Happy Labor Day 2024

 

More labor like I am used to seeing it in the upper Midwest. 

In keeping with the tradition of previous labor days - this is my annual greeting. I started writing these Labor Day greetings as an update on the work environment for physicians.  My rationale is that over my nearly 40 years in medicine that environment has continuously deteriorated.  Like any field there have been obvious improvements and innovation in clinical care along the way.  Even though that has happened the work environment has worsened every year leading to widespread physician dissatisfaction, burnout, and moral injury along the way. 

I was fortunate enough to hang on until about three years ago when I retired.  Compared to working my entire career as an employee - retirement is quite literally a walk in the park. I  stay active in the field by reading, writing this blog, and working on various publications. I get plenty of rest and exercise. I have time for activities that were on hold for decades during my working years. I have not seen or treated any patients in about 3 years. A friend of mine who went back to work told me that he had to work on an inpatient unit for 2 months because the organization he worked for had that requirement for anyone who had not seen enough patients in the past two years.  If you were an acute care psychiatrist like myself that requirement makes little sense. Reading all of the notes and plans from the first week of outpatient practice should suffice.  After all we have a Presidential candidate who brags about passing a rudimentary cognitive screening exam - and he has a briefcase with all of the nuclear missile launch codes. 

I do miss the detailed conversations with people and discussions about how to approach their problems.  In some of the discussion formats there is still controversy about psychotherapy in psychiatry.  The only way I can see this as a real controversy is if we are arguing that all psychiatrists should be psychoanalysts.  I don't think that anyone believes that any more. But it has always been clear to me that psychiatric practice needs to be informed by psychotherapy and that includes psychoanalytical/psychodynamic psychotherapy both on the expressive and supportive sides. Psychiatrists need to be able to talk with people in a therapeutic way across a number of diagnoses and settings.  Psychiatrists need to be able to maintain relationships with people who have a very difficult time maintaining relationships with anyone. Psychiatrists need to maintain relationships with people who are actively avoided by their own families and acquaintances.  The only way that will happen is if a psychiatrist is trained in these techniques.  Without them - a person is just talking with another doctor about medical treatments. 

As I have stated many times on this blog in the past - that type of quality psychiatric treatment takes time.  Taking time away from psychiatrists and their patients is one of the functions of modern healthcare administration.  It leads to the previously mentioned problems in the work environment.  I did an update just before typing this post by searching developments in the physician work environment in the past year.  The same concerns about dissatisfaction, burnout, and moral injury were still there.   There was something slightly more specific on the AMA web site pointing out how Medicare reimbursement is not indexed to inflation and does not cover the expenses.  That leads to higher volume work (something that managed care rationing was supposed to prevent) and in many cases lower quality.  It can also lead to a lack of available care as physicians drop out of Medicare or just have too much low reimbursement work to see new patients.  But that message from the AMA is far from optimal.  It seems to imply that if patients were aware of these problems they would lobby politicians to improve working conditions for doctors.  Patients already know the problems - at least some of them.  I had several patients comment on the low reimbursement I was getting from Medicare for seeing them.  It might be useful if physician organizations like the AMA provided information on how to set up a practice that would maintain financial viability.    

I did try to volunteer as a research analyst.  I was involved in a great research project at the time I left my last employment.  I offered to analyze data for a local large healthcare organization (one of the three largest in Minnesota).  I emphasize again that I offered to work for free on this data analysis and any subsequent publications.  The research project I suggested had never been done in a large healthcare organization - but had been done in registry studies in Sweden and Denmark.  There are no national registries in the United States and all of the data is proprietary.  That company was not interested in me working for free even though I did plenty of free work for them when I was an employee working on research committees.  The only difference was that I still had to generate revenue by seeing enough patients while doing the additional work for free.  That offer still stands for any serious research being done in psychiatry.

That is my brief Labor Day message this year.  It is repetitive because physicians have very little leverage against businesses and governments and that had led to the current work environment problems.  I continue to go to conferences and see a lot of people who I know are still actively working.  From their descriptions they are working too much.  Like me they enjoy talking and working with people.  That is probably how a person ends up in psychiatry.  I wish them well in the coming year and hope for developments that will make their work easier.  And as always - I hope all of my colleagues make it to retirement.

George Dawson, MD, DFAPA

Supplementary 1: I decided to include this graphic from about 4 years ago that I made to indicate how much physician/psychiatrist time is diverted away from clinical care basically to satisfy some administrative requirement.  It should be obvious that has increased greatly over time and although other health care providers are also affected the burden is somewhat disproportionate on the physicians.  As I pointed out - during this time frame I replaced 4 full time employees when I was expected to also do their work.  It is also apparent that a lot of this worked is free for other organizations (managed care organizations, pharmacy benefit managers, etc).  

 

Graphics Credit:  click directly on the photo and it will take you to detailed information on the origins, credits, and CC license on Wikimedia Commons. 

Happy Labor Day

 

Happy Labor Day

 

“It should be evident to all students, residents, and practicing physicians that the enormous investment in time, money, and commitment typically necessary to become a physician makes no sense if practicing medicine frequently fails to be interesting and enjoyable.”  Samuel B. Guze, MD 1992 (1)

 

Every year I try to post something about my impression of the physician work environment. That has been a progression of depressing posts as the work environment deteriorates every year largely due to micromanagement by managed care companies and various governments that has resulted in a trillion dollar overhead, quality as an advertising meme rather than a clinical reality, poorer reimbursement for physicians, massive numbers of wasted hours for the bureaucracy and its documentation requirements, and the negative feedback loop of using the healthcare system as a jobs program for business administrators.  Each of those iterations moves use farther and farther from Dr. Guze’s reality of an enjoyable and intellectually stimulating career in medicine.  Interestingly – enjoyability is not an obvious factor in the most frequently used scale to detect burnout in medical staff.  Those scales tend to be focused on a learned helplessness/loss of personal efficacy model.  Lack or loss of enjoyability is probably the first step toward that extreme conclusion.

