Decoding Health Care

Part 27: Physician Burnout Part 2

The most challenging contributor to burn out is actual medical practice, meaning patients. The most rewarding part of being a doctor is taking care of patients. It can also be the absolute worst part of being a doctor. Allow me to explain. The doctor patient relationship has evolved tremendously over the last 50 years (Patients and Doctors — The Evolution of a Relationship | New England Journal of Medicine). In the past, this relationship was described as “benevolent paternalism” and reflected the responsibility of doctors to do the best thing for their patients (as described in the Hippocratic oath). But this concept of “the doctor knows best” got turned on its head with the emergence of patients’ rights. In fact, all of a sudden the patients were the ones calling the shots.

This extreme flip has been moderated by the “shared decision making” model which is what I was taught in medical school. In this model the expertise of the physician and the rights of the patient are considered together to formulate a treatment plan. Or at least that’s the idea.

Several factors have interfered with this goal of shared decision making. Perhaps the most important is the easy access to information on the internet. But the problem isn’t the easy access to information, it’s the lack of critical assessment of the value of this information. As we all know, there is no guarantee of factual accuracy on whatever we download. In a perfect world, this would be a starting point for discussion but that isn’t always the case. In fact, one of the most stressful situations I encountered as an oncologist was when a patient printed out page after page of information on their diagnosis and came to the office set on a course of action irrespective of how well supported that treatment plan might be.

It can take a lot of time to wade through that swamp of information. And given the time constraints we have already identified, to most doctors it feels like an absolute waste of time. But you have to do it. It doesn’t always go well.

For one thing, trust in the medical establishment isn’t very high. Studies that have examined the question as to whether people trust their doctors show that, much like congress, people trust their own doctors (or their elected official) but not medicine (or the government). This basic distrust has gotten worse over time. It was especially bad during the Covid pandemic (Trust in Physicians and Hospitals During the COVID-19 Pandemic in a 50-State Survey of US Adults | Public Health | JAMA Network Open | JAMA Network). People really thought the medical establishment wasn’t telling the truth.

Now I won’t get into the root causes (there are many, and without a doubt some prominent medical leaders that were the face of public health during the pandemic shoulder part of the blame) but this isn’t a new problem. Over forty years ago, there was a “theory” that cystic fibrosis was due to selenium deficiency (there was an animal model in Rhesus monkeys). The molecular basis of this disease wasn’t worked out for another 20 years. The human evidence for selenium as a contributing factor was non-existent, but the hypothesis was widely reported in the mass media (https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2821693). This created a crisis in the cystic fibrosis community. People were angry that this unsubstantiated information wasn’t shared with them. It ruptured doctor patient relationships.

Another issue is that of medical malpractice. Doctors live in daily fear of getting sued, and that fear is even greater if they have been sued before. The number of suits has been increasing steadily, with one of three doctors getting sued in their lifetime. The plaintiff bar will suggest that it’s no big deal, since most suits never get to trial and if they do the doctors usually win. In addition the settlements are usually pretty modest. But the truth is that the number of BIG awards has dramatically increased. And I will tell you from personal experience that the doctor suffers from the day they are served, not just at the point the suit is resolved, and this is irrespective of the merits of the case. Lawyers don’t get this (or maybe they do and use it to their advantage to extract settlements).

The reason I mention malpractice in the setting of the physician patient relationship is that although there are certainly medical errors that warrant restitution, a lot of suits are related to lack of communication, unreasonable expectations and ultimately lack of trust. Our adversarial tort system feeds into that. Every doctor I know who has been sued changes the way they practice medicine. And they change the way they think about patients. This costs the health care system real money from the practice of defensive medicine. But more importantly it strikes at the soul of the doctor patient relationship. I will discuss medical errors and medical malpractice in an upcoming post.

