Burnout Industry Just Doesn't Get It

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.

The Real Solution To Burnout

One of my favorite things these days is the concept (or is it diagnosis?) of burnout.  It seems to be a popular topic in medical and psychiatric news these days.  In the Psychiatric Times January 2016 edition, Editor in Chief Allan Tasman, MD published a column on burnout entitled My New Years Prescription for You.  He goes on to detail the syndrome and what can be done about it.  He points out the high prevalence of burnout in physicians including house staff, physicians in general and psychiatrists.  These studies generally depend on checklist surveys of symptoms suggestive of "burnout."  Dr. Tasman points out that they are relatively nonspecific and people may not see psychiatrists about burnout until there are more recognizable syndromes of anxiety or depression.

My problem with the concept of burnout is that it doesn't accurately describe the problem.  As I think back on some of my most engaging clinical rotations in training - the teams frequently worked to the point of exhaustion.  The attending came in the next day.  There was an air of collegiality and a lot of learning occurred.  There was a lot of dark humor on the part of house staff.  There was an understanding that all of this exhausting work would end some day when you made the transition to a staff or attending physicians and could work more normal hours.  That was the late 1980s and early 1990s.  As politicians and business people wrested control away from physicians, suddenly most physicians continue to work like they are house staff.  Senior physicians in their 60s are suddenly taking all night call and working 60-70 hours per week.  Hospitalist services were invented requiring physicians to work 7 days on and 7 days off - another exhausting schedule.  I have observed to many of these physicians that they are working like they did when they were house staff - interns and residents.  They numbly shake their heads in the affirmative when I ask them that question.  They also acknowledge the fact that by day 6, their cognitive capacity is markedly diminished.  Suddenly it takes them twice as long to do tasks especially all of the documentation.

The reference to Studer in the Tasman article is interesting.  I don't know if any other physicians have had to suffer through a business consultant-based inservice on how to improve "customer satisfaction scores".  There are discussions on how to introduce yourself to the "customer".  There are the usual business based mnemonics.  Physicians may actually have to demonstrate that they know how to introduce themselves to "customers"!  Think about that for a second, especially if you are a psychiatrist who was trained for years in how to interact with patients rather than customers.  If you are a psychiatrist who passed the oral boards,  you know that failing to make the appropriate introduction led to an immediate failure on that exam.  Now flash forward to the bizarre world where patients are "customers" and now there is a formula designed by business people who know relatively nothing about interacting with patients in a therapeutic manner.   You are expected to demonstrate competency in this shallow business paradigm that is setup to optimize results on customer satisfaction surveys.  This is a great example of how physicians are stressed on a regular basis in health care organizations and their time is wasted.  It is also a great example of how public relations, rather than the latest medical knowledge is the dominant performance metric for healthcare organizations.  If there is a recipe for burnout - this is it.

The dynamics of burnout are the dynamics of many clinical situations that psychiatrists try to address.  The referrals are people with chronic depression or depression that seems to have occurred as a result of a sudden change in their life circumstances.  A common scenario is an unreasonable employer or work supervisor.  I will understand it if the employers jump in here and say that they are entitled to tell people how they want them to work for their salary or that their employees are free to find another job.  Those are political arguments that I don't really care about.  Those arguments are also improbable ways of addressing burnout.

When I am faced with person who is chronically anxious and depressed, chronically sleep deprived due to forced swing shifts or double shifts, is dealing with an obnoxious demanding boss, and is not able to change jobs for economic or insurance reasons - I know the patient and I are up against a wall.  I speculate that there are millions of people in this situation who are diagnosed with one anxiety or depressive disorder or another or chronic insomnia and who are trying to get some kind of treatment to alleviate this stress.  There is no evidence that I am aware of that treatment that targets what is basically a chronic stress response is effective.  There may be some small incremental changes if people feel supported and are getting active feedback in therapy about how to deal with the stress in realistic ways, how the dynamics may have personal meaning, and how to reframe the stressful relationships but many people are likely to stay in treatment for the diagnosis for months or years and have little to show for it.  Many people have the expectation that there is a medication that will restore their ability to function in this situation and not require any significant changes on their part.  That is completely false.

That brings me to the issue of physician burnout.  Burnout is more than the clinical diagnoses that are used to describe people who are experiencing chronic workplace stress.  The current work environment for physicians is designed to produce burnout, anxiety, depression, and all of the associated comorbidity.  One of the central dynamics is administrators with no medical knowledge creating an environment that moves physicians away from patients and creates an onerous clerical and administrative burden.  The large increase in managers has created an environment that is both hostile and full of busy work.  The idea that this is something that can be overcome with medications, meditation, exercise, lifestyle management or psychotherapy leaves a lot to be desired.  It is time that psychiatrists focus on an optimized environment for mental and physical well being rather than than trying to treat the fallout from some of those horrific scenarios.

Addressing burnout in physicians is more than a health and wellness consult.  It is more than a weekend retreat to a local resort.  It is more than "lifestyle changes" when you don't have enough time to have a life.  It is a lot more than going on vacation and realizing that on the day you come back - it is like you never left.  Optimizing the work environment for physicians rather than treating burnout is a good place to start.  Recognizing this when it happens in our patients is also more useful than treating it like depression.



George Dawson, MD, DFAPA