Physician burnout: The additive effect of bureaucracy on the psyche

In trying to understand my own burnout, “control” (or lack thereof) is a dominant theme. This is nothing new. In fact, I doubt I’m unearthing bones not already thoroughly analyzed. But I can give instructive personal examples.

For a while I was on the board of directors of my clinic, which was then and is even more so now one of the most successful doctor-owned and -managed in the US. During my tenure, we were deeply in the thrall of the managed care model as the guarantor of our future.

My feelings about it were, diplomatically, mixed. If I may be allowed to say it for the ten thousandth time, providing cost-effective care has always been as much a part of me as the Krebs Cycle. I’ve never needed anyone to remind me of it.

Nor — take my word for it — have I ever been a trigger-happy surgeon: many is the patient sent to me for an operation, returned to his/her referring doc with a note pinned to the shirt saying, “Please excuse Johnny from surgery today. He doesn’t need it.”

So the idea of being required to seek approval from a peach-fuzzed (or even a grey-muzzled) primary care doc (need I repeat myself?) sat, diplomatically, unsteadily in my saddle. (In fairness, some of the internists who knew me over several years filled out all the authorizations the minute they sent the patient to me. Not, however, the family docs. But I’ve been over that. In one sense of “over” anyway.) Frosting a burnt cake, we even agreed to pay primary care docs a “gatekeeper” fee. Perfect.

I never objected to scrutiny; in fact, I welcomed any legitimate comparisons of my work to that of others. But it was always my contention that being in a clinic was the ideal situation in which paperwork could be minimized. After all, we had a medical director whose job included oversight; we knew each other well; we worked in a closed shop. Hell, we’d even cashiered a couple of losers. Ought there not be a presumption of quality?

So when one of my fellow board members — a young family doc whom I actually admired for his practicality — announced at one of our meetings that he’d come up with his own form (in addition to the required ones!) he was going to send to specialists along with his patients, and showed it to us (couple of pages, lots of blanks to fill in) I hit the roof. Sailed right through it. Covered the man, the board room, and myself with plaster. Lots of it. Then, still rising, I resigned from the board. The form was never distributed, but it took enough days for my pulse to return to its usual 1.5x that I figured who needs the extra aggravation.

Every few weeks the medical staff at the hospital came up with a new committee, for which it obtained members by also coming up with regulations requiring and penalties for failing to sign on. Among the three or four on which I sat was the “Blood Utilization Committee.” People from the blood bank (really good people, I might add) presented quarterly data on the use of blood and blood products and we looked into any deviations from accepted indications.

Without fail, the data showed near perfect compliance, with the only outliers being nephrologists buffing up their dialysis patients — outside of “standard” indications, but within “special” protocols. If ever there were proof that doctors knew what they were doing in an area, this was it.

Yet, after a couple of years on the committee we were presented, for our approval, with a blood products ordering form. What’s the patient’s blood count, list this lab or that, provide seven indications for the use of the product you are ordering and click your heels three times. And yeah, another roof repair job was needed. I’m happy to say the form didn’t appear in charts until a year or two after I was off the committee. But appear it did.

Small potatoes, I suppose. But multiply those incidents by a number that increased every year, and pretty soon there’s salmonella in the salad. It’d be easy to quantify the amount of paperwork, if I had the desire and the money to hire a hundred people to work on it. What’s hard is to measure the additive effect on the psyche; especially a steadily smoldering one. If it were one or two things, I might not have ex/imploded. Had I been getting more sleep, spending more time away from the hospital, maybe some of it would have rolled off. But at every turn, literally almost weekly by the latter years of my career, I’d find myself staring numbly at another missive announcing another rule, another form, another penalty, from the clinic board, the hospital administration, from medicare, blue cross et al, the malpractice insurer. Not so numbly; more accurately, with cold and trembling hands. Seriously. If adrenaline were water, I think my adrenals could have pumped out New Orleans.

I’m a lot of bad things, but stupid isn’t one of them. And I’m enough of a realist to recognize it ain’t Camelot and doctors — myself included — aren’t perfect. (Some much less so than others.) So yes I accept that scrutiny is necessary, regulations are unavoidable. “The best of all possible worlds” is as illusory an idea as is that of a functioning Congress. But somewhere along the line — and it happened in my practice lifetime — the assumption changed from “doctors generally know what they’re doing” to “doctors are incompetent, uncaring, unethical, and untrustworthy.” Officially, anyway. Paperwork-wise. I may be more paranoid than most: I guess I took every form as a personal accusation, and it grated more deeply in me than in some of my peers. But I know it affects everyone.

I don’t think it’s just ego, or some inflated sense of myself. To a degree it’s the opposite: I beat myself bloody over the slightest deviation from what I considered perfection, and generally knocked myself out to make amends and to prevent the next blemish. Yet I foolishly imagined that I had more control over my world than was true: why, I thought, can’t problems just get ironed out? Do we really need all these committees breathing down out necks, these forms, these threats? Can’t we just talk when someone thinks there’s a problem? (Answer: of course not!)

Here’s another example of how it works: a lot of surgeons use fluoroscopy during surgery. We don’t operate the machines, but we are quite capable of interpreting what we’re seeing, because, among other things, we know exactly what we’re looking for when we’re doing it.

[Disclosure: there may be some politics at work here. Before useful intra-operative fluoro, the patient would be on a special table under which an x-ray plate was slud, a hard film taken, and the radiologist would read it -- with or without the film getting returned to the OR for viewing by the surgeon. I always insisted on getting the film brought back before the radiologist saw it and generally we were sewing up by the time I got the call. With fluoro, I rarely had a hard copy made, so the radiologist never saw a film and, therefore, never got to bill for (irrelevant) reading. So the advent of surgeons reading their own fluoros was not well-received in all quarters.]

Nonetheless, once upon a time I and many other surgeons were using it with no problems. Then one day a new cardiologist came to town, and used fluoro in the x-ray department for some procedure or another, and someone turned him in for exposing the patient to too much radiation.

Ok, fair enough. But what was the response? Talk to him? Maybe even send around a little memo with information about proper use? Hell no. With no input from any non-radiologist doc who used fluoroscopy, the medical staff officers got together and made some rules. Mind you, the incident occurred not in the OR, but in the radiology suite; but suddenly everyone who used fluoro was required to take a course, get certified, fill out paperwork for each case, or have a radiologist present. For one friggin’ incident, by a non-surgeon, after a gazillion proper uses!

Here, in exact real-time replication, is how much time my x-rays took (for any radiologists out there, the image was saved until I sauntered over for a closer look): “Ok, ready? Shoot. Thank you.”

Sid Schwab is a retired surgeon who blogs at Surgeonsblog and is the author of Cutting Remarks: Insights and Recollections of a Surgeon.

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