Decoding Health Care

Part 27: Physician Burn Out Part 1

When I was in medical school and during my residency training there was no talk of physician burnout. The doctors portrayed in television and in movies were often perfect, like Marcus Welby, or sometimes quirky, like Bones McCoy in Star Trek or Hawkeye Pierce in MASH. But they weren’t burnt out. But then something changed. We entered the era of House. I am certain that there was physician burn out before Y2K. But nobody really talked about it.

The Agency for Healthcare Research and Quality (AHRQ) is an agency within the Department of Health and Human Services tasked with enhancing the quality and effectiveness of health care services; they have had a longstanding interest in physician burnout (https://www.ahrq.gov/prevention/clinician/ahrq-works/burnout/index.html). They define physician burnout as “a long-term stress reaction marked by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment.” Why does AHRQ care? Burnout is associated with poorer patient outcomes, increased medical errors, lower patient satisfaction, lower staff satisfaction (with resultant staff turnover), physician substance abuse and physician suicide.

The characteristics of a burnt-out physician include:

1. Physical and emotional exhaustion.

2. “Compassion fatigue”, i.e. cynicism, sarcasm, and a general negative attitude towards your patients and your job.

3. Loss of meaning, a feeling that your work is unimportant or low quality.

Now on any given “bad day” every physician experiences one or more than one of these. The burnt-out physician experiences these repeatedly.

The extent of physician burn out is astonishing. Almost all surveys put the number at or above 50% of all physicians. I suspect that if you ask any practicing physician, they can identify one or more colleagues that is burnt-out. Burn out varies a lot by specialty. Interestingly, Emergency Room physicians are tops on the list but are followed by internal medicine, Ob-Gyn and primary care specialties.

Much has been written about the cause of physician burnout (Physician Burnout: Its Origin, Symptoms, and Five Main Causes | AAFP). There are many, and you can probably guess what they are:

1. Work conflict with family responsibilities.

2. Administrative burdens including the EHR and insurance mandates.

3. Time pressure, including inadequate time allotted to caring for each patient.

4. A stressful work environment.

5. Patients.

This list is not meant to be inclusive, and certainly each individual factor will have variable impact on any given physician. In addition, it is important to recognize that these factors can contribute to burn-out irrespective of one’s chosen profession. But they are particularly important since physician burn-out impacts not only the physician but the patient.

Work conflict with family responsibilities is a good place to start. Most physicians are challenged to balance family obligations with work obligations. This largely stems from the long held dictum that the patient always comes first. This conflict is most acutely felt by women because of childbirth and maternal responsibilities. There is no doubt that female doctors delay having children, and that having children derails their professional advancement (Childbearing, Infertility, and Career Trajectories Among Women in Medicine | Equity, Diversity, and Inclusion | JAMA Network Open | JAMA Network). This has become more and more of an issue since close to 40% of all doctors are women and women make up more than 50% of medical students. And a higher percent of female physicians report burn-out.

Administrative burdens are often singled out as an important cause of burn-out. In particular, the adoption of the electronic medical record (EMR) which had been touted as a way to make physicians more efficient has proven to do exactly the opposite. Almost all doctors I know say the EMR adds one or two hours to each work day. And a lot of doctors take their computers home and finish their notes after dinner.

One major administrative headache is related to health plans and especially prior authorization (PA). Virtually every commercial health plan uses utilization management as a way to control costs, and PA is a big component of utilization management. In some types of insurance, like Medicare Advantage (MA), PA is universal. If the drug or test or procedure is expensive you can bet that PA will be required. Now you would think that the evidentiary requirements to justify PA would be generally agreed upon; however, each health plan has their own PA process. And you would think that this process could easily be automated but unfortunately a lot of PA still occurs via fax and phone.

A closely related administrative headache is with appeals. If a health plan decides a service is not medically necessary, they will deny payment. This puts the doctor and the patient in difficult position. All health plans, including Medicare, offer the option to appeal. And in fact the appeal process can go on for some time; if the first appeal fails, there may be a second and third opportunity to appeal further. Appeals are a real pain. Often (especially with the first level appeal) the health plan medical director does not have specialty training so having a meaningful discussion is almost impossible (this is referred to as a peer-to-peer but that is obviously a misnomer).