It is equally frustrating for patients who have seen access get markedly worse.  Just this month I tried to assist a friend in finding a therapist either inside or outside of her insurance plan. And there were none. I am not talking about a waiting list and an appointment 2 or 3 months out.  I am talking about no access at all.  The clinics would not even place her on a waiting list.  I saw a consultant myself back in January who told me he was referring me to another specialist to be seen this August.  When that did not happen, I called and my calls were not returned. Eventually by sending enough messages to my primary care MD they called me and set up an appointment on September 2.  I was called yesterday and told that appointment was cancelled.  They gave me another appointment in mid-November with the qualifier: “We have you penciled in but there is no guarantee that this won’t change again”.

I am very aware of the strain the pandemic and its mismanagement has put on the system.  Also aware of physicians and nurses resigning in droves (2). In the case of primary care specialties and psychiatry there was a serious shortage before the pandemic hit.  The pandemic itself is an insufficient explanation for what has happened over the past three years. The lack of an adequate pre-existing public health infrastructure had a lot to do with it (4).  Inadequate protection for front line workers and an inability to scale as the morbidity and mortality increased in some cases exponentially. In the case where public health officials were doing what they could they often found themselves threatened and attacked by pandemic deniers, anti-vaxxers, and let’s face it various elements of the right wing (3). The same people basically responsible for building out America’s immense for-profit and inefficient health care system. What could be more depressing than to try to treat a pandemic while a political party is basically denigrating standard public health measures and either verbally attacking or threatening public health officials to the point that many had to get security personnel for protection. When you have a big enough platform – I consider acts of omission-like not taking a stand firmly against political violence as bad as the people making the threats. I also don’t make any distinction between threats from the average man or woman on the street and members of Congress making clear threats.  Many seem to act like they have immunity in those situations.

The politically designed medical systems of care that is basically run by unqualified business people was ramped up to even worse performance by the associated political anarchy. That anarchy continues. Who could blame physicians for bailing out in those circumstances?  I think there is a legitimate concern about whether the system will every get back to its baseline prepandemic inefficiency.

Some have considered the increased use of telemedicine and telepsychiatry to be a positive correlate of the pandemic. I gave a continuing medical education presentation on it in November of 2021. For various reasons – I think the eventual outcome of telemedicine is uncertain. The main reasons have to do with businesses taking over and managing the visits for profit and to the detriment of any therapists or physicians involved. A review of what can happen was published in the New York magazine (5). I see television ads all the time for rapid access to all kinds of prescriptions just by calling a business running a specialty telemedicine site. Some of these sites are already controversial and there appears to be very little transparency when it comes to comparing these sites to the even meager quality of care offered by in-person managed care.  Payer gaming at all levels is another possibility. During the pandemic reimbursement for care delivered was at the standard rate.  We are just starting to see decreased reimbursement or no reimbursement for televisits. I have also seen very disadvantageous contracts for physicians and therapists attempting to do televisit work at the levels of reimbursement, risk, and required access. That is consistent with the decade’s old observation that medical practice environments deteriorate in quality with increasing business involvement.

On a positive note this year – the main alternative to maintenance of certification by  American Board of Medical Specialties (ABMS) is the National Board of Physicians and Surgeons (NBPAS). This year the NBPAS was given recertification status by the Joint Commission and hospital accrediting agencies. The NBPAS model is the original “life long learning” model proposed for all physicians since the Flexner era. I have personally been recertified every two years by the NBPAS, but until this year realized that most younger physicians were not in a position where they could abandon much more costly and some would say overly involved ABMS recertification procedures.  The change this year apparently makes it easier to make that transition, but a lot will depend on hospital committees and local accreditation procedures. ABMS recertification is onerous enough to tip the balance in favor of leaving the field for retirement of a different occupation so that this change may also lead to physician retention.  But a lot will depend on how all of this unfolds.

I can still recall reading about why Paul Tierstein, MD came up with the original idea for NBPAS. He noticed a colleague who was an electrophysiologist cramming for a recertification examination and learning details he would never use in his day-to day practice.  Most physicians – even within their own specialty or subspecialty develop a knowledge base for that practice.  That knowledge base is not consistent with a preparatory based knowledge learned in medical school or as a resident. Relearning irrelevant material for the sake of taking an examination is another unnecessary drain on a physician’s time and finances. Life long learning is a better way to acknowledge that physician’s highest level of certification and ongoing efforts to maintain that specialized knowledge.

All things considered it has been another very stressful year for physicians. There is a glimmer of hope on the recertification front that will hopefully alleviate a lot of unnecessary stress.      

We still have a very long way to go to reach Dr. Guze’s suggested practice environment that is both fun and intellectually stimulating.  Like he says in his book – I was taught about that is medical school and experienced it only in the very first years of practice. We need to make medicine interesting and enjoyable again and that’s a very tall order.

 

George Dawson, MD, DFAPA

Supplementary:

 Explanation of the graphic: sometime ago I posted that heavy lifting is a metaphor for what has happened to medical practice in the US. This is another example. 

References:

1:  Guze SB. Why Psychiatry Is a Branch of Medicine. New York; Oxford University Press: 1992: p. 118.

2:  Abbasi J. Pushed to Their Limits, 1 in 5 Physicians Intends to Leave Practice. JAMA. 2022;327(15):1435–1437. doi:10.1001/jama.2022.5074

3:  Ward JA, Stone EM, Mui P, and Resnick B, 2022:Pandemic-Related Workplace Violence and Its Impact on Public Health Officials, March 2020‒January 2021.American Journal of Public Health 112, 736_746, https://doi.org/10.2105/AJPH.2021.306649

4:  Bishai DM, Resnick B, Lamba S, Cardona C, Leider JP, McCullough JM, Gemmill A. . Being Accountable for Capability—Getting Public Health Reform Right This Time. American Journal of Public Health 0, e1_e5, https://doi.org/10.2105/AJPH.2022.306975

5: Fischer M.  The Lunacy of Text Based Therapy (And other technological solutions for a nation in trauma).  New York Magazine March 29-April 11, 2021.

