I was sent a long list of burnout interventions from a colleague today. It was quite amazing. Opinion pieces on Burnout. TED talks on burnout. Books, videos, and web-based resources on burnout. All with the message: "Physicians - in the event that you could not figure this out yourself - here is what you can do to alleviate burnout." The disease model of burnout, except in this case we are not treating with with medication or surgery we are using life style modification. What is wrong with this picture?
It turns out there is plenty wrong with this picture. The biggest problem of course is that all of the factors that lead to burnout flow from incompetent management. We have had a surplus of that in the past 30 years with no end in sight. I would venture a guess that in all of my time in practice, I have seen about 1 manager who I would consider to be competent. Nobody working for him was at risk for burnout. More importantly, the most important protective factor against burnout has also become a casualty of bad management. That factor is collegiality. I could regale the reader with stories from my past on how much work I and my teammates did in various medical and surgical settings. But I think that most people in working settings realize how much better the job and the day goes if they are working with bright, knowledgeable and highly motivated people. A sense of humor is always a plus and I am convinced that at least some of the physicians I worked with were some of the funniest people I have met anywhere.
Rather than more stories, I will get right to the point about how bad management subverts collegiality. Very early in the process, managers sold the idea that "there are some slackers in the group and therefore we need to introduce a way to measure productivity." I was skeptical. I looked around the room and did not see any slackers. The statement appeals to those who are competitive by nature or anyone who wants to make sure that everyone is working as hard as they feel they are. The next part of the process was adapting a very crude systems and after several missed starts applying it to everyone. Even then I was quick to point out that it looked like 95% of the group was working hard and the only difference were the correction factors applied to the work units. At that point I was told that this was not an academic exercise and we were now on this system whether I liked it or not. Over the years, the calculations fluctuated and everybody did the same job, but now we were all cast as competitors rather than colleagues. In the end the productivity system was just a manipulation, more hoops to jump through as management made us less and less efficient with a series of roadblocks.
The second step is to set some arbitrary rules about how individual productivity affects the entire group. In other words, penalize everyone up front and let the group know that this "holdback" in earned wages would be paid out only if everyone made their productivity requirements. I have never seen that rule applied to any other group of employees.
The next step is to set up some kind of arbitrary and meaningless employee evaluations. Solicit random anonymous comments from any staff working with the physician employee and have them defend this one-sided criticism in their annual evaluation as if it is true. Have the physician who is working 60-70 hours a week, teaching, and doing independent educational activities select some goal at work that they will quickly forget until the next annual review. All of the steps so far have served to isolate physicians and create a general paranoia about who might be making negative comments about them. Paranoia is never good for collegiality.
Top this entire mess off with a primary school disciplinary system with a very low threshold. Nurse Cratchett says that a physicians was too "curt" with her and suddenly that physician is called into the Chief of Staff's office and told that they are a disruptive physician. Furthermore, that physician is advised that they have "one strike" against them and if they accumulate two more strikes they are "out". There is no appeal process or due process. If Nurse Cratchett complains - it must be legitimate and that conclusion based solely on the opinion of one person and supported by the Chief of Staff - stands.
At this point collegiality is gone and the physicians are further isolated from other non-physician staff. Anyone can "report" them and that report will be taken seriously whether it is true or not. The physician-administrators are no longer colleagues but hostile flunkies of the business hierarchy.
The final step was a stroke of genius by the incompetent managers. For about 30 years managed care companies have had physicians reviewers sitting in a different state - remotely viewing records and telling the physician who is actually treating the patient - that patient must be discharged from the hospital or in some cases treatment for substance use disorders or outpatient psychiatric treatment. In the last 10 years managers decided to have their own on site case managers, sitting in rounds and team meetings telling the physicians when to discharge patients. If the physician doesn't go along with them they are reported to the medical director. That creates additional problems and possibly another accusation of being a disruptive physician.
