USA Today op-ed: Physician burnout harms patients

in Potpourri | 24 responses

My USA Today op-ed was recently published: Burnout hurts doctors as well as their patients.

I discuss physician burnout, and how patients suffer from medical errors by burnt out doctors. Furthermore, doctors leaving medicine won’t help the tens of millions newly insured patients that will be looking for care in the coming years:

Burnout affects more than half of doctors, according to researchers at the University of Rochester School of Medicine. Beyond mere job dissatisfaction, these doctors are emotionally exhausted to the point where they lose focus. They tend to be more depressed — perhaps one reason why doctors have a higher suicide rate than the general population.
While burnout can happen in any profession, the performance of stressed-out doctors can hurt someone else: patients. Studies show these doctors exhibit less empathy that erodes the doctor-patient relationship.
More ominous is how physician burnout can lead to medical mistakes. A Mayo Clinic study released last month found that burnout in surgeons correlated to a higher rate of major medical errors. That corroborated last year’s conclusion in the Journal of the American Medical Association that found a similar effect among internal medicine doctors.

Enjoy the piece.

Comments

http://www.notebookingdiscovery.org/wordpress Alice
Burnout affects more than half of doctors, according to researchers at the University of Rochester School of Medicine. Beyond mere job dissatisfaction, these doctors are emotionally exhausted to the point where they lose focus. They tend to be more depressed — perhaps one reason why doctors have a higher suicide rate than the general population. [end quote]
This article is of high interest, for the very reason you state…..people get hurt. Is there is a correlating factor(s) why a certain segment (up to half is astonishing) of doctors succumb to burn-out (job dissatisfaction or emotions seem to be something that could have been foreseen)? One wonders if there isn’t a test that should be done yearly……some type of psychological test that could send the stressed doctors off to Tahiti for some rest…….lest they do hurt someone. I believe some senior citizens are given driver tests so they can’t drive and hurt others……maybe……doctors should be tested in some vain (although, I ask with much reticence because moms get burned out too, but they get over it and do just fine….maybe the comparison isn’t a good one, but ultimately, we are still quite happy to be moms even with the bumps in the road….then again we aren’t paid to perform…..it’s a labor of love)?
Testing pre-medical school and after (like they do now with policemen)………because a patient can only do so much to protect themselves (my daughter needs surgery next week because a doctor didn’t read the lab notes correctly. Not once, but twice, and he refused to listen when I questioned him [fluffed me off and said I had nothing to worry about when I asked what in the world we would do with the growth]. Yeah, he was probably burned-out….and, in truth, I wish he would take a break before someone else gets hurt. Maybe a test could have weeded him out before he got to my daughter or others).
Vox Rusticus
Where to begin? On the private practice side, there are the constant requirements of small business added to the professional demands of practice, in a climate of relentless pressure to produce more work for less money. Then the aggravation of dealing with insurance companies whose behavior most closely resembles organized crime syndicates. Then there is the reality that unlike a store or restaurant, where hired staff could run things while you are away, the solo practitioner has zero income but commonly full expenses while vacationing, a reality that goes beyond just opportunity cost with work absence, those are real costs.
So now our society of demands and accommodations now wants less stressed-out doctors who, like the latest LED lighting product burn brightly and never burn out. Well let me get that for you right now, and will you be using your credit card today? No? Oh, your Insurance card, now that makes a difference. Well, take a seat, we’ll have to get you a referral and while we are at it, I’ll have to call and get a pre-approval from someone who will need me to explain what it is I am asking them to approve.
And for weeding out those who might not be cut out for the work, that is rich beyond words, Alice. Enjoy your fantasy.