Image Credit:

National Archives and Records Administration, Public domain, via Wikimedia Commons https://commons.wikimedia.org/wiki/File:Girls_deliver_ice._Heavy_work_that_formerly_belonged_to_men_only_is_being_done_by_girls.

Heavy work that formerly belonged to men only is being done by girls. The ice girls are delivering ice on a route and their work requires brawn as well as the patriotic ambition to help. - NARA - 533758. https://upload.wikimedia.org/wikipedia/commons/0/0a/Girls_deliver_ice._Heavy_work_that_formerly_belonged_to_men_only_is_being_done_by_girls._The_ice_girls_are_delivering_ice_on_a_route_and_their_work_requires_brawn_as_well_as_the_partriotic_ambition_to_help._-_NARA_-_533758.gif

Happy Labor Day 2021

 

This is my annual Labor Day greeting to my physician colleagues. I had to go back and look at last year’s greeting to see if I had factored in the pandemic or not.  It appears at the time that I was fairly enthusiastic about telepsychiatry and its applications during the pandemic. Ironically, I will be giving a presentation on telepsychiatry later this year and in reviewing a fairly massive amount of information my initial enthusiasm has been tempered. Although it appears to have had a semi-permanent effect on the regulatory environment there are still unanswered questions about its optimal applications. How it will be used by the business community is also unknown at this point.

One of the articles I reviewed in New York Magazine - outlined a pattern of questionable business practices at least as it was applied to therapists. Direct interviews with therapists suggested that they were being exploited by being paid much less than their going rate with the expectation that they would be more available after hours and by texting. Preliminary surveys indicate that there are psychiatric clinics popping up looking for psychiatrists to staff telepsychiatry visits. There are many unknowns about their practice. In another article, some employers were asking therapists to see people outside of the state they were licensed and hope that the regulatory environment would catch up with the employment practice. Those are not good signs for the labor environment.

I noticed in my 2020 post that I had an initial drawing of how the practice environment had changed and now that drawing has been expanded and includes many more details. It captures most of what I have endured as employed psychiatrist. I include a graphic below and hope that as physicians we can reverse the trend at some point.

The pandemic has clearly been demoralizing for physicians in general but much more for frontline acute care physicians responsible for COVID-19 patients and their frontline colleagues in nursing and hospital support. There has been a shortage of personal protective equipment (PPE), beds, adequate ventilation, and supportive services. There have been deaths and resignations compounding the personnel problem. As the staffing ratios worsen - the emotional stress is at an all-time high. Local disasters compound the COVID crises in many areas.  All the descriptions I see indicated that the healthcare system will end up permanently altered by this pandemic and probably not in a positive way. There seems to be no effort to incorporate a public health approach into the current subsidized business rationing approach that dominates American healthcare. That is not only detrimental to physicians and their coworkers but also the public health infrastructure in general.

A new dimension to the demoralization has been the misinformation industry associated with the pandemic. Physicians trying to provide information in good faith have been attacked and even threatened by some of the zealots associated with or affected by that misinformation. That includes some of the top experts in the world who have been active in research and teaching immunology, epidemiology, virology, and vaccine production. Physicians are given the message that is up to them to communicate to the zealots and convince them that the pandemic is real, it is a really a virus, and that immunizations are the best approach. There appears to be no convincing a large group of people that wearing masks may reduce viral transmission even though that practice was widespread in the 1918 epidemic in the US and is currently widespread in many parts of the world. Physicians are getting the message that they have to magically find a way to communicate with this group of people who have rejected all of the usual channels.

It seems obvious to me that physicians are the only group that are excluded from empathic communication. The expectation is that physicians will be all-knowing, all understanding, and that somehow will correct most of the anti-vaccine, anti-science, anti-expert, and anti-COVID sentiment out there. I think that is a fairly naïve approach and what physicians need is concrete help from politicians, community leaders, and regulators.  Social media is gradually coming around but has responded at a glacial rate. 

I also notice in my greeting from last year that I commented on an APA Presidential Task Force on Assessment of Psychiatric Bed Needs in the US.  I saw no further action and that and was not able to find it in a search. That potential bright spot maybe on hold due to the pandemic, a lot also depends on the conclusions if they are available.

Progress against the burnout industry has been maintained but it is clearly a war of attrition. Physicians in general reject the idea that burnout is due to some inherent personal deficiency and are more likely to see it as the real product of an unrealistic work environment. In many cases that unrealistic work environment has increased many-fold due to the pandemic and all of the associated problems. I hear from physicians every day who are able to exercise minimal self-care due to overwork and limited time away from work. Weight gain is common due to unhealthy diet and no time for exercise. A solution for some has been to leave those work setting behind even if it means early retirement or taking an undetermined period of time off. Many physicians who could easily have worked into their early to mid-70s are retiring at age 65.

Employers seem to be doubling down in this adverse environment. I quit my last job in January 2021. Since then, I have been actively looking for new positions. There has been a recurrent pattern of highly leveraged job descriptions, that I would accept only if I really needed employment. By highly leveraged I mean that the job description contains anywhere from 20 to 30 bullet points, the majority of which have nothing to do with being a clinical psychiatrist. To cite one example, many of the applications describe a “leadership role” where the really is none. No organization that I am aware of wants a frontline clinical psychiatrist to attempt to correct their obvious administrative problems. I received a cold call one day from a recruiter who asked me if I was interested in a “very good” inpatient position. I asked him what the productivity expectations were and he said I have the options of seeing 18 or 22 patients per day. He quoted a disproportionately greater premium for seeing 22 patients a day. He seemed convinced that I would accept the position until I asked him “When am I supposed to live or sleep?” I had the thankless job of covering inpatient unit of 20 patients for an entire year with the help of an excellent physician assistant and that almost killed me.