But even in a trusting, positive physician patient relationship there is the potential for stress. A great example is how doctors deal with patient death. If you look at the top 10 medical specialties associated with burn-out, oncologists always make the list. I have some personal insight into this. At the risk of sounding callous, all deaths are not equal. Everyone dies. But a teenager dying of lung cancer or a 30 yo mom dying of colon cancer is just unnatural. Oncologists feel real pain when this occurs; I certainly did.

It is interesting though that hospice and palliative care physicians rarely experience burn-out from patient deaths (Improving physician well-being: lessons from palliative care - PMC). Although it’s not completely clear why this is, one reason is probably the acceptance that in many cases deaths of patients on palliative care are “expected”. The real problem is when deaths are unexpected. Another possible explanation is that palliative care docs are trained to deal with death as a natural outcome, the normal final chapter of life.

Physician burn-out is a real problem. Burnt-out out physicians make medical errors at a higher rate. Burn out contributes to substance abuse; 10-15% of male physicians abuse substances during their careers and the number is double among female physicians (The prevalence of substance use disorders in American physicians - PubMed). The substance of choice is overwhelmingly alcohol.

Depression is extremely common in physicians. Between 15-30% of physicians experience depression. Again the rate is much higher in female physicians. And physicians have double the suicide rate of the general population.

Both substance abuse and depression are hidden by most physicians. Seeking help for either opens a Pandora’s box of difficulty with licensure and credentialing, not to mention stigmatization. The old rubric, “physician heal thyself” takes on a whole new meaning in this context.

So what do we do about physician burn-out? There isn’t an easy answer but we seem to have accepted that it’s a problem. The American Medical Association has taken the lead on developing and disseminating self-help tools (Physician Burnout | AMA STEPS Forward | Ed Hub). A lot of these tools help with advice about using the EMR more efficiently or coaching life skills and wellness. They are mostly designed for the established physician. I fear too few people are aware of these tools or have the time to avail themselves of them.

There are in fact some things that we can do right now that might relieve some of the burden. Let’s start with the EMR. For better or worse, the EMR is here to stay. The technology exists to make it better. For years, physicians have been piloting the use of medical scribes. But in the era of ChatGPT your computer can be your scribe. There are now several commercial entities that record your patient visit and transcribe it into a text document. These notes are really good. Every doctor I know would welcome some tech enabled solution to their EMR woes.

Likewise, AI should be able to solve prior auth without much difficulty. The data elements can be extracted from structured fields or from text quickly. All you need to do is ask the EMR the data questions you are interested in and then have the computer send them to the payer’s electronic mailbox in a structured format. Of course the payers will need to develop a way to ingest that info and marry it to claims processing. But are we really going to block the implementation of such a tremendous improvement because its going to cost a few bucks?

I am really not a fan of concierge medicine because it’s a solution for rich people. But I love team based care. The ability to enlist all the members of the care team, from medical assistant to social worker to physician to optimize patient care just seems like a great way to diffuse responsibilities and deliver better care. The Medical Home that I have previously discussed has team based care at its core.

But for this to work optimally we need to move away from fee for service towards an episode based payment model. If you are paid a certain amount to care for your patient whether you see them in person or do a telehealth visit we can start devoting the largest chunk of time to the patients that need the attention. But there is a catch. It will probably mean a pay cut, especially for hospitals and procedure driven specialties. I think that is OK.

None of these will relieve family pressures. And none will fix the trust problem. In fact, with the continued development of AI tools in medicine it won’t be long before the computer will vie with the master clinician in diagnosis and treatment planning. But computers will never be able to hold a patient’s hand. This core of the medical profession, the humanity of doctors and patients, is what ultimately will prove that doctors are indispensible.

And we need to help medical students prepare for the challenges they will face. We need to teach them about what being a doctor means, both the good and the bad. And we need to help them develop wellness and coping strategies before they are in trouble. If they get into trouble we need to equip and encourage them to find help.

I loved being a doctor. But there were days when I felt burnt out. Every doctor does. We need good doctors. And we need them to like their jobs because then they will be more likely to do a good job and stick around for a while.

In my next post I will discuss medical errors and medical malpractice.