smartdoc
Ouch.
I am sorry to say it, but I agree with your analysis.
Primary Care Internist
Weeding out? that is indeed rich. Like the Cigna rep in my office when i just started practice, extolling the virtues of super-low insurance reimbursements for primary care office visits, “really selecting for those who have a true passion for primary care” – her exact words, i sh!+ you not.
If doctors are so dangerous, simply just stay away from us. You can even get whatever meds your google-MD degree says you need, from mexico. And if you actually want to see a doctor for some strange reason, there’s always Cuba, much better than the US according to multiple measures memorized by Alice types.

http://www.twitter.com/alicearobertson Alice
And if you actually want to see a doctor for some strange reason, there’s always Cuba, much better than the US according to multiple measures memorized by Alice types [end quote]
I answered you below, but I was thinking since you don’t agree with weeding out and want to send people to sub-standard countries you may need to make sure you gather up some doctors guilty of malpractice to be your own primary care doctors. Well……..that is if you are consistent with your ungrateful *patients are the problem* mantra. Or maybe you don’t mind that people are getting hurt…..hey you’re entitled…so what if a few surfs end up hurt…….you are way up the food chain….and the surfs can just go to other countries or self-treat because they aren’t worthy of your supposed Midas touch.
Honestly, it seems sometimes doctors can’t see that it’s their own colleagues that are the problem, and that they are a paid-for service, and going to school and running up debt doesn’t give you carte blanche on your paying patients. And, in truth, as much as I am a libertarian leaner if doctors don’t stop this type of outbursts and self-pity it’s foreseeable that the government will continue to regulate you right into socialized medicine (which is really scary).
I guess it really is true empathy can’t be taught. Sigh!

http://www.drjshousecalls.blogspot.com Dr. Mary Johnson
You left out the part about frustrated/burned-out/exhausted/depressed/over-worked physicians being “diagnosed” as “disruptive”.
It’s all the rage.
Like Obama and Congress, JCAHO/hospital executives/medical boards LOVE to pile the blame for every ill on the doctor rather than look at the underlying root causes.
http://www.twitter.com/alicearobertson Alice
And for weeding out those who might not be cut out for the work, that is rich beyond words, Alice. Enjoy your fantasy.[end quote]
I like the way you summed that up. I really did find it amusing (I mean a girl can dream ya’ know…particularly, one who is suffering from the harm a doctor caused)……so…….um…..ultimately, it doesn’t matter why….if you are placing patients at risk…..you need to get out of the way. My child was hurt by a doctor………..no, it’s not unforgivable (not that he has apologized….or ever will………he knows what he did), but he needs to go into research or somewhere that lives aren’t at risk.
Next time a bully hits your own child and you want to report them and get them removed from the playground….try exemplifying that feeling by 100 and see how it feels to suffer and watch your child get cut open because a burned out doctor couldn’t be bothered doing his job right. I would rather see a career demolished, than another human being hurt or dead because some doctors are so self-pitying, and so cavalier about the patients they are supposed to care so much about. It’s really a disgrace to the caring doctors, and I still think it’s just too risky.
smartdoc
My impression of the quasi-totalitarian “health care reform.” (just rammed through Congress over the documented overwhelming opposition of the American People) is that it is also a potent recipe for massive physcian burn-out.
Seriously, how much more bureaucratic abuse are professionals going to take from Medicare and Medicaid… for starters?.
http://www.twitter.com/alicearobertson Alice
After reading the Cato Institute booklet I would have to say I agree with Smartdoc, that the government is just too overbearing. As a patient it’s terrifying, yet some doctors say they wanted the bill. That attitude is really one of curiosity to me, yet when you question them they say it’s because of their country of origin, etc., and they think it will be helpful.
http://www.twitter.com/alicearobertson Alice
There is an interesting front page article that was just uploaded by Kevin. It ties in well with this thread. Here is the last paragraph.
quote:
Still, the authors found that people translate the phrase evidence-based medicine to mean that the government steps in and tells doctors how they have to practice by establishing evidence-based guidelines that can’t be overridden or changed in any way. That view, unfortunately, is just plain wrong, and explains how the public’s misconceptions remain one of the greatest barriers to improving our health care system.
Brad Wright is a health policy doctoral student who blogs at Wright on Health.
[end quote]
Alice
Ya’ know sometimes when enough doctors join in a conversation you realize they prove your point for you. I am so grateful for our surgeon who loves his job. How about instead of avoiding doctors (and don’t you sound like the spoiled child who takes his toys and runs away in a huff) I give you the name of the arrogant doctor who let cancer spread in my child and you can make that doctor your children’s doctor?
Alison
Wow, way to prove Alice’s point for her. Here you have a terrified parent who believes one doctor has harmed her child, and you pile on her for suggesting some screening to identify doctors at risk of burnout. Treating at-risk docs with some downtime or stress management doesn’t seem that terrible to me. Surely none of us wants to harm a patient OR our career due to burnout or overwork.

