Mike Henderson had always wanted to be a doctor. He wanted to help people. Drawn by the intellectual challenge medicine offered, he figured he’d never be bored. Medical school, while a grind, only helped to convince him he had made the right career choice.
But all that changed during his residency.
“I finally started to realize how dysfunctional the system is,” he said. “I knew in the first year of residency that I had made a huge mistake. I had gone from my dream to ‘What the hell did I just do?’”
He quickly became disillusioned with the assembly line pace of medicine. At times, it seemed his employers just wanted him to do something, to do anything, and move on to the next patient, rather than to take the time needed to properly diagnose and treat each patient. Within six years, he would give up on organized medicine and treating patients, another victim of an epidemic of burnout that is plaguing doctors today.
Surveys suggest more than half of U.S. physicians now show symptoms of burnout and the rate appears to be escalating. Each year more doctors are hanging up their stethoscopes, leaving hospitals and contributing to a growing shortage of doctors even as the aging population drives up demand for medical care. As emotionally exhausted doctors begin to check out, patients are left at risk of medical errors or substandard care.
“It’s the flip side of the same coin,” Henderson said. “Patients are suffering; physicians are suffering. Why don’t we do something?”
Henderson completed his medical degree in 2001 at Des Moines University, an osteopathic school in Des Moines, Iowa. After completing his residency in 2005, he took a temporary job as a hospitalist at McKenzie-Willamette Medical Center in Springfield.
“That’s where things just really got worse,” he said.
While some hospitals cap the number of patients under the care of a single physician somewhere in the mid-teens, Henderson said he never had fewer than 20 patients at one time.
“It was high churn and burn. We would admit and discharge like crazy,” he said.
He often couldn’t get through four or five patients before his phone started ringing with calls from nurses, or caregivers came up to him with questions. Soon he’d be a half-hour, 45 minutes behind schedule, rushing to catch up.
“It was constant distraction,” he recalled. “That’s a recipe for error. Somebody was going to get hurt.”
He began to question whether some of the things he was doing were truly helping the patient. One of his last patients he cared for was an elderly man with complete renal failure. A chest X-ray revealed metastatic cancer. Henderson first met him when he responded to a cardiac arrest code.
“We revive him. His eyes are wide open. We’re breaking ribs. We’re sticking needles in him,” he said. “After a while, I just realized all we did was make this guy die twice.”
Henderson thought he could avoid the frenzied pace of medicine by starting his own practice in Bend. He took only cash payments from patients to avoid jumping through hoops to satisfy insurance companies. In his own practice, he could spend 30 minutes, an hour, an hour and a half with patients, walking them through the steps they needed to take to improve their health, rather than just writing out a prescription and sending them on their way.
His wife worked as a nurse to support the family as he got the practice up and running. The practice was just starting to break even when the 2008 recession hit and the bottom fell out of his business plans. He went to work for a local physician’s clinic but lasted all of six months. He signed with a sleep clinic for another nine months before leaving patient care altogether.
“By that time, I had no tolerance,” Henderson said. “My clinic had burned me out.”
He felt the system wouldn’t allow him to do his job well consistently, and in the end, he couldn’t reconcile what he needed to do to take care of himself and what was right for the patient.
Now, Henderson performs consultative exams to assist the state in determining whether someone meets the requirements for disability benefits.
“The irony is my business now is dependent on the failure of the system,” he said.
Burnout can be hard to define, but a number of survey tools have been developed to identify it.
The gold standard across all industries is the Maslach Burnout Inventory, developed by social psychologist Christina Maslach and colleagues at the University of California, San Francisco, in 1981. She would later describe burnout as “an erosion of the soul caused by a deterioration of one’s values, dignity, spirit and will.”
The tool measures burnout in three main areas: emotional exhaustion, depersonalization and personal accomplishment. Workers incurring emotional exhaustion feel overextended or exhausted by their jobs, often saying things like, “I don’t know how much longer I can go on like this.” Depersonalization involves cynicism, sarcasm and a loss of compassion for patients or customers. People who feel burned out have a low sense of personal accomplishment, doubting they’re making a difference.
Researchers at the Mayo Clinic have used the Maslach tool to measure burnout among their physicians for nearly a decade, and the trend appears to be worsening. Between 2011 and 2014, the prevalence of burnout among doctors increased from 45 percent to 54 percent, while remaining stable for other U.S. workers.
