6,880 physicians reported burnout, and a 2016 survey conducted by the physician recruiter firm Merritt Hawkins reported that 49 percent “often or always” experience feelings of burnout.5

A 49 to 55 percent prevalence of burnout among physicians does not bode well for the delivery of healthcare—particularly primary care. Evidence also suggests the following:

  • That medical students are learning to stay away from primary care,6 and only one in 10 doctors recommends medicine as a career.7
  • That physicians already in practice are reducing the number of patients they are willing to see per clinical session, or are transitioning to part-time.8
  • That physicians are converting to concierge practices.9
  • That 50 percent of physicians over 50 aim to retire within five years.10
  • That physicians leave clinical practice for administrative positions.11

What are the effects of burnout on patient care? They are not good for either patient or doctor. To quote Dr. Donald Berwick, former administrator of the Centers for Medicare and Medicaid Services (CMS) and former chief executive officer of the Institute for Healthcare Improvement: “As joy in the workforce erodes, quality goes down.”12 For each one-point increase on the depersonalization dimension of the MBI, the likelihood of reporting an error increased by 11 percent,13 with obvious liability and medical board implications. In addition, patient satisfaction surveys, increasingly important for both practice marketing as well as compensation, reflect negatively on physicians who are dissatisfied with their work.

The EMR and computerized physician order entry (CPOE) have been major contributing factors to physician burnout. Shanafelt et al. report that over 80 percent of physicians now use EMR and CPOE.14 Physician satisfaction is generally low, with the amount of time spent on clerical tasks of particular concern. Valuable time is taken away from direct patient contact, including history taking and thorough physical examination.

Other concerns relating to EMR and CPOE are these:15

  • Physicians spend two hours on the computer for every hour with a patient.
  • Fifty percent of time is spent on the EMR, while only 27 percent of time is spent in direct contact with the patient.
  • Emergency room physicians average 4,000 total mouse clicks for charting functions and documenting patient encounters during a 10-hour shift.
  • EMR documentation requires 6.5 hours per week more than time spent on paper record systems.
  • EMR and CPOE compromise focus on the patient (not unlike operating a car while texting).
  • EMR design is inefficient and nonintuitive.
  • EMR use reduces productivity by 20 to 40 percent.
  • EMR use decreases face-to-face communication with nurses, medical assistants, and other physicians.
  • EMR alerts are too frequent, and too frequently make no sense.
  • For every patient seen in the office, a physician receives a non-visit-related inbox message for another four patients.

Of course, EMR and CPOE are not the only burdens on clinical practice. ICD-10 has increased the number of diagnostic codes from 14,000 to 69,000. It has also added laterality and severity parameters, as well as combination codes to designate complexity. E&M coding and documentation is complex and time-consuming.

Physician burnout can result in decreased quality of care, reduced physician productivity, and diminished patient satisfaction. Burnout increases medical error and physician turnover. Personal repercussions of burnout include broken relationships and marriages, alcohol and substance abuse, depression and suicide. Burnout is expensive. The cost of replacing a physician is estimated to be two to three times the physician’s annual salary. Each one-point increase in burnout on the MBI is associated with a 30 to 40 percent increase in the likelihood the physician will reduce work effort in the next two years. Burnout clearly needs to be addressed at the personal, institutional, and system-wide levels.

Progress requires an understanding of the multiple root causes of burnout and a willingness on the part of the individual physician, institutional clinic leadership, EMR software designers, and, importantly, those involved with healthcare regulation and documentation requirements to confront the issues leading to burnout. As Dr. Dike Drummond describes it, burnout represents a dilemma, the solution to which requires a commitment to foster a healthy balance between the energy put into work and the effort spent on the restoration of energy: i.e., decrease work-related stress and/or increase the ability to recharge energy.16 Drummond describes many potential causes of burnout and provides a matrix of 235 ways to prevent burnout.17 From this matrix the physician should focus on the three to five measures most germane to him or her.

Examples include:

  • Improving EMR skills through mentoring by a colleague who is skilled at making the EMR work efficiently for him/her.
  • Shifting more data-entry burden back to clinical staff. This could include medication reconciliation, laboratory, and imaging CPOE.
  • Using a scribe.

Of great importance is to make the case to the clinic administrator that changes will improve productivity and patient satisfaction.

Shanafelt and Noseworthy describe nine organizational strategies used at the Mayo Clinic to promote engagement and reduce burnout.18 The Mayo Clinic has been able to reduce physician burnout by seven percent despite an 11 percent rise in the absolute rate of burnout in physicians nationally. As a result, the physician burnout rate at Mayo Clinic is 33 percent compared to 49 percent nationally. The authors list nine organizational strategies to promote physician well-being. A few examples are these:

  • Acknowledge the problem of burnout at the leadership level, and demonstrate that the organization cares about the well-being of its physicians.
  • Consider ways to mitigate the potential negative effects of productivity-based pay.
  • Promote flexibility and work-life integration.
  • Provide resources to promote resilience and self-care.