Vox Rusticus
Alison:
The allegations that the poster’s child was injured should be seen as just that, one person’s opinion, and possibly (read: probably) not a peer opinion. What that has exactly to do with “burnout,” a pretty loosely understood notion here that might mean many things from simply being tired, distracted, and over-scheduled to having a clinically-significant impairment, is just not stated, nor is it particularly significant. If the poster wants to speculate that the alleged error was the result of “burnout” then, like anything in the anonymous blogosphere, that is her privilege. If that same poster wishes to go on and further opine that there should now be some (undefined, perhaps we should guess just what) process to identify those medical students or residents prone to the so-called “burnout,” that is fine, too. Just understand, no one else has to agree with her nor do we have to behave like an online “Moms club” support group where everyone gets to have their ideas validated in a warm and fuzzy way.
I hate to break it to you, but in the real world of medical practice, you don’t just get to schedule some downtime whenever you like, or whenever you need to. For many doctors, the business of running a practice is one that demands a great deal of time and requires significant personal expenditure. Payroll has to be met and the business requirements of practice have never in the history of modern medical practice been more demanding or difficult than they are right now. There isn’t a line coach ready to whistle out the doc who looks a little too stressed and could use a week or two at a spa.
I don’t see anyone picking on Alice. Her posts reflect a very common perception of the lay public that there is some nebulous but benevolent supervising body ready to intervene whenever a doctor starts acting as if he could use a decent vacation. The reality is a bit harsher. What there is is a large number of small private businesses, some of which demand a significant amount of work and responsibility from their principals but which at the same time struggle to make themselves a viable enterprise one month to the next. If you want to know why primary care doctors are in short supply, that is the reason. Suggesting that some doctors now need some downtime to relieve their stress without bothering to consider the stressors really says that you have no serious interest in addressing why there is “burnout,” only that you don’t want to be inconvenienced or affected by it.

http://www.twitter.com/alicearobertson Alice
one person’s opinion, and possibly (read: probably) not a peer opinion [end quote]
Hmmm……..so you are diagnosing my situation when there was a peer review. Ever think of asking before assuming? The doctor was cited by an Ombudsman (four doctors..one was a Chair were involved). If you had thought to ask the case is cut-and-dry, it’s isn’t one of those cases where it’s up in the air. I think you can politely bow out of your assumptions about this case, or I will give you permission to check into it if you would like to find the truth. The truth is exactly as I stated. An arrogant doctor messed up and cancer spread to another area of my daughter’s body.
I think your posts just proof my point even more. A doctor from this board wrote to me privately and said it’s too bad doctors don’t go back and reread the letter they wrote when they desired to enter medical school and why they dreamed of being a doctor. What a refresher that would be. He called it dream realignment.
I am reading another book of Dr. Atul Gawande’s and every medical school student and doctor should read his Afterword and his five observations. One was for doctors to knock off all the complaining. All it does is cause more bitterness within you, and that causes you to do your job less well. You are paid……you aren’t donating your services for the good of mankind. So, why you feel a type of arrogance is beyond your patient’s mindset (when many of them are seeing you because of stress related problems). It’s just such an odd occupation to choose for someone who seems so disinterested in compassion and empathy, or even reaching out to someone who is hurt. You seem to choose vindication of doctors like yourself as your number one priority. This is why Gatawande and Groopman are wildly popular authors. It’s because they tell the gritty truth with humility, and actually care about people as Alison did. Anyone reading this board would correctly assume she cares about her patients, and mankind in general.
To choose the kill the messenger stance is really unbecoming for your profession, and it proves another point…….other doctors are hurting the whole cause of doctors who are really interested in helping others.