To be fair, some of these denials are appropriate, i.e. the medical plan is not evidence based. But that is not always the case. To get a handle on this, a recent publication of MA prior authorizations, denials, and appeals is instructive (Use of Prior Authorization in Medicare Advantage Exceeded 46 Million Requests in 2022 | KFF). In 2022, each MA beneficiary had 1.7 PA requests submitted. Of these, 7% were denied. Among denied PA’s, only about 10% were appealed but of those appealed, 73% were overturned. Over time, the number of denials has increased but the number overturned on denial has actually decreased. In a separate study (Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care | Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services), the OIG determined that 13% of denials should have been approved (and would have been paid by traditional Medicare). No matter the number, PA and appeals take a lot of time and effort and drive doctors nuts.

This data for patients with commercial insurance is not available but there is no reason to believe it is very different. And the economics (the ROI, or return on investment) for the health plan is certainly not transparent. But it must generate some savings, otherwise health plans wouldn’t do it.

Time pressure is another economically driven cause of stress. As we have previously discussed, American medicine is based on fee for service. The more services you provide the more fees you generate. This is true whether you are a specialist or a primary care physician. Your compensation is based on the RVU’s you generate (as we previously discussed in the post on physician compensation); specialists who do procedures can generate a lot more RVU’s with those procedures so they make a lot more money. Primary care doctors have a limited ability to generate RVU’s so they need to see a lot of patients. The average PCP sees 11-20 patients a day and spends about 18 minutes with each patient (the 25% of PCP’s that spend the most time with patients spend 24 minutes per patient). This creates an assembly line mentality. If a patient is complicated or needs extra time then productivity and by extension compensation decrease.

Doctors hate viewing patients as RVU generating widgets. In response we have seen increasing popularity of concierge medicine. In concierge medicine, the physician (usually a primary care doctor) limits the number of patients they are responsible for. In order to be on your chosen physicians list, you (the patient) pay a subscription fee. In exchange for this fee you get personalized care, not constrained by time, and enhanced access to the doctor (like the doctor’s cell phone number). You get special treatment for the extra payment (typically $1500-$2500 a year, but sometimes much more). The doctor will also typically bill the insurance for the medical services provided. What’s not to like?

Not much if you can afford it. Patients like it. Doctors like it (supposedly though the data is somewhat limited). But it clearly creates a two-tier medical system with the rich getting more than their fair share of medical attention. And there are few to no concierges in many parts of the country. SO although I am certain I would prefer a private jet to the friendly skies of United it’s just not a scalable model.

In the past, many hospital employed or academic physicians were salaried. But those days are largely over. Almost everybody has moved to productivity based reimbursement.

This “assembly line” mentality also contributes to a stressful work environment. Staffing support is a constant problem for physicians. Running a medical practice is complicated. And as we have discussed, your medical training does not prepare you for this challenge. A lot of young physicians choose to be employed physicians, allowing them to avoid this problem. But this can be even worse. When a hospital administrator is the person deciding how much staff you need you know you are in trouble. There are a million staffing models, but these generally focus on patient volume targets. They certainly do not account for patient complexity or physician practice style.

Another very stressful area involves dealing with employees or physician colleagues who are “problems”. They may be problems because they have substance abuse issues. They may be problems because they have personality disorders. They may be problems because they just do not fit. No matter the reason, resolving these conflicts is painful. If you are in private practice, it can be very difficult to rid your practice of a problem employee/physician. While they are working in the practice they are incredibly disruptive. And when you try to fire them it often ends up in litigation; I speak from experience; I have been deposed several times. And if you work in a hospital system as an employed physician it is even worse. The physician often has little or no say on who gets hired or fired. It is easy to see how this could lead to burnout.

In part 2 I will discuss the biggest contributor to physician burn-out, taking care of patients.