Americans think that most physicians have it made. They’re wrong.

Americans think that most physicians have it made. Theyre wrong.

There’s at least one hidden reason the health care system is failing people who just want some face time with a doctor: too many dedicated physicians are not just overwhelmed but burned out.

According to a 2012 JAMA Internal Medicine Mayo Clinic study, 46% of all U.S. physicians are emotionally exhausted, feel cynical about work or have lost their sense of personal accomplishment … or all three.

Americans think that most physicians have it made. But the reality is very different.

Many physicians have little control of their work.  They feel emotionally detached from patients and like cogs in a medical industrial machine. Slotted into 10 or 15 minute appointments, often double booked or more, without leeway to offer more time without penalty, physicians careen from one place to the next, like pinballs.   Endless new forms and electronic screens, a chaotic work pace, substantial debt, uncertain reimbursement and a perpetual concern about lawsuits are to blame.

Burnout also sickens physicians, who commit suicide more often, have more trouble with addictive drugs and alcohol, and divorce more frequently than other professionals. Some retire early or leave medicine entirely.  A 2012 study of 5000 physicians showed that 89% of practicing physicians would not recommend medicine as a profession to their children or other family members.

When physicians are unwell, patient care suffers. Referral rates for diagnostic tests and specialists rise, increasing risks for unnecessary and redundant tests and conflicting advice. Physicians interact with a computer screen instead of the patient. They take short cuts, follow procedures less, and can make serious mistakes.

Physician burnout may be one reason that the VA appointment waiting lists are so long: The newly approved VA bill provides for hiring more physicians, but in the current system, they too will be simply chewed up.

Primary care physicians have it worst.  There is a predicted deficiency of 45,000 primary care docs (and 46,000 specialists) by 2020. But the reason primary care is on the ropes is not because of too limited primary care residency training positions, as is currently thought in Congress. It’s because doctors are leaving medicine: A 2012 Urban Institute study of primary physicians found that 52% of those over 50 planned to leave practice within five years.

For new physicians, it is no better.  They owe a median of $170,000 upon medical school graduation, according to the AMA. Their residency training is not supposed to exceed 80 hours per week (in practice it is up to 50% more). Their salary mean is about $51,000 a year, for three years. They see attending physicians having to fight with insurers for care that patients need.  They spend, on average, but eight minutes with each patient. They see medicine as a job to be negotiated, not a calling to serve.

What can we do about physician burnout? Its causes are systemic, not individual. Yet most interventions are individual: meditation, stress reduction, self-awareness and reflection.  These interventions require more time, almost always unpaid, from the physician, already at wit’s end.

One solution is organizational change within health care systems. Organizations should allow physicians to structure more of their own work flow. They should teach and pay for time and training to avoid, prevent, recognize and improve burnout, and allow physicians to rediscover resilience and fulfillment.

Primary care especially requires innovation. Pharmacists and nurse practitioners could do routine primary care like checkups, screenings and explaining medication.  Primary care physicians could be better utilized for coordinating care, evaluating more serious conditions and helping patients make complex, personal medical decisions.

Practicing better lifestyle habits helps both physicians and patients: those physicians who exercise regularly recommend it more to their patients than those who don’t. Ditto for those who eat healthfully.

What would happen if physicians could practice more of what we preach about fitness and food, and physician’ employers helped them do it? Would patients’ blood pressures and cholesterol numbers improve?

Being a physician is a privilege and an honor. But even the best physician can burn out. It’s time physicians and health care systems shared the responsibility  to lessen the depersonalization and exhaustion so many physicians feel.

To fix the primary care delivery problem, we must fix burnout, and heal physicians.

John La Puma hosts PBS’ ChefMD Shortsand blogs at Paging Dr. La Puma.  He is the author of REFUEL.

Image credit: Shutterstock.com

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  • Dr. Drake Ramoray

    “Primary care especially requires innovation. Pharmacists and nurse practitioners could do routine primary care like checkups, screenings and explaining medication. Primary care physicians could be better utilized for coordinating care, evaluating more serious conditions and helping patients make complex, personal medical decisions.”
    ===========================================

    Pharmacists doing primary care check ups. Ummm….. no. As for evaluating only the complex and serious conditions, and this improving burn out.. I just shot my morning diet coke through my nose on the computer screen.