http://www.drjshousecalls.blogspot.com Dr. Mary Johnson
Alice, I re-read my “personal statement” fairly often – to remind myself of why I got into this “business”:
http://drjshousecalls.blogspot.com/2007/01/why-pediatrics.html
Alas, the problem is that I was young and naive and stupid to believe that hard work, honesty and good deeds would be punished rather than rewarded.
Greed and pure evil have oversome this profession. Recent “reform” efforts will only lead to more mediocrity and more expense.
I suppose you could say I’m burned-out. But I’ve been on these Board for five years trying to get someone to CARE about what was done to me/my practice/my patients twleve years ago (while I was in public service – and at the hands of my hometown non-profit) . . . and to help me find some kind of vindication and justice.
Meanwhile, someone like Shirley Sherrod (the kind of disinterested bureaucrat I was forced to plead my case to years ago) has all of her problems wrapped up in three days.
Heavy sigh.

http://www.twitter.com/alicearobertson Alice
Alas, the problem is that I was young and naive and stupid to believe that hard work, honesty and good deeds would be punished rather than rewarded. [end quote]
It doesn’t mean your original dream was wrong. It means the ambitious dreams of those who hurt you are wrong. Idealism is still a worthy dream, because one needs a vision lest they fall short. Aim at nothing and you will hit it everytime.
About the news coverage……..it seems if something smacks of racism it will get front page news. A doctor (or citizen in general ) getting railroaded just doesn’t have the factor it usually takes because the general public has a skewed view of doctors. There is little public sympathy for doctors, and it could well be because just as a few posts here that reflect how doctors really feel about those they don’t consider in their own league (and that constant defensiveness while pointing out the ills of others). That mindset needs to change.

http://www.drjshousecalls.blogspot.com Dr. Mary Johnson
Alice, I would submit that the public’s “skewed” view of doctors is not going to change until stories like mine get told to the (largely ignorant of what is really going on in medicine) masses.
And they are NOT getting told – either by the MSM or “important”/MSM-connected bloggers.
In fact, they have been buried to serve one larger agenda or another.
So I would submit that some of the posts here that you bemoan are being taken “out of context”.
After all, it worked for Shirley Sherrod. In three short days.

http://www.twitter.com/alicearobertson Alice
So I would submit that some of the posts here that you bemoan are being taken “out of context”.
After all, it worked for Shirley Sherrod. In three short days. [end quote]
If we want to discuss context I think from a public interest a racial story draws viewers/readers. In this case there was a youtube video that was snipped, and unfortunately some vocal conservatives were too quick to jump. And the story, ultimately, ended up a conservative/liberal type of news story because of the political scandal. Sadly, because the public already thinks doctors have ulterior motives your story may not get the type of interest this one does.
The posts I bemoaned were not taken out of context. It’s those posts that make people angry at uncaring doctors, and I would think those are the very attitudes you are fighting…….the arrogant ones who show no compassion, but only care about their own jobs. Oddly, I thought saving lives was utmost, but I guess it’s more important to a select few to get some type of public pity while being condescending (I didn’t see an apology for casting doubt on my story……so what else can you assume?)
I hope a doctor doesn’t hurt one of their children or family members. A mom spends her life protecting her children from harm. So..let me tell you it’s worse than you can imagine……..and one never really understands it fully until it’s your child. When someone hurts your child you experience real grief and fear, so when you share openly I have compassion for you.
When I read some of these doctors hammering away online anonymously I am compelled to tell my own doctors just how grateful I am for them.