The unrealistic expectations being placed on physicians are still out there and they are as bad as they ever have been. It is why I used a heavy lifting graphic for this post again. Despite the pandemic the business leverage against physicians is not letting up and that is not a good sign. To make matters worse, there always seems to be room for it in the medical literature. The latest example I can think of is a recent essay in the New England Journal of Medicine claiming that digital healthcare fee-for-service payments are unsustainable and there must be a capitated system. That seems to be part of the master plan to continue a rationed-for-profit system that guarantees over-employment of bureaucrats and business managers as well as corporate profits at the cost of treating physicians like highly paid laborers as depicted in the above diagram.

I don’t think physicians will have any reason to celebrate Labor Day, until that rationed- for-profit system is dismantled.  Until then do what you need to do to take care of yourself and survive. Help from professional organizations would be useful, but there are too many conflicts of interest for that to be realized.  I am still hopeful that we can get back to the stimulating clinical environment of the 1980s, but I will be the first to admit - there is no obvious path back in the face of a trillion dollar healthcare rationing business - largely invented by Congress.

 George Dawson, MD, DFAPA

 

Graphic Credit:

Robert Yarnall Richie, No restrictions, via Wikimedia Commons. "Workers Adjusting Tracks, Texas Gulf Sulfur Company."

Physicians Preservation Act?

I got this idea today while reading the usual Twitter complaints about the electronic health record. A post by physician I knew was particularly poignant. She pointed out that she was getting burnout from the excessive time it takes to do EHR documentation compounded by the fact that nobody ever reads it. This is a complaint I have had for a long time.  I was lucky enough to be on the ground as the EHRs rolled out. There was quite a prelude to the rollout with about a solid 10-year buildup of documentation and billing requirements. Those requirements originated with the federal government specifically HCFA – the precursor to CMS. All of the initial EHRs were designed around these documentation and coding templates. It was strictly a business focus sold as something necessary for medical practice.

I can recall the first people on the medical staff who were designated to sell the system. They came to see me and I pointed out that I have never been a touch typist and the fastest I can type is 12 words a minute with two mistakes. When they realized I wasn’t kidding they tried to soften the blow by saying that we would be slowly transitioned to creating the entire document. During that transition time we would still be able to dictate admission notes and discharge summaries. When I complained that this would still be quite a burden on physicians producing all these documents I was told by an internist (who I had a very high opinion of) “You need to thank our CEO for getting us this state-of-the-art system.” That was one of the more depressing remarks that I’ve heard in my career.

I did try to make the most of it. I got an early version of Dragon and started dictating all my notes and into Word and pasting them into the EHR.  It was not pretty. There were many mistakes and if I missed some of those mistakes it could prove to be an embarrassing document. The nursing staff I worked with helped to edit those documents and point out the mistakes but some mistakes invariably went through. I learned that the nursing staff in my immediate proximity were the only people who ever read those notes. I was generating multiple 500 to 1000 word documents a day and suddenly realized that I had to complete that work between 10 PM and midnight every day. Within a few years the new car smell was off the EHR and things were getting ugly.  I started to see 18 to 20 page progress notes based on import and cut-and-paste features. My speculation is at one point the vendor was desperate to prove they could introduce some physician friendly features. The ability to start a new daily progress note based on yesterday’s note soon became history. Administrators decided that the new note looked too much like the old note even though they were based on same template.

EHR politics is always interesting to observe. There are a cadre of administrators and “super users” who are tasked with selling the product to the frontline physicians. There are also various helpdesks that are run by the vendor. Staff at those helpdesks are supposed to be available for troubleshooting and problem solving. The troubleshooting and problem solving eventually fades away. EHRs are typically implemented in modules. I walked into work one morning and realized that the module that allowed electronic prescribing was completely changed. The change was not announced and since it was an enterprise wide implementation there were hundreds of physicians trying to figure it out for themselves. It added hours to everyone’s day.

With the shift of billing, coding, and documentation to physicians many other jobs were lost due to the EHR. For 15 years I would go to the basement of the hospital every Sunday and make sure all of my records were dictated and signed. I ran into the same staff there every weekend who greeted me and assisted me with completing those records. Suddenly they were gone because now I was doing all of their work in the EHR. When I first started working at my job, I would dictate daily progress notes and they would be pasted into the chart by the secretarial staff the next day. Billing and coding specialists would come to the unit, read those notes, and attach a billing fee. I had no idea about the billing system and didn’t really care. With the EHR all of those staff were replaced. I was not only doing their jobs but now I was legally responsible for any billing errors and the suggested penalties were high. All of this additional work and responsibility was directly transferred to physicians through the EHR.

The only real bright spot from the EHR was the ability to see imaging studies, electrocardiograms, and laboratory results as soon as they were available. It took years to get that implemented to the point it worked effectively.

Are there workarounds to successfully use the EHR without burnout, depression, and excessive work? I think that there are. The last few years I have been seen by ophthalmologists who were retinal specialists and an otolaryngologist or ENT physician. In both cases these positions were using a scribe or a third person in the room who documented the history, exam, findings, and treatment plan as indicated by the physician. In the case of the retinal specialist he was working with an ophthalmology fellow and made corrections to that examination by directions to the scribe. The same thing happened with the ENT physician but in that case the scribe was also an RN who could provide more details about the suggested treatment plan. In both cases the physician walked out of the room at the end of the encounter with no further documentation burden. That led one of my colleagues to point out that the only reasonable workaround for the EHR problem is to use two people - the physician and a scribe or staff person who could also function as a scribe.