In “Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians,” published in the Annals of Internal Medicine, the authors acknowledge that the “growing number of administrative tasks imposed on physicians, their practices, and their patients adds unnecessary costs to the U.S. healthcare system, individual physician practices, and the patients themselves.”19 The American College of Physicians (ACP) “calls on stakeholders external to the physician practice or health care clinician environment who develop or implement administrative tasks (such as payers, governmental and other oversight organizations, vendors and suppliers, and others) to provide financial and time and quality-of-care impact statements for public review and comment.” The authors acknowledge that EMR vendors need to comply with MU and E&M documentation guidelines, but “not at the expense of being unable to offer tools that are tailored to a practice’s workflow and the clinical needs of its patients.”

Physician burnout is a big problem that has been a long time in coming. The root causes of burnout are interwoven into the American healthcare delivery system and will require solutions on the personal, institutional, and regulatory levels in order to bring joy back into the practice of medicine for many physicians and other healthcare providers.

Here are a few successful examples I’ve seen of successful adaptions to burnout, which demonstrate the importance of flexibility and innovation:

  • A 60-year-old internist worked in a rural practice associated with the local hospital, which was acquired by a large hospital group, resulting in inflexible patient scheduling and rigid treatment protocols. After several years of frustration and burnout, the physician left his practice and joined a large physician-owned group in a nearby city, which has allowed for a greater degree of physician autonomy in medical decision making and scheduling. He is very happy with his practice.
  • A 62-year-old internist adapting to the EMR and onerous regulatory documentation demands found that his productivity had declined by 25 percent while his work-related hours on data entry had substantially increased. This resulted in burnout. His medical group provided a scribe, which has increased his productivity above the pre-EMR levels and, most importantly, restored greater access for his patients while facilitating his return to a satisfying career.
  • A 35-year-old pediatrician and single mother with school-age children was unable to meet both the practice schedule and parenting demands, resulting in fatigue and burnout. Her medical group provided a scheduling solution that has allowed her to meet full-time practice requirements and fulfill her parenting responsibilities.

For Further Reading

ACP Internist

acpinternist.org/

Dike Drummond, MD

thehappymd.com/blog

Paul DeChant, MD, MBA

pauldechantmd.com


References

  1. DeChant P, Shannon DW. Preventing Physician Burnout: Curing the Chaos and Returning Joy to the Practice of Medicine. North Charleston, SC: Simpler Healthcare; 2016.
  2. Maslach C. Maslach Burnout Inventory. http://www.mindgarden.com/117-maslach-burnout-inventory. Accessed February 7, 2017.
  3. Shanafelt TD, Boone S, Litjen T, et al. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. Arch Intern Med. 2012;172(18): 1377-1385.
  4. Shanafelt TD, Hasan O, Dyrbye L, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015 Dec;90(12):1600-13.
  5. 2016 Survey of America’s Physicians: Practice Patterns and Perspectives. The Physicians Foundation. http://www.physiciansfoundation.org/uploads/default/Biennial_Physician_Survey_2016.pdf. Accessed April 24, 2018.
  6. Gordon M. “Why I’m becoming a primary-care doctor.” The Atlantic. September 8, 2014. https://www.theatlantic.com/health/archive/2014/09/why-im-becoming-a-primary-care-doctor/379231/. Accessed February 15, 2018.
  7. DeChant P, Shannon DW. Preventing Physician Burnout: Curing the Chaos and Returning Joy to the Practice of Medicine. North Charleston, SC: Simpler Healthcare; 2016.
  8. 2016 Survey of America’s Physicians: Practice Patterns and Perspectives. The Physicians Foundation. http://www.physiciansfoundation.org/uploads/default/Biennial_Physician_Survey_2016.pdf. Accessed April 24, 2018.
  9. Ibid.
  10. Ibid.
  11. Ibid.
  12. Institute for Healthcare Improvement. How Does Joy in Work Advance Quality and Safety? [Video]. YouTube. https://www.youtube.com/watch?v=3JTdHStR6KI&utm_campaign=Joy+in+Work&utm_content=31858022&utm_medium=social&utm_source=twitter. Published March 23, 2016. Accessed February 7, 2018.
  13. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010 Jun;251(6):995-1000.
  14. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016 Jul;91(7):836-48.
  15. Erickson S, Rockwern B, Koltov M, McLean, R. Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians. Ann Intern Med. 2017;166(9): 659-661.
  16. Drummond, D. Stop Physician Burnout: What to Do When Working Harder Isn’t Working. Collinsville, MS: Heritage Press Publications; 2014.
  17. Drummond, D. Burnout Prevention Matrix 2.0. https://support.thehappymd.com/physician-burnout-prevention-matrix. Accessed February 7, 2017.
  18. Shanafelt TD, Noseworthy, JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 2017 Jan:92(1): 129-146.
  19. Erickson S, Rockwern B, Koltov M, McLean, R. Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians. Ann Intern Med. 2017;166(9): 659-661.

The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.

Second Quarter 2018

Director's Forum
Physician Burnout: Defining the Problems, Revealing the Solutions

An Ounce of Prevention
Team Synergy: A Critical Core Competency for Safe Care

Government Relations Report
Judicial Review of Medical Liability Legislation

New CME/CE Courses Added Every Month

Innovations in Patient Safety
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