Researchers have also found a consistent link between burnout and doctors leaving medical practice. The increase in burnout between 2011 and 2014 surveys suggests an additional 1 percent of U.S. doctors leaving practice. That’s more than 1,000 physicians nationwide, the equivalent of eliminating seven U.S. medical school graduating classes.
Similarly, a national survey of nearly 1,200 hospital nurses found 35 percent had a high degree of emotional exhaustion, and 18 percent showed signs of depression, double the rate of the general population.
That toll on physicians and nurses then trickles down to patients, affecting their quality of care.
“A healthy and well doctor is going to be at the top of his or her game hopefully, to be the very best that they can be for their patients,” said Dr. Jeff Absalon, chief physician executive for St. Charles Health System.
The opposite also appears to be true.
One study found that each one point increase in emotional exhaustion scores or depersonalization scores on the Maslach Burnout Inventory correlates with a 3 to 10 percent increase in the likelihood of a medical error in the prior three months. Other research has shown that doctors who are burned out are less likely to fully discuss treatment options or answer all of a patient’s questions.
“When we’re burned out (our patients) definitely feel it,” said Dr. Elaine Cox, a professor of clinical pediatrics at Indiana University who spoke at a symposium on burnout at St. Charles Bend in November.
There are correlations between physician satisfaction and patient satisfaction scores, and patients of burned-out physicians are less likely to follow their treatment guidelines.
For hospitals, higher mean stress levels among physicians likely means higher rates of malpractice suits. And as mean burnout levels among nurses increased, so did hospital-acquired infections among their patients.
In a study of some 7,100 U.S. surgeons, burnout was an independent predictor of medical errors and medical malpractice suits. While the researchers said it was unclear whether burnout led to mistakes or the mistakes led to burnout, they concluded it was likely a two-way street. Burnout led to errors, which in turn fueled greater burnout.
A study conducted at three freestanding children’s hospitals in the U.S. found that 1 in 5 resident physicians met the criteria for depression, and those who did made six times as many medication errors each month as their colleagues.
One study found that as mean emotional exhaustion rates for doctors and nurses in intensive care units increased, the patient death rate rose as well.
It’s hard for many patients to understand why their physicians are so unhappy. Doctors make good salaries, drive fancy cars and live in big homes. It is one of the most respected professions in the U.S., and its members are honored by being called doctor wherever they go.
But medicine has steadily become a more difficult industry. Physicians are expected to be nearly all-knowing and infallible, even as the collective volume of medical sciences increases at a breakneck pace.
An ever more costly health care system is rapidly evolving, spawning new payment and care delivery models. Government and private payers are demanding more data, more proof that what doctors are doing actually improves health care.
Studies have linked burnout to work processes inefficiencies, excessive workloads, work-home conflicts, organizational climate, and loss of control or autonomy. While doctors talk about the practice of medicine as an art as much as a science, the system is quickly converting doctors, nurses and other providers into highly educated and highly paid factory workers.
Health care systems count the number of patients seen and the number of procedures completed, rather than the number of patients whose health has improved.
Doctors are expected to see more patients, providing better care at a lower cost, so they work longer hours. An American Medical Association survey found that about 25 percent of doctors now have workweeks of more than 60 hours, compared to 11 percent in other professions. And according to researchers from the Mayo Clinic, every additional hour per week worked increases the risk of burnout by 3 percent. Each night and weekend on call increases the risk by 3 to 9 percent. And every hour spent at home on work-related tasks — a phenomenon doctors call pajama time — increases the risk by 2 percent. And doctors on the front lines in primary care, internal medicine or the emergency room have four times the burnout rate of other doctors.
Part of the problem is the way doctors are paid for treating patients. The reimbursement system is still mainly fee-for-service, where doctors get paid based on the number of procedures they complete. That prompts doctors graduating with an average of $225,000 in medical school debt and years behind other professions in buying a house or saving for retirement to pursue specialties that do more procedures. Primary care doctors, on the other hand, get paid less for evaluating and managing patients, and must overbook their daily schedule to maintain their salaries.
The average salary is now $200,000 for primary care physicians and $300,000 for specialists.