    ========================================
    “Organizations should allow physicians to structure more of their own work flow. They should teach and pay for time and training to avoid, prevent, recognize and improve burnout, and allow physicians to rediscover resilience and fulfillment.”
    =============================================

    So we won’t do anything to remove the things that are causing physicians to burn out, we will actually make it worse (see above about seeing only complesx patients) And then, we will provide time and courses for training to deal with the burn out that we have inflicted on physicians. Yeah, that makes a lot more sense than actually changing the healthcare environment to one where you know, phsyicians don’t burn out in the first place. /s

    • Patient Kit

      Docs seeing only the most serious complex patients as a solution to burnout does seem pretty counterintuitive to me. When I got to the “What can we do about physician burnout?” line, ever the optimist, I read on in hope that an actual solution would be suggested.

  • NewMexicoRam

    Sounds like they are describing me.
    Except I’M NOT SUICIDAL. No way.
    But this kind of life isn’t what I had signed up for.

  • QQQ

    “Americans think that most physicians have it made. They’re wrong.”

    I thought this was interesting (from my previous post)

    If you want to read articles, read “why doctors don’t get
    rich”and “why doctors are poor, and computer geeks are rich”. These articles are from money managers by Michael Zhuang and Karen Cheong and they explain why medical doctors are poorest of high income earners and are financially struggling!
    ————————————————————————-
    “Many of them are woefully financially illiterate. I cannot understand why people who are supposed to be clever can be so inadequately informed in areas of managing their finances.”
    -Robert Kiyosaki-, author of “Rich Dad, Poor Dad”

    “Physicians have a significantly low propensity to accumulate substantial wealth.”
    – Thomas Stanley-, author of The Millionaire Next Door

    • rbthe4th2

      What about mortarboards to millionaires or http://economix.blogs.nytimes.com/2012/01/18/what-the-top-1-of-earners-majored-in/? When we’re now talking that 40% of female physicians marry another doctor, what happens when the debt rate is done? You have maybe 2 PCP’s (at the least) making $300K or more a year at the very very least. Don’t tell me you can’t live well on that. More so than those who made $125 a year.

      • QQQ

        I guess you can bring that up to the money managers that wrote and mention these articles!

        • rbthe4th2

          There are money managers and the like that are there for doctors specifically but not for nurses. So if the $$$ amounts were right on the side of docs not making it, they would go for the teachers and not the docs.

      • TFW, MD

        I think physicians should stop complaining about the money. It is a projection away from, at least for me, the real issues of loss of control of your schedule from administrators, the inability to get tests without a fight with a insurance company employed physician, computer systems that require over 15 screens to click through, each with at least 10 drop down boxes, in order to handle a patient’s simple medical issue, and long working hours that involve stressful life or death decisions at odd hours. No physician salaries are, for the most part, higher than they have ever been. Physicians are strained and are trying to sock away money so that a career change to a much lower stress / paying job is possible.

        • rbthe4th2

          That and getting better patient care, less missed or delayed diagnoses, which is the main cause of lawsuits. Medical boards that truly protect patients and not their buddies or MD’s just because they’re MD’s. Risk Managers and lawyers who lose their licenses, etc. for protecting the corporation at the expense of human beings.

      • Heather Franz Nichols

        You are saying that their combined income is 300k? What about the fact that they each owe 200k in Medical School debt? What about they have the highest divorce rates so they were married previously and now have alimony and a prior mortgage, etc. Many PCPs live paycheck to paycheck.

  • Karen Ronk

    Physicians are not facing anything different than most workers these days. We have all become chattel for socially irresponsible corporations who profit at our expense. The ranks of the working poor grow every year. Physicians do at least have a better chance of achieving some financial stability if they stay in the profession. Although I would agree that most make much less than people assume.

    Wealth comes these days to companies/celebrities that simply were inconceivable 20 years ago. People have become billionaires by “creating” internet sites that provide no lasting value and very few jobs. Until we get back to basic values and expect/demand more from our elected officials, there is not much reason to think things will get better for anyone.

    • rbthe4th2

      I find it interesting that we get a lot of comments from doctors now about the job stress/daily life and $$. http://www.medscape.com/features/slideshow/public/residents-salary-and-debt-report and then you see http://www.baltimoresun.com/news/maryland/sun-investigates/bs-hs-medical-errors-20140726,0,477185,full.story, http://www.torontosun.com/2014/07/19/shielding-doctors-from-the-consequences-of-their-actions-isnt-fair-to-patients-and-wont-improve-health-care, and this today: http://blogs.einstein.yu.edu/chewing-on-a-farm-to-table-dilemma/ comes enough information that I think gives the idea that doctors are not in the same class as we are. They can afford lawyers for suits, admin to protect them, and now CMS doesn’t report a number of major errors.