I have been talking about this sequence of events since I started writing this blog. I recently encountered some resistance for the first time. A colleague suggested that since burnout in physicians in other countries exists - there must be more to it than managed care. I think that misses the point at a couple of levels. First, it is possible that there are other bad managers - managed care companies certainly don't have a monopoly but they are highly standardized so that the onerous management practices that you find in one will certainly exist in another. The literature on burnout in other cultures is small at this point and in some cases non-specific. In other cases there is clear overlap. But as I think more about this argument it seems lacking. It seems like finding burnout and bad management practices in other countries can be used to rationalize the existence of ultimate bad management or managed care. Secondly, bad management of personnel is just one aspect of bad management in general. Does management ever do anything positive from an intellectual or creativity perspective? Apart from one physician manager, I have not seen a single positive management outcome after observing a significant number of these people.
In fact, if managed care administrators could not treat physicians like production workers they would have absolutely nothing going for themselves. Nothing at all.
George Dawson, MD, DFAPA
References International Physician Burnout:
1: Jesse MT, Abouljoud M, Eshelman A, De Reyck C, Lerut J. Professional interpersonal dynamics and burnout in European transplant surgeons. Clin Transplant. 2017 Apr;31(4). doi: 10.1111/ctr.12928. Epub 2017 Mar 19. PubMed PMID: 28185307.
2: Głębocka A. The Relationship Between Burnout Syndrome Among the Medical Staff and Work Conditions in the Polish Healthcare System. Adv Exp Med Biol. 2016 Dec 31. doi: 10.1007/5584_2016_179. [Epub ahead of print] PubMed PMID: 28039665.
3: O'Kelly F, Manecksha RP, Quinlan DM, Reid A, Joyce A, O'Flynn K, Speakman M, Thornhill JA. Rates of self-reported 'burnout' and causative factors amongst urologists in Ireland and the UK: a comparative cross-sectional study. BJU Int. 2016 Feb;117(2):363-72. doi: 10.1111/bju.13218. Epub 2015 Jul 30. PubMed PMID: 26178315.
4: O'Dea B, O'Connor P, Lydon S, Murphy AW. Prevalence of burnout among Irish general practitioners: a cross-sectional study. Ir J Med Sci. 2016 Jan 23. [Epub ahead of print] PubMed PMID: 26803315.
5: Tomljenovic M, Kolaric B, Stajduhar D, Tesic V. Stress, depression and burnout among hospital physicians in Rijeka, Croatia. Psychiatr Danub. 2014 Dec;26 Suppl 3:450-8. PubMed PMID: 25536981.
6: Misiołek A, Gorczyca P, Misiołek H, Gierlotka Z. The prevalence of burnout syndrome in Polish anaesthesiologists. Anaesthesiol Intensive Ther. 2014 Jul-Aug;46(3):155-61. doi: 10.5603/AIT.2014.0028. PubMed PMID: 25078767.
7: Kravitz RL. Physician job satisfaction as a public health issue. Isr J Health Policy Res. 2012 Dec 14;1(1):51. doi: 10.1186/2045-4015-1-51. PubMed PMID: 23241419; PubMed Central PMCID: PMC3533582.
8: Putnik K, Houkes I. Work related characteristics, work-home and home-work interference and burnout among primary healthcare physicians: a gender perspective in a Serbian context. BMC Public Health. 2011 Sep 23;11:716. doi: 10.1186/1471-2458-11-716. PubMed PMID: 21943328; PubMed Central PMCID: PMC3189139.
9: McKinlay JB, Marceau L. New wine in an old bottle: does alienation provide an explanation of the origins of physician discontent? Int J Health Serv. 2011;41(2):301-35. Review. PubMed PMID: 21563626.
In creative cultures like Silicon Valley, "disruptive" is considered a compliment.
ReplyDeleteMost of situational psychotherapy is geared toward ownership of responsibility for neurosis. Which is usually appropriate.
In the case of physician burnout, we have the rare exception when it really is someone else's fault, but we are asked to
internalize it.
This all seems so basic but physicians are moral masochists who would rather sulk around the playground with a wedgie than punch the bully in the nose.
"This all seems so basic but physicians are moral masochists who would rather sulk around the playground with a wedgie than punch the bully in the nose"
ReplyDeleteThat explains why I read a young MD vigorously defending MOC the other day.