http://www.twitter.com/alicearobertson Alice
Suggesting that some doctors now need some downtime to relieve their stress without bothering to consider the stressors really says that you have no serious interest in addressing why there is “burnout,” only that you don’t want to be inconvenienced or affected by it.
[end quote]
I am sorry, but in my opinion (of the supposed petulant patient) you need some fallacy classes By your own estimation you don’t mind if drunk drivers are on the road? It’s more important why they were drinking, not their risk to mankind and innocent victims. Why they were drinking seems more important to you, than the potential damage they will cause. I care about the reasons, but if you are stressed your very occupation dictates that harm could be done and you need to take a break. I don’t know what part of that is illogical…….sure it caused knee jerk reactions in my direction, and even a personal smear (trying to discount my version while the doctor’s club unites and defends for fear their own mistakes will be brought to light. The front page article here today was very good in exposing why doctors cover-up for each other. To rat can often mean shooting yourself in the foot…..so make sure you make the laymen out to be the problem……not a doctor who is stressed enough to make an error that could kill someone). Let’s be grateful nuclear physicists don’t have your disposition.
From the sound of your posts…….I certainly hope you aren’t suffering from burn out. Maybe if some doctors are resistant to understanding when they are stressed, we should be teaching patients how to tell if your doctor is suffering from stress or burn out? From the books authored by doctors I understand doctors, themselves, run when they think a treating doctor is stressed or incompatible. I suggest patients follow other doctor’s lead on this problem and learn how to cut the cord and run (problem is some seem incapable, and some can’t). It’s a good formula.

Vox Rusticus
If you are concerned so much about the effects of “burnout” in doctors, then you should be equally concerned why such burnout exists in the first place and how it can be avoided. If you are not, then all you are is a wordy whiner.
Too many doctors are overworked. Under the current practice climate, that cannot always be remedied by reducing workload. Practice costs are not scalable, so reducing patient census or days worked or appointments scheduled results in increasing relative overhead and sharply reducing personal income. That isn’t exactly a working formula for stress mitigation in my thinking.
I completely agree with doctors that have chosen to re-work their practice model and dump the entire burden of third-party entities and all of the pernicious features of their contracts. Payment from the patient, in cash and at the time of service is a far less stressful way of managing one’s professional relationships. Too much of a practice’s activities have been overtaken by the under-compensated and uncompensated demands of these actors, and too much expense is wasted on them as well. That is also true for Medicare.
Of course patients won’t necessarily like it, at least those who have been conditioned to expect someone else to pay their charges. But care and attention require adequate time, and the third-party payment enterprise has robbed both doctors and patients of that time.
I am not burned out, at least i don’t think so, but I see a very great risk of that if things do not change.

http://www.twitter.com/alicearobertson Alice
Maybe we talking past each other?
I want you to know why I post here….it’s to give doctors an insight into just how hard it is when they are careless. I teach classical literature, so words very rarely elude me……but on this level…..at times it’s excruciatingly painful and spirit crushing to my mother’s heart. Particularly, on the eve of a surgery to cut my daughter’s neck open that I believe would not have happened if the doctor had did his job well. Thankfully, errors like this are rare, but sometimes it’s painful to read doctors defense of other doctors (one starts to wonder if a type of programming happens in medical school…….to the average patient it starts to look like a cult mentality). Just as it bothers doctors when patients generalize, it’s painful to patients when doctors use a wide-sweeping brush on us. So, the dialogue is good!
Okay……..I will try again. Do you care why your waitress is giving you bad service? Or do you get flustered when a waitress or cashier is arrogant and compassionately think, “Gosh, their management must really be rough……let me encourage them even though they were arrogant to me!”? With doctors it’s not just emotionally hard to be treated rudely, it could cost you your life, or operations, or harm that takes a long time to deal with. The emotional and physical pain is very hard on a patient when a doctor brings harm.
I am concerned with the reasons why, and have discussed in person with doctors. I try to be the best patient, and send encouraging notes to let our doctors know how much I appreciate them. No patient wants over-worked doctors, but if they are at the point an error could they occur please take a break, because my daughter lives daily with the repercussions and as I shared earlier it’s much harder than you can imagine (a doctor recently shared with me that they would not want to be where I am sitting. Think of how much his caring words mean to someone like me).
The difference is I think patients usually want more time for them, and don’t like the slave driver mentality, yet sometimes I wonder about how doctors (overall…our own doctors are caring) feel about the patient population they have a type of honor to care for? It’s discouraging at times. In truth, I am uncomfortable in my new role and would do anything to rewind time and go back to a time before all of *this*!