Yet a recent survey found that only 25 percent of doctors were willing to take a salary cut to reduce the administrative burdens they say add to their stress. At the Pease Symposium on burnout in November in Bend, a physician wellness coach suggested doctors schedule patient-free days before and after vacations to ease the stress of taking time off. One doctor attending countered that they don’t make any money on days they don’t see patients.
“Is it worth a 10 percent salary cut to have sanity and time?” asked Dr. Frances McCabe, an emergency room physician working at St. Charles Bend. “If you look at my stats, I’m the slowest person there by a mile. I take a minute to talk to the person about who they are.”
The result is McCabe sees fewer patients and makes less money than many of her colleagues, a trade-off she’s more than willing to make in exchange for greater joy in her practice.
She recalls meeting an elderly woman who came to the ER after a fainting spell. She learned the woman had been a B-17 flight instructor during World War II and marveled at the stories the woman told.
“If you don’t take a moment to discover how special your patients are, you’re missing an opportunity for joy,” she said. “We give that up because we worship productivity and money. But once you sacrifice that, you’re on the inverted death spiral to crash and burn.”
That’s not always possible. Physicians in smaller private practices may have more control over their schedules but often struggle with the requirements of dealing with government and commercial insurance.
Those administrative hassles have gotten so great, many have opted to become employees of larger health care systems. More than 75 percent of physicians are now employed by hospitals or other large health care organizations. Many want their jobs to be more like shift work, working a set eight or 10 hours and then being done. But what they gain in escaping responsibility for administrative hassles, they lose in overall control and autonomy.
“They have this relief that they don’t have to do whatever it was that was bothering them, but there will be in its place this frustration for something that they weren’t recognizing that they liked a lot about independent practice,” said Dr. Laura Pennavaria, chief medical officer for the St. Charles Medical Group, the 240 doctors and other health providers who are employed by the hospital.
Pennavaria said the hospital system tries to help doctors understand those challenges before they sign on. But some physicians don’t understand the grass isn’t always greener on the other side of the health care fence.
“There’s no easy place to practice medicine anymore,” McCabe said.
At the top of many physicians’ list of complaints is dealing with electronic health records. While such records offer great promise in helping to reduce duplicative care and getting physicians up to speed on a patient’s medical history, doctors say they alter and disrupt the workflow patterns in clinics and hospitals and interfere with patient interactions. Doctors routinely complain they’ve been reduced to data-entry clerks, spending more time in front of the computer than they do with patients.
In a recent Medscape survey of physicians, the top cause of burnout cited was too many administrative tasks. Electronic health records have increased a doctor’s work time by an estimated one to two hours per day.
Patients complain that doctors spend more time during their appointment looking at their laptops than looking at them.
Even after their workday is done, many doctors log in to the record system from home to catch up on patients notes.
Both Bend Memorial Clinic and St. Charles Health System have recently adopted new medical records systems forcing doctors and nurses to relearn how to enter patient information and adding new stress to the system. As much as doctors gripe about it, Pennavaria says there are major benefits from electronic records and they’re not going away.
“It’s the reality of medical practice now and we need to learn how to adapt to it,” she said.
McCabe said unhappiness over electronic records could be a generational issue, with younger doctors who have grown up using computers and smartphones adapting more easily than their older counterparts who started practice with paper records.
“Medicine is just another example of how it’s hard for one generation to accept shifting paradigms from another generation,” she said. “Is EHR a big part of burnout? I think it is for a particular generation of physicians because it moved the cheese. It changed the rules.”
McCabe believes that some of the complaints around electronic records stem from their use to satisfy all of the new regulatory requirements and quality improvement initiatives.
“It ends up getting blamed,” McCabe said. “Since we’re always leveraging EHR, it’s always at the scene of the crime.”
Sense of mission
Doctors counter that they went into medicine to help patients, not enter data. And that may be, in part, why physicians burn out instead of slowing down and taking things at a more sustainable pace. It’s hard for a doctor to turn down a request knowing it could literally be a life-or-death situation. It’s hard for them to ignore a patient who might be in pain or suffering from some illness. It’s part of the culture of medicine that the patient comes first, and that by proxy means the doctor comes at least second if not further down the line.
That mindset is ingrained in medical school and residency, which has become a rigorous, sometimes torturous process, designed to screen out those unwilling or unable to accept the never-say-die lifestyle.
“In medical school, in training to be a doctor, neglecting yourself is rewarded, not overtly, but that is how you get to be where you need to be,” Pennavaria said.