That led to my idea about the Physicians Preservation Act at the top of this post. It addresses all the flaws in the system that were brought about by heavy lobbying and Congressional advocacy for a burdensome inefficient electronic documentation system. As I pointed out in a 2015 post, the system has never lived up to claims of efficiency or savings even when physicians started to do the work of four or five people. This entire administrative structure is there to produce excessive documentation that nobody reads. There is also a massive environmental cost since the system must operate through thousands of networked personal computers that in many cases are operating 24/7 along with the associated data storage facilities. 

My suggested solution is a compromise between the likely inertia of the current EHR system and the politics that keep it in place and the massive burden it places on physicians and their families. There are just too many special interests in Congress keeping this system afloat. The question is how long can the country afford to lose doctors because of it.

My guess is not too much longer.

George Dawson, MD, DFAPA

I Was Compassionate Today ........

I attended the Minnesota Psychiatric Society (MPS) Spring Scientific Meeting today entitled "Reclaiming Our Joy and Wonder as Healers."  The full program of that venue is available online at this site.  In the registration process I noted that a lot of the content seemed to be experiential and that is my least favorite kind of conference.  To make sure I did not miss anything I compared notes with a long time colleague and she agreed and had the same selection process - try to avoid the experiential components of the program.  I was generally successful, but more about that later.

The program did begin with three lectures and ample audience participation.  The presentations on happiness and burnout seemed to be an uncritical look at happiness and gratitude science.  The lead off speaker talked about his personal experience in a health care system that sustained 2 physician suicides in less than a year and how he led the effort to reduce physician burnout.  He discussed some straightforward exercises in gratitude and happiness as well as the importance of human relationships.  He encouraged psychiatrists at one point to help out their nonpsychiatric colleagues in this area.  He provided extensive resources for physicians to use through a web site.

I worked with the second physician for over a decade in my previous position.  He discussed the clash of professional values and expectations with what happened in the family and intrapsychically and how he negotiated some of those transitions including going to a clinical track from an academic- research track.  He read part of this piece by Jamie Riches, DO - an Internal Medicine resident at Sloan Kettering and the impact of resident suicides.  It contained the familiar refrain: "The work does not stop!"  No matter what catastrophe you encounter as a physician (and there are many) you are expected to take a deep breath and get back to it - immediately.  A resident I worked with completed his shift and the final admission note on 15 patients he had seen that night despite an upper GI bleed.  He did not seek medical attention until he had signed out at 8AM the next day.  Any bystander can look at these occurrences and other problems listed by Dr. Riches and see how physicians are shooting themselves in the foot.  You can't provide good care to patients if you can't take care of yourself.

The third morning lecturer was on the state hospital association and he discussed their attempts to address physician burnout.  They had graphed the degree of burnout in various medical organizations and concluded that interventions could be useful for decreasing burnout in general and burnout specifically due to the EHR.  I have seen first hand how survey data can be manipulated by health care organizations and I am skeptical that this data means much - especially when there was acknowledgement that the EHR itself has either not changed or the organization implemented the usual unhelpful EHR teams as the primary intervention.         

I was able to propose a thought experiment in an afternoon session on Compassion Training.  I am no stranger to Buddhism, meditation, or mindfulness techniques.  As a psychiatrist trained in the theory and maintenance of therapeutic neutrality, I was skeptical of emotionally loaded terms like "happiness" and "compassion" being used in the context of a therapeutic relationship.  Just about every definition of compassion includes terms like sympathy, pity, concern, and or sorrow for the plight of another person.  That seems a lot less precise than empathy.  The definition of empathy that I use is the technical version from Sims (1) : ".....empathy is a clinical instrument that needs to be used with skill to measure another person's internal subjective state using the observer's own capacity for emotional and cognitive experience as a yardstick.  Empathy is achieved by precise, insightful, persistent, and knowledgeable questioning until the doctor is able to give an account of the patent's subjective experience that the patient recognizes as his own."  Some definitions confuse empathy with passive understanding of another person's emotional state and compassion with understanding and a willingness to take action to help that person.  Psychiatrists trained like me use empathy to explore the person's subjective state for the purpose of understanding it and trying to help them.  It is anything but passive.  In the course, the various stages of meditations were also focused on developing a baseline compassion toward oneself.

I asked the instructor to consider the following thought experiment:

1.  In Room 1:  I am interviewing a patient with borderline personality disorder and proceeding by using the guiding concepts of therapeutic neutrality and empathy.

2.  In Room 2: A psychiatrist with compassion training is interviewing a patient with similar problems.

Question:  How would an observer compare the psychiatrists in Room 1 and Room 2?  Would there be any discernible differences between the two?

The response I got was quite interesting.  She suggested that the main difference would be after the interview was terminated - the compassion trained clinician would be less distressed after the interview than I would.  The problem with that response is that I am not distressed at all interviewing patients.  I have plenty of experience across a wide array of scenarios.  At some level, I am much more comfortable talking to people in my office than just about anywhere else.  The expectations are clear.  I know what I have to do and have done it tens of thousands of times in the past.  I can talk about anything a person wants to talk about including how they perceive me in that  situation.  In the interest of time and not wanting to appear argumentative, I did not bring that up.  It does raise the issue of whether the new interventions for burnout have much to add over appropriate training from the past.  I have practiced mindfulness techniques and meditation and like a lot of the patients  I see - they don't seem to add much.

In the summary session I requested the microphone.  I don't come across well in a potentially contentious environment.  When I speak people think that I am irritated or angry and that probably affects my message.  I consider myself to be passionate - but I am not really angry about anything.  It would be foolish to be angry about various things that haven't changed in 20 years.