      I don’t see the horizon as being a good one where doctors feel that they’re getting the shaft. Are some? Yes, primary care being that. Otherwise, specialists marrying specialists and with about 25% of kids not owing any medical school debt should tell you that medicine is starting to sway towards only the richer people going into it.

      • Karen Ronk

        You make some great points and I think that it is reasonable to come down on either side of this issue. My belief is that if you are a great doctor/surgeon who really takes excellent care of your patients, then I could never begrudge you the wealth you accumulate – because that care really is priceless. And if your argument about medicine swaying toward the rich is correct, then that may be a good thing because those people might be going into medicine for the right reason and not just to “get rich”.

        But in terms of errors and the protection of doctors, I think we have to create a system where the lawyers are removed and some type of mediation process involving impartial (if that’s possible) experts could help get patients the fair treatment they deserve. Maybe more than anything else we discuss here on KMD, I think doctor/facility errors – both major and lesser – are a serious problem that need to be addressed.

        • rbthe4th2

          Agree on the really good doctors point. Disagree on the docs swaying towards the rich, because as one of the links pointed out, you then don’t have the same mindset or background as your patients. I dont want to see people dumped out of a profession due to their heredity or lack of funds.

          The problem is that the lawyers are part of the problem and part not. Do you need lawyers, yes? Do you need a different type of system where the doctors take responsibility for a number of smaller issues or system issues and get those fixed? Yes. The problem is that profits come before patients, so how are you ever going to get this going in the system we have now?

          The problem is serious. We’re only starting to see a few bits and pieces here and there of it getting addressed but for the most part until Christopher Duntsch and Charles Cullen stories stop, the medical profession is going to have a very blackened reputation that is quite frankly: earned.

          Because of the retribution worked in the system, its the good docs who take the brunt out of this. I’ve seen them and I do feel for them.

      • Heather Franz Nichols

        we pay thousands of dollars a year in malpractice to be able to hire lawyers for when we need it. And usually cases are dropped out of court because there is no grounds.

        education in this country is available more to those with wealth, i agree. another problem to fix.

        • rbthe4th2

          You know that both docs and patients are getting taken to the cleaners in terms of $$$ by the lawyers? Premiums going up but lawsuits going down. That means the $$$ are going to insurance companies and lawyers.

  • Eric W Thompson

    I work for the VA. No insurence influence here; just the government. Same issues.

    • querywoman

      My opinion of my local VA hospital in the years I was a welfare worker was that all they really cared about was stuff like heart disease. Sure, they were good with burns. But my VA clients never seemed to get much better. I thought the county hospital was better!

  • Eric W Thompson

    I have been watching the health care system for over 30 years. I see the transformation and deterioration of doctor’s work situation. I can’t figure out why anyone would want to be a doctor anymore.

    • Patient Kit

      And yet…….how do you explain this?…….

      “A record number of students applied and enrolled in U.S. medical school this year, bucking predictions that President Barack Obama’s health-care system overhaul would dissuade people from becoming doctors.

      Total medical school applications increased 6.1 percent to more than 48,000, breaking a record set in 1996, according to data released today by the Association of American Medical Colleges. The number of students who enrolled this year rose 2.8 percent, exceeding 20,000 for the first time, the group said.” (Source: Bloomberg News, 10/24/13)
      ******
      Presumably, those who are choosing to go into medicine now, post-ACA, are doing so with their eyes wide open about the current changes in our healthcare system. And they still want to be doctors. I really can understand how older docs feel deeply betrayed by the system they work in, i.e. it’s not what you signed up for when you sacrificed so much in your youth to become a doc. I get that. But how do you explain all the young people who are choosing to become docs now? Are they clueless about what they are getting into or do they want something different than what older generations of doctors wanted?

      • rbthe4th2

        $$$$$ and the fact that unemployment rate is low. For the really high banker/financial/CEO salaries, there are few who go into business making that. For doctors, look at the vast majority who are going to make it to a nice retirement.

      • Eric W Thompson

        Very good numbers and research on your part. Talking with the students, they don’t realize what it is like today. They see ‘House’ and other shows. When they start getting the true info while in school, a large number of them go into specialties where the money is. Primary Care is stretched as evidenced by posts on this blog. I work with doctors and do not believe they get anywhere near the respect or compensation that their years of study and hard work deserve. Just my experience, your ‘mileage may vary’.