Residents and their supervisors joke about it with phrases like “Sleep is for the weak” or “If you call in sick, you’d better be intubated in the ICU.”
That culture persists through residency and into private practice or hospital employment, prompting doctors who help patients cheat death into believing they can fly above the fray.
“Physicians tend to believe they’re Superman or Wonder Woman,” said Dr. Matt Eschelbach, an emergency physician at St. Charles Redmond. “Do everything and more. And they constantly have to be reminded they’re not.”
In 2004, Eschelbach was seemingly doing everything and more. He was medical staff president at the Redmond hospital, medical director of the emergency department, a full-time emergency physician, medical adviser to several Central Oregon EMS agencies, a coach for three of his sons’ soccer teams, a husband and a father.
It was a stressful life that would soon take its toll. Two days before Thanksgiving, he felt a flu coming on and asked a colleague who came in early to cover the rest of his shift. On the way home, he called another doctor to cover this shift the following day. He self-treated himself for the flu and climbed into bed.
The next morning, as his wife was preparing the Thanksgiving dinner, he sat up in bed with a stiff neck and the worst headache of his life.
“You idiot!” he said to himself. “You have meningitis.”
Back at the emergency room, a colleague confirmed the diagnosis. A CT scan revealed a brain lesion and an MRI showed it was a brain abscess. He was transferred to St. Charles Bend where he underwent brain surgery.
Eschelbach made a full recovery but realized he had put himself at risk with his breakneck pace. His immune system was compromised from fatigue and overwork.
“Sometimes you need to juggle a few less balls,” the neurosurgeon told him.
For doctors who don’t learn how to manage the stress and take care of their own well-being, the results can often be tragic. With ample access to potent medications, many deal with the stress of modern medicine by self-medicating with drugs, putting both themselves and their patients at risk. Burnout is associated with 25 percent increased risk for alcohol abuse.
In other cases, stress can lead to depression or other mental health issues. And physicians dealing with substance abuse or mental health issues — true to their superman persona — rarely ask for help.
A recent survey found that 1 in 16 surgeons in the U.S. had thought about suicide in the previous year. Of those, 39 percent said they would be reluctant to seek help for depression for fear their licenses would be revoked by the medical board. State medical boards have set up diversion programs that allow physicians to confidentially ask for help and enter treatment without fear of losing their licenses. But doctors have complained the process is more punitive that therapeutic.
“What ends up happening is a lot of times people will just keep it to themselves, out of fear of that stigma or some kind of bad outcomes for them, and then it just comes out one day, it comes to a head and it comes to everyone’s attention,” Pennavaria said. “Had we known about it, we could have helped them. And we still can help them, but now it’s a little bit harder to help.”
Licensing forms routinely ask about mental health conditions when physicians apply or renew their licenses, although a 2009 study found that 69 percent of such questions likely violated the Americans with Disabilities Act. A 2015 survey of 2,000 physicians found that about half met criteria for a mental health disorder, but only 6 percent had disclosed this to a medical board.
“Early in my psychiatric career I frequently saw medical students, residents, practicing physicians who not only were suffering from the syndrome of burnout, but had traveled down the short path from burnout to depression to suicidality,” said Dr. Darrell Kirch, president and CEO of the Association of American Medical Colleges. “This problem that we need to acknowledge has existed for a long time.”
An estimated 400 physicians commit suicide every year, and many believe the true number may be much higher. Many experts speculate that drug poisoning deaths among physicians may be deliberately miscoded, ruled an accidental overdose.
“Even in cases where there have been clear notes, we have seen a underrepresentation of these numbers,” Cox, the Indiana pediatrician, said. “Maybe that’s to protect our colleagues, maybe it’s to protect their families, maybe it’s to protect ourselves.”
One analysis of physician suicides found a much lower rate of depression medications in the blood of physicians compared with nonphysicians, suggesting doctors are less likely to seek treatment.
The suicide rate for male physicians is 40 percent higher than for other men, while the rate for female physicians is 130 percent higher than for other women.
In Central Oregon, at least three physicians have committed suicide over the past decade.
The tragic irony is that so much is invested in training doctors, yet remarkably little in physician wellness. When a doctors burns out and leaves, the cost to the health care organization can be staggering. The cost of replacing a nurse is estimated at $82,000 to $88,000, while the cost of replacing a physician, factoring both recruitment cost and lost productivity, is more than $1 million.