At the micro level my emphasis was on direct connections. I described a scene from my internship, where another intern and I were responsible for a patient on a balloon pump in an ICU setting.  At one point we looked at one another and realized there was nothing more we could do.  I knew from the look on his face at 4AM that he was as distressed about the situation as I was. We did not know enough at the time to realize that there was nothing anyone could do - but it would have been very useful to have somebody tell us that.   In those days, there was an implicit rule that attending physicians should probably not be called at night and that everything in the hospital could be resolved by you and your Internal Medicine PGY3.  I only heard one attending ever give us explicit instructions and that was "I don't want to be surprised in the morning."  My resident had to translate it for me: "We need to call him if somebody is going down the tubes."  As an attending physician myself, I wanted to make  sure that never happened.  I got called by a resident who had a very confusing patient presentation and went in and made the diagnosis of serotonin syndrome and had the patient transferred to the ICU.  My emphasis at the micro level was that there has to be clear communication that you don't mind discussions and consultations about cases even when you are out in practice.  I am consulted by and consult many psychiatrists by phone and email on an ongoing basis and any time of the day and it has been a great source of professional development and peer support.

At the macro level, my message was politics.  The speaker touched on the EHR as a burnout factor and what they might need to do about it.  Nobody mentioned maintenance of certification.  Some people seemed irritated that I mentioned either politics or MOC in this course that was supposed to be about preventing burnout and creating a more resilient workplace.  I don't know what a more resilient workplace is.  The workplace is resilient simply because it is out of physician control and completely resistant to change.  There are more ways to get the EHR and MOC changed than hope that a hospital association will do it with survey data.  I proposed that physicians consider political activism at the level of the practice environment and the government level and that they consider defeating MOC.

At the end one of my colleagues told me she appreciated the approach to providing residents support and wished she had it in her training program.  I was glad I got that message out.  No takers on the EHR or MOC.

I will keep going and adding my two cents - even though my anxiety seems to be getting higher and higher every time.  At some level I probably realize that there are very few people who see the psychiatric world the way I do - and I know my time is limited.  I also know that I don't see anybody coming along who is prepared to challenge the status quo that seems to keep dictating our deteriorated practice environment.


George Dawson, MD, DFAPA


References:

1:  Sims A.  Symptoms in the Mind, 3rd Edition.  Elsevier Limited, London (2003): p 3.



Graphic Credit:

Incense burner is from Shutterstock per their standard licensing agreement.

There Is No Joy In Medicine

At least not nearly as much as there used to be.

I read a comment by a medical student recently who said that he found nothing in medical school - none  of the clinical rotations to be enjoyable at all.  As I looked back on it, at the interpersonal level there is a lot of subjectivity.  Although it was never stated personalities could make or break a rotation.  There was none of the anonymity of sitting is a large lecture hall and passing three or four tests.  As a medical  student, most of the teams I was on consisted of me, an intern, a resident and occasionally a more senior resident and one or more attending physicians.  Just as in real life, it was common to find people who really did not want to be on those teams.  They were fulfilling some sort of obligation.  As in real life, it was fairly common to be on a team where someone did not like you and if they were personality disordered could make your life a living hell.  But that was relatively rare.  As a medical student, the job was to keep your head down, not make any waves and absorb as much information as possible.

And some of those rotations were a dream.  A perfect combination of senior staff who knew they were there to teach, did a great job of it, and went the extra mile to be as cordial as possible to everyone in the process.  I have written about the last team I was on in medical school as an example.  The Renal Medicine team of of Milwaukee County Medical Center and Froedert Hospital in Milwaukee.  In those days there were three senior attendings who were also Professors in the medical school.  They ran an inpatient unit, outpatient clinic, and hypertension clinic. They also covered all of the inpatient consults. There was an associated group that took care of transplant and dialysis patients and all of the complications.  As a medical student my job was to do the initial patient interviews on the consults and present it to the team and round with the team on all of the inpatients.

It was an inspiring team to be a part of. One of the senior Internal Medicine residents was a guy who I had worked with before.  He was bright and had an incredible sense of humor. The most senior attending would give us all a hard time, but you could tell he was joking.  I never saw him lose his temper.  We were typically putting in 10-12 hour days with both patient care and didactics.  There was scheduled teaching time every day and plenty of teaching on the case presentations. Everyone was interested in the work and flexible. On my absolute last day of medical school the Internal Medicine resident told me they were swamped with admissions.  It was 6 PM and he knew I was graduating the next day.  He let me know that and then asked me if I could see 2 consults that needed to be staffed.  I did and felt good about it.  I lived about 1/2 mile away across the golf course sized county grounds and was ecstatic that night for completing medical school and that rotation.

Enjoyable rotations were not limited to medicine specialties.  I had plenty of contact with neurosurgeons in the same hospital.  The Neurosurgery residents had a grueling schedule starting as second year residents where they were basically on call every night.  They were in surgery in the morning and had to assess and treat acute emergencies in a very hectic emergency department.  The also ran a neurosurgery ICU.  On that service we rounded every morning and tried to get all of the work done on hospitalized patients by  11 AM.  The rest of the day was typically spent dealing with one emergency after another. The head of neurosurgery did not say much and appeared to be brusque, but he was an outstanding surgeon and teacher in the operating room.  We also had Radiology rounds every Saturday morning where he would review all of the imaging studies done on our patients in the previous week. That was a two month rotation for me and very enjoyable.

When I think of the common elements in those rotations that made them implicitly joyous - a few things stand out:

1.  They were intellectually rigorous:

There was no dispute that the teachers and professors knew the field inside and out and were interested in discussing it.  My only regret is that as a medical student - you really don't know enough to ask the best possible questions - at least I didn't.  My standard procedure was to study the problems that were being addressed in detail and in retrospect it might have been easier to ask a lot of questions.  Teaching occurred in detail and at length every day.  It was routine.

2.  They managed their own services:

These days practically all hospitalized patients are managed by hospitalists. Hospitalists will call in specialists as needed, but they basically assess the patient and leave a note in the chart.  People will say this is more efficient and have that same argument about primary care physicians not seeing their own patients in the hospital - but a lot is lost in the process.  Teaching is an obvious casualty. Are you going to learn more about a patient who is on your service 24/7 or one who you drop by and leave a note for the hospitalist team?  I have seen medical students following consultants around and they often look bewildered.  As a team, there is a sense of belonging and typically a place to hang your hat and discuss the work every day.