bw
You have a valid point, Alice, and I think your analogy of a server is a fair one. Servers work for a restaurant for a menial wage ($2.13/hour last I heard) and have to work hard to balance multiple demands in a limited amount of time. They have to meet the often pointless requirements enforced by corporate america (think: flare), while they are trying to meet the individual orders of each table and guest separately. Their tip from the table is somewhat unpredictable, like reimbursement from many insurance companies, and, in my experience as a server, most people tip based on their generosity, and not on the quality of the service rendered. So average and excellent servers at the same restaurant often bring home similar pay.
Of course, the take home message is that when you are at a restaurant, most people don’t really care about these problems facing the server when they are waiting for their water. If you see a waiter being hassled by a difficult customer, some compassion might be extended. However, when the server is out of sight, most people don’t consider that they might be hassled by a difficult customer in another part of the restaurant.
So, simply put, the majority of the population doesn’t care about what the problems are when they can’t see them first-hand. They only care about the result–when will my food get here? Or, when will my physician finally see me? Or, why can’t I get an appointment for six weeks? Or maybe just, “jeez, what a jerk.”

Chris Keller, MSN, RN
There is seldom a single causative factor for anything . . . Medical errors are multi-factorial. Perrow, quoted in the document, “To Err Is Human,” (IOM, 1999) uses the DEPOSE formula:
Design, Equipment Procedures, Operators, Supplies and materials, and Environment all contribute to medical errors.
I am an intensive care nurse, a veteran of 21 years, who has been on the brink of burnout many times. I am currently preparing for a meeting in my healthcare organization on medical errors. I have not found “burnout” as a causative factor in human error in my research, but I HAVE found “unhappiness”.
Other factors: distractions, fatigue, overconfidence, multi-tasking, expectations of self, expectations by employers, by society. These factors are discussed in a reasoned way(i.e., backed by research) in a book by Hallinan, J.T., Why We Make Mistakes (2009).
Possible antidotes: The practice of Mindfulness (see ISMP articles on Mindfulness I and II), & adjustment of expectations. A personal antidote is to work part-time . . . if you can swing it. Other obvious antidotes, related to the above factors: 1) adjust one’s overconfidence; 2) no multi-tasking and limit distractions; 3) get enough rest so that you can be resilient to the demands of healing.
Blaming individuals has been found to be an oversimplification. You have to look at the system (see DEPOSE above) and do the root cause analysis . . .
http://www.twitter.com/alicearobertson Alice
Blaming individuals has been found to be an oversimplification. You have to look at the system (see DEPOSE above) and do the root cause analysis . [end quote]
The only problem with this simplification is that it’s the doctor that does the misdiagnosing (i.e. not reading the notes from the lab that a slide didn’t have enough cells on it), so the root cause is a doctor who is either sloppy, maybe burned out, and he is definitely arrogant.
I posted something about 12 hours ago on the peer review, but it hasn’t come through yet. In our case the doctor was cited, and I don’t blame the system.

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