Despite evidence that provider burnout is a system-level problem driven by excessive job demands and limited resources or support, most health systems still seem to believe there is little they can do about it. Dr. Tait Shanafelt, the chief wellness officer and one of the leading researchers on physician burnout, argued in a recent article in the Journal of the American Medical Association that it’s just the opposite. Studies have shown that organizations that tackle the issue as a systemwide problem can reduce burnout.
That’s the way hospitals have tackled quality, he and his co-authors wrote, using system-level interventions including hiring a chief quality officer and promoting culture change around safety and quality.
Most health systems remain stuck at the most basic of responses: building awareness of the issue, creating wellness committees and adopting individual-based interventions such as mindfulness training or providing resources for more exercise and better nutrition.
The most effective responses, they said, are when health systems create a culture of wellness among their physicians and other providers, allowing provider well-being to influence key operational decisions. Such organizations hire chief wellness officers and routinely invest in physician well-being.
“We tell physicians to get more sleep, eat more granola, do yoga and take better care yourself. These efforts are well intentioned,” Shanafelt said in a presentation at the Mayo Clinic in 2016. The message to physicians, however, is that they are the problem and they need to toughen up.
“We need to stop blaming individuals and treat physician burnout as a systems issues,” he said. “It affects half our physicians. It is indirectly affecting half our patients.”
A quality problem that affects half of a hospital’s patients would likely spur a team of physicians, administrators and outside consultants to solve, Shanafelt argues. Yet, physician burnout goes on largely unchecked.
There does appear to be some traction on addressing the issue. Numerous medical societies and physician professional organizations have started to study burnout and issue policy statements calling for more investment in physician wellness. The National Academy of Medicine decided to take on burnout at a national level, holding the first formal meeting of a work group on burnout in December 2016.
“(Attendees) started out with the default position that the problem is the electronic health record and if the electronic health record could become more user-friendly and more relevant to clinical practice things would change rapidly,” Kirch, the AAMC president, said. “At the midpoint of the meeting, we began to realize that it wasn’t that simple. None of us believe there will be a quick solution to it.”
There is also movement on the local level to address physician wellness and stave off burnout.
“We’ve got a movement statewide to recognize that we have to keep ourselves healthy in order to keep our patients healthy,” Eschelbach said.
He would like to see a rapid response team where individuals who experience a bad outcome or have a medical error can get immediate support from their colleagues. A patient complaint about a doctor who hasn’t had any problems before might be an early warning signal for burnout.
The Central Oregon Medical Society is also launching a wellness initiative partnering with the Oregon Wellness Coalition, which provides an anonymous way for physicians struggling with stress, depression or substance abuse to access help. St. Charles officials are supporting that effort, maintaining that physicians may feel more comfortable going that route than opening up to their superiors or the medical board.
The provider governance council’s recruitment and retention subcommittee at St. Charles is also focusing on wellness in 2018. Part of that effort may be to start a physician wellness program that has been adopted by other hospitals.
“The basis of that program is helping physicians find joy in their practice again,” Pennavaria said. “What is it that brings you satisfaction in your practice, and shifts away from the frustrations of medical practice, of which there are many.”
Some clinics are redesigning workflow, offloading some tasks on medical assistants or nurses to free up time for physicians. Other doctors use medical scribes to lower the computer-entry burden. And some practices have switched to more of a group approach with physician assistants, nurse practitioners, pharmacists and behavioral consultants working in concert with physicians to take care of the patient.
Other groups, like the emergency physicians, offer doctors some flexibility in their work schedules, allowing them to work half time or three-quarter time tracks that provide more time for work-life balance.
Other doctors find that balance on their own. Pennavaria is married to a farmer and escapes to her farm on the outskirts of Bend each night for what she calls goat therapy.
“We have 14 goats. They’re better than dogs. They’re so interactive. They’re entertaining,” she says. “I will go home from work, and I will walk around and look at what’s going on. It’s like a 180, completely different world.”
McCabe, the emergency room physician, says she’s advised colleagues feeling stressed to take fewer emergency room shifts and to work at Volunteers in Medicine, which provides free care to the uninsured.
“There’s no money — you’re a volunteer. But you get paid in joy,” she tells them. “Maybe at this point in your life, you need more joy than money.” •