3.  There was no outside interference by the business world:  

The hospital landscape has become bizarre relative to the hospitals I trained in. Instead of morning rounds - you might see a team of physicians in a "huddle" in the morning.  That huddle may contain non-medical staff and administrators who have no role in patient care. There are really there to manage physicians. Some might tell physicians when to discharge patients.  Others are just there to report what physicians are doing to senior management.  Let me clarify that these are not multidisciplinary treatment teams. I had 20 years of those teams meetings that were clinically focused and then one day there was a case manager in that group and she was reporting what I was doing to a hostile medical director who threatened to override my decisions. At a team level there was an equally malignant administrator trying to undermine the relationship between medical and nursing staff.  It is clear from my medical school experience that none of the managers were necessary and they made the clinical situation much worse. Add utilization review and prior authorization done by companies with an obvious conflict of interest and the hospital landscape suddenly becomes a complete nightmare.  I found myself in the position of needing to go though 2 hours of prior authorization time in order to discharge patients on the same medications that they came in on. In other words the medications were already authorized but I had to do it again.

4: Physicians weren't treated like criminals:  

Physicians tend to not be very good with politics and have a short memory but I don't.  In the 1990s, a billing and coding system was introduced that was supposed to capture physician work and provide commensurate reimbursement.  Unfortunately the inventors of this system did not realize that it was totally subjective and far too detailed. In the only study ever done on the validity of the system, the chance that any two coders could agree on the same billing code was a coin toss. In the meantime, at some point during that decade my hospital colleagues and I were cloistered in a lecture hall and told that any mistakes on our documents were a crime and if a billing statement went out based on that crime - we could be prosecuted under federal racketeering charges. In the meantime, the FBI was raiding doctors offices and trying to make documentation errors into a federal crime.  Eventually the federal government must have seen this was a bit heavy handed and they turned enforcement over to compliance monitors in organizations.  I was awarded the "best documentation" one year by a compliance officer and the next year it was the worst. Over that year, I had made no changes to my documentation. Today there is a mountain of worthless documentation that takes each physician about 3-4 extra hours per day to produce that is the direct result of this initiative. If I was back on my neurosurgery rotation - the document would have been 3-4 handwritten lines.

5: Everybody was an expert - not pretending to be one:

Fake medical news is common across all social media.  Journalists commonly print the story that they want rather than reality.  A common story on this blog is is how physicians were bought off by (often trivial) gifts and this led to inappropriate prescribing and massive drug company profits. It was a good story while it lasted and some media is still trying to push it but when gifts to physicians were eliminated, the USA still has by far the most expensive pharmaceuticals in the world.  There are even more provocative headlines out there that don't pass the smell test.  It is in the best interest of click-bait journalists and business administrators to make it seem like knowledge in medicine is relative and anyone can possess it.

6:  Clinical care was cohesive and not fragmented: 

Business innovations in medicine leave a lot to be desired.  When the field is structured around the ideas of business managers and some of these problematic ideas are published as commentaries in prestigious medical journals - adequate care becomes an increasingly remote possibility.  On the services I mentioned patients were triaged to receive the state of the art care of the day.  They did not end up seeing a series of physicians or providers who had no clue about how to address the problem and hoping to see the appropriate specialist.  In fact one of the most embarrassing developments of managed care was the idea that they were going to put specialists out of business or install a gatekeeper to see who gets referred to a specialist.  There are ample examples on this blog of the importance of seeing the appropriate specialist without having to deal with any administrator erected obstruction.  The main fracture in medicine at this point has been the destruction of the psychiatric infrastructure and the incarceration of the mentally ill.

Just a few obvious reasons why my most joyous experience in medicine happened in medical school over 30 years ago.  I think it could all be distilled down to the basic truths of autonomy, professionalism, a singular patient focus, an intellectual approach to the field, and doing the right thing. That is when you have hard working physicians who enjoy the work and are not burned out.  Medicine is currently creaking under the weight of bad ideas from politicians and bureaucrats and all of the associated rationalizations.

It is no wonder that I often find myself thinking about my old renal medicine and neurosurgery teams and whether future physicians will ever be able to capture that joy again.

It is no wonder that when Grace Slick sings with conviction over my Bluetooth player that I am focused on those first 4 lines.......



George Dawson, MD, DFAPA




Graphics Credit:

Photo licensed directly from Gijsbert Hanekroot Fotografie. Title below:

Jefferson Airplane Perfornm Live At Kralingen Festival
ROTTERDAM, NETHERLANDS - JUNE 26: Grace Slick and Jorma Kaukonen from Jefferson Airplane perform live at Kralingen Festival in Rotterdam, Holland on June 26 1970 (Photo by Gijsbert Hanekroot/Redferns)


Lyrics:

From the song Somebody To Love performed by Jefferson Airplane.  Words and music by Darby Slick.


Supplementary:

Interested in Grace Slick photos from around the time of the release of this song. Contact me if interested.

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 Burnout Disease

I got an ominous e-mail from the Psychiatric Times yesterday.  The title was "Before it's too late".  It reminded me that at some point the professional trades are just like everybody else - desperately vying for attention through provocative headlines.  The irony is that that there are numerous areas in medicine and psychiatry that could be labeled in this manner but are routinely ignored.  I recently point out that detoxification services and the shortage of psychiatrists have been ignored for 30 years.   It may be accurate to say there was a lot of lip service paid to the psychiatrist shortage with no real action.  At any rate I decided to click on the provocative e-mail to see what the new risk was and was taken to a set of 6 slides on burnout or more accurately "6 Strategies To Prevent Physician Burnout." by Eva Szigethy, MD, PhD.

