I posted my opinion on burnout interventions for physicians on another blog. That opinion was that mental health interventions to address the product of a toxic work environment that is increasingly toxic seems futile to me. The author agreed with me, but stated that her program was designed to help residents survive their residencies and nothing more than that. She pointed out and I agree that residents can't change the structure of their work environment and they can't quit. That is one advantage that more senior physicians have - they can do both. The additional rhetoric on the thread suggested that there was no definition of a toxic work environment. Based on what I have posted here, I thought it would be fairly easy to pull together a few elements of that definition.
Before I proceed there are a few qualifiers. As a more senior clinician it is possible like other areas in life, that younger colleagues do not have the same experience and therefore do not relate to what you are posting. In this case it would have to do with whether or not they worked and trained in managed care environments. I think that it is entirely possible that if you have worked and trained exclusively in a managed care environment, that your experience is entirely different. That could make it more difficult to identify the cause of distress or it might make it easier to tolerate all of the non-medical intrusions into the daily work environment. There are documented personality factors and cognitive styles like perfectionism and obsessiveness that have been implicated in burnout, but they tend to be traits that are inherent in most physicians so I am focused here on immediate environmental factors that are the cause of this widespread problem. They are really quite straightforward and they can all be attributed to mismanagement:
1. Sleep deprivation: The adverse effects of sleep deprivation on cognition and emotional health are well documented. The expectation that physicians will be sleep deprived is a well known tradition. While there have been some improvements with restrictions in residency training on the number of hours of continuous work, current practices have in many ways led to a worsening of this problem. The hospitalist movement had led to the 7 days on and 7 days off schedule that creates fatigue and decreased work performance toward the end of that stretch. I have interviewed hospitalists about their experience and they have told me that their work slows down, largely due to cognitive inefficiency the last two days. That slowing adds an additional 2-3 hours of added time to complete all of the work. It seems like a questionable practice to extend working hours to the point of cognitive inefficiency and fatigue for the sake of the administrative simplicity of not having to schedule cross coverage for weekends. Outpatient physicians are no less immune when they are expected to sit in their clinics long after hours to complete what are essentially administrative tasks. Many of these administrative tasks are unnecessary from a medical standpoint. In both cases the electronic health record (EHR) places a large burden on physicians everywhere and access to it from home can create a 24/7 work environment.
2. Excessive workload: The invention of RVUs has given administrators unprecedented leverage in establishing a high volume, low quality production line of physician services. Markedly different quality of service can be provided by different physicians submitting the same billing code, but there is an unquestionable race to the bottom from the administrative side. There is no better example than the annual review conversation where physicians are told where they are on the global productivity scheme and one of two things happen. They are told that they should target a higher decile (or two) next year or they are simply given an RVU expectation that they need to meet in order to "justify" their salary. In some cases there is just an arbitrary expectation of a percentage increase in RVUs with no theoretical upper limit.
3. Changing work load: There has been no accounting for the fact that physicians have taken over more and more work tasks in the past thirty years that were previously done by other people. Transcriptionists and billing personnel have been replaced by the hundreds of thousands. The burden for generating detailed medical documents and accurate billings falls directly onto physicians and it is a heavy price. After seeing all of the patients in a day, physicians generally settle down to do all of this documentation with the associated phone calls and billing. The expectation that physicians need to know about matching their documentation to a purely subjective billing and coding scheme that can change from year to year within an organization is a reminder of the absurd administrative burden paid by all physicians.
4. Uncertainty: Medicine is a demanding field that is mapped onto significant biological variability that increases with the age of the patient. Coping with that uncertainty is one of the baseline tasks of physicians. The best way to cope with it is to stay current with the best diagnostic and treatment practices of the speciality being practiced. Business and government intrusions into this field based strictly on cost and regulatory changes introduce much more uncertainty. These intrusions take the form of case managers or external reviewers demanding that ill people be discharged from hospitals based on an arbitrary length of stay figure, those same reviewers denying a recommended therapy by the physician who has seen and is personally responsible to the patient, denied medications based on expense or contracting, or treatment based on guidelines promulgated by business organizations rather than medical or professional organizations. There is also a broad movement to train physicians as basically customer service representatives through the use of very basic interpersonal techniques. Many organizations use "customer" feedback as another piece of the algorithm that determines compensation. The important physician task of telling patient what they might not want to hear is not "incentivized".