The presentation begins with a definition of burnout as chronic exhaustion and decreased interest in work.   Three stages were defined with more mild and transient symptoms in Stage 1 progressing to Stage 3 with chronic symptoms that progress to psychiatric and physical disorders.  That basic definition contains a lot of information and assumptions.  The basic assumption is that a person must be interested in work.  I have certainly encountered people who were interested in work, but they are generally few and far between.  If I had to globally characterize them, they tend to be people who bring a lot of creativity and skill to a particular job and for various reasons they are allowed to use that creativity and skill in an optimal way.  I don't think that those characteristics map onto any particular degree or occupation.  I think it is probably the driving force behind why people want to work for themselves or establish their own businesses.  There is no better way to maintain a high level of interest in work than to be working for yourself.   The introduction of any management hierarchy is a potential threat to interest in work.

There are also a large number of jobs (if not most jobs) where people work very hard and are not rewarded.  Oren Nimni wrote an interesting article about this in Current Affairs while commenting on the recent plagiarism concern about a political speech.  He points out that the American economy is fundamentally skewed and unfair and political speeches about values, hard work and achievement based on merit do not necessarily apply.  He is blunt about telling people that hard work will necessarily get them somewhere is a cruel lie (par 10).  Many of the jobs he is referring to here are physically exhausting and as a physician, I can say with certainty have a high probability of injury and disability.  It is difficult if not impossible to work at many of these jobs until you are old enough to retire.  The path I observe is that when you are too disabled to do one of these jobs, you move onto to a more sedentary and even lower paying job.  This may be an entire group of workers for whom the idea of burnout is a luxury.  Every day is exhausting whether you have physically adapted to the circumstances of the job or not.  When I think about these definitions of burnout, they necessarily don't apply to a lot of occupations.

The Psychiatric Times slides go on to identify the early markers in the burnout process and what can be done to prevent them.  They start out with an assessment of the weekly schedule and eliminating nonessential tasks.  There is the implicit assumption that the potential burnout casualty is in control of the schedule.  I can say with certainty that every person who I have ever seen who was anxious or depressed as a direct result of their work environment - this is never true.  In fact, the people in control of the schedules tend to be some of the most unpleasant people.  They work from a general concept that work is standardized, everyone needs to do it the same way, and if workers don't like it - they can always find another job.  Those work environments are partitioned into highly reimbursed professionals who have to tolerate out of control managers and non-professionals who have to put up with similar management.  The professionals may have slightly more leverage in the workplace.   In the case of physicians, they used to have leverage because of legal requirements in many healthcare settings.  Managers have found their way around these requirements and in practically all organizations there is a chain of command that involves physicians being ordered around by nonphysicians with no medical expertise.  What constitutes management expertise is anybody's guess.

The suggested strategy to assess various professional goals and the impact of the work on the physician is the next step.  In an ideal world there would be some freedom to move laterally within organizations or between roles.  In the regimented world of physician employees and managed care organizations it is next to impossible.  One of the biggest burnout factors for physicians is the measurement of so-called productivity.  Productivity expectations in most organizations are a setup for overwork and overinvolvement in the most mindless aspects of medical practice - billing and coding and the electronic health record (EHR).   There is no room for breaks, sleep, or intellectually stimulating activity.  The entire process is driven by management and the final product (in spite of all the hype) is an inferior one.  I have written on several occasions about how the most elaborate and expensive EHR - costing millions per year in licensing fees cannot seem to produce a coherent report that I could print from a hundred dollar software package in the 1990s.  And that doesn't take into account that every physician in America is now a scribe in this process - producing terabytes per day of useless data - used only for billing and coding purposes.

The human factor in burnout especially for physicians is always a huge question mark.   Who can you turn to?  One of the colleagues in your system who in all probability is as burned out as you?  A colleague outside of your system who has successfully evaded corporate medicine and is quite happy to advise you on how to do the same?  Most physicians in this situation feel trapped either way.  Many have been able to escape medicine completely, either working for less or in medical industries.  In advising colleagues over the years, jobs within the industry are far more difficult to get - almost impossible if you are middle aged and have been focused on nothing but productivity for decades.  Often the best outcome is to settle for less and retire, especially if there are signs that mental and physical health are being affected.  Under duress many physicians add to the problem.  They get involved in management specifically utilization review or similar rationing jobs for managed care companies.  I have also encountered physicians who view themselves as being disruptive and who tell me that I need to learn how to "play in the sandbox" with the other health care managers.  They teach physicians management as though anything but managed care rationing strategies are likely to apply.  That may be a temporary solution for that particular individual.  At a personal level, I would not be able to suspend my knowledge of medicine and psychiatry to make arbitrary cash decisions for my employer.  But clearly that is just me.  Plenty of physicians have gone that route.

The final consideration of vacations is also not a good solution.  Although it has not been studied, I can predict that any physician with a serious burnout problem will feel almost as bad on the first day back from vacation as the day they left.  By day 2 they certainly will feel as bad.  Many work environments for physicians these days are hostile territory.  The goal is really to get in and get out with as minimal damage as possible.  Many will leave as early as they can and if they have remote EHR access - work from home into the night.  I have called primary care clinics at  7PM and talked to a physician amid a flurry of typing sounds and mouse clicks from their colleagues in the background.  There is no way that you can walk into that environment and not feel burned out.

My conclusion about burnout is basically unchanged from an earlier post.  If the Psychiatric Times, had invited me to made a slide set (that won't happen anytime soon) - it would have been just one slide:

               


George Dawson, MD, DFAPA


References:  

1:  Eva Szigethy.  6 Strategies to Prevent Physician Burnout.  Psychiatric Times.  July 22, 2016.

2:  Oren Nimni.  Melania's plagiarism actually just shows how vapid political speeches are.  Current Affairs.  July 19, 2016.

3:  My previous posts on Burnout.

       

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