The other relevant dimension here is that the staff who are ordering the physicians around are frequently not physicians and have no real responsibility to the patient. They are frequently working from proprietary guidelines devised by people who are also not physicians and have no direct responsibility to the patient.
5. The expectation of free work: There is no better example of free work than looking at all of the employees in health care organizations that physicians have replaced, but it doesn't stop there. Teaching medical students and residents is another good example. Lectures and lecture preparation is not only not reimbursed but there is usually the expectation that the same number of patients needs to be seen that day or made up at some point during the week. The teaching tasks are typically unsupported and lecturers and teachers are responsible for the lecture content and even getting the necessary copyright permissions. Before managed care, medical education was more of an integral part of the work and physicians typically got credit for it and department support. The current work environment emphasizes RVU productivity as the sole measure of reimbursement. This has become problematic in academic environments that are supposed to emphasize teaching. In many cases those academic goals have become secondary to so-called productivity.
Managed care has added an immense amount of additional free work for physicians. It comes in the form of all of the additional work due to utilization review, medication prior authorizations, and a blizzard of additional paperwork. In the case of medication prior authorizations it takes a minimum of 35 minutes a day and additional staff to do all of the paperwork, but I am sure that most physicians have spent that kind of time on a single case. The initial impetus for these measures was supposed to be cost effectiveness, but it should be apparent at this point that making money for managed care companies is the real priority and physicians are forced into the role of rubber stamping these measures. That rubber stamping comes at a significant time cost. Aggressively holding physicians to a productivity standard, while wasting significant amounts of their time is probably the single most toxic factor in what is already a toxic environment.
5. Overt abuse: With the unprecedented leverage that business administrators have over physicians and the proliferation of administrators there have also been additional strategies developed to get rid of physicians who are dissenters or don't fit with corporate expectations. A familiar one is the disruptive physician concept and its many forms. The corporate interest is in taking any complaint about a physician whether it is substantiated or not and using it to manipulate that physician. There are many possible sources. The 360 evaluation solicits complaints from all of the coworkers in the environment where the physician works. Making those complaints anonymous will predictably results in more significant and negative complaints. These may be reviewed in an annual review and used for compensation purposes or disciplinary action. There are variations within organizations like a "three strikes and you're out" rule. In all of these procedures the physicians involved have no recourse other than filing a lawsuit or defamation suit. These procedures become tools that can be used by any administrator against any physician who is viewed as a dissenter to the latest and greatest idea by that administrator. I have seen physicians subjected to firing and onerous rehabilitation schemes like meeting with an administrator and the supposedly aggrieved employee to help them get along on an ongoing basis. Those exercises in manipulation are superimposed on the physician who is already trying to keep his or her head above water in the sleep deprived assembly line environment.
6. The not so covert war against the medical profession: Let's face it - business administrators would obviously love physicians to act the way they treat them - like production workers rather than knowledge workers. They would really like to replace physicians with less expensive providers or prescribers and will eventually make the argument that a corporate structure with various computerized whistles and bells will be superior to trained medical staff. The only reason there is any tension at all at this point is that some physicians have skills learned in medical school and residency that have been codified to a certain degree in the legal and regulatory landscape. The only reason that behavior inconsistent with corporate behavior is tolerated is that a particular physician probably has skills that nobody else does. That does not prevent administrators from threatening entire blocks of physicians with either disenfranchisement or firing. The disenfranchisement can occur along the spectrum of decreased reimbursement, additional work expectations without additional resources, or both. Additional sorties include campaign to teach physicians basic interpersonal skills learned many times in medical school and residency. Bringing in consultants to tell physicians how to perform their work in a manner more consistent with what administrators want and ignoring the often considerable internal expertise in the department is another familiar strategy. The legislative front has been exploited to the maximum already with business tactics like utilization review and prior authorization included in many state statutes. The resulting business friendly legal and regulatory environment leaves very little room for criticism by physicians or their patients.
These are a few of the examples of a toxic work environment for physicians. I realize that many are not unique and that other assembly line workers may be subjected to the same abuses. The problem of course is that physicians are not trained to work on an assembly line. They are trained to be scientifically inquisitive and intellectually active. That dimension alone requires many hours apart from work. In addition to family life that intellectual aspect of being a physician suffers the most from the currently toxic work environment.
George Dawson, MD, DFAPA
Supplementary 1: This blog is full of posts on the mismanagement of knowledge workers and the abuse of physicians by business systems. Here are a few examples:
Mismanagement of knowledge workers
Mismanagement of knowledge workers
Demoralizing micromanagement of physicians