      • Christina Downing

        I’m currently in medical school and I didn’t know anything about insurance or reimbursements or how I would ultimately be paid until I was IN medical school. The same can be said for all of the med students that I know personally, so I’d go with the “clueless” explanation. I’m in my third year and just learned two days ago how surgeons get paid. I always thought I’d get a salary, but it wasn’t until recently that I learned that most likely won’t be the case, regardless of what specialty I choose. I thought about job security, not how my paycheck will be calculated, when making the decision to become a physician over other careers. It should be noted that I was warned many times to not expect to make a lot of money and to go into business if a high salary was important to me and even if I had known then what I know now, I still would have gone to medical school.

        • Heather Franz Nichols

          Good for you. Keep your heart in the right place. You did this for the right reasons. So did a lot of us old timers. I hope you love your job one day.

  • Joe

    The only thing I’ve ever seen that improved physician burnout was bringing in more physicians to spread the workload around more. Of course, you might as well hose down the medical schools with applicant repellant at this point given how interest in being a doctor is dropping. Look for burnout to increase.

    • guest

      Burnout is not just about the amount of work. It is about the quality of the work. If I worked 2 hrs a day I would still feel the burnout. Medicine has become demoralizing. It is a sweatshop.

  • Patient Kit

    Agreed about the more comprehensive well checks. But, on the other hand, being able to get a simple flu shot at the pharmacist has proven to be a winner for many patients. Those who don’t have insurance or a regular primary care doc can still easily get a flu shot if they want one. And those who do have insurance and a regular primary care doc, don’t have to take time off from work just to get a flu shot. And doctors’ schedules aren’t taken up by people who just want a flu shot.

  • Lisa

    I certainly think that pharmacists can and should explain medication to patients. And I also think it is overkill to see a pcp for minor health issues. I think that nurse practioneers are quite capable of providing such care, in addition to regular check ups. Such suggestions are not the reason medicine is circling the drain.

    • querywoman

      Overkill? I expect my doctors to work, even on the minor stuff!

      • Lisa

        Overkill in that I do not need to see an MD for common complaints – sore throat, cough, other minor illnesses. Even though I like my PCP, I would be quite willing to see a NP for such matters.

        • querywoman

          I am stable with specialists, so I don’t mind an NP. What I hate is docs who delegate it all and never see patients.

          • Heather Franz Nichols

            They are seeing their full load, too, in most cases. I’d love to know where you think a doc is just reading kevinmd.com all day but has NPs running around for him. No NP I know would stand for that!

          • querywoman

            I know a doctor who farms all his work out to NPs and PAs and got fined by the federal government for that. He seldom see patients himself.
            Some of his assistants may be excellent, but I regard people who do all of his work as swarmy!

            Real medical doctors want to see patients.

  • Brunhilde

    I forgot that labor and delivery nurses are always so polite.

  • dynamicdeebythesea

    I saw this coming when Obama (or any politician) started getting involved in Health Care. I figured it would end up on the backs of the workers and not the money grabbers like Insurance Companies and the Drug Companies. Those with the most lobbyists continue to thrive while those on the front lines take the brunt. As an RN, we are asked to do more with less resources. Many clock out and continue to care for patients as management won’t allow overtime. Until a politician takes on the entities that created the Health Care problems, Health Care Reform will never be a total success. The Insurance Companies started this with DRGs, when they starting dictating how doctors were to treat patients. The Drug Companies and Insurance Industries are still benefitting with the new Health Care Laws. No politician can or will take on these industries and without that, Health Care Reform will never be a total success.

  • Heather Franz Nichols

    I think most PCPs still think of it as a calling… but we get very frustrated. At least I’m a pediatrician and get to work with happy healthy kids every day. That helps. But “Pharmacists and nurse practitioners could do routine primary care like checkups, screenings and explaining medication.” is a slightly scary sentence to me. Nurse Practitioners of course… but Pharmacists? In what way are pharmacists trained to see patients!??!? This is a ridiculous idea, even though it has been suggested by others as well. It would make healthcare a horrible situation. In Australia, Public Health Nurses go out to the homes and see patients for their Well Child care. That seems like a great beginning solution. If nurses did regular well child care and we just saw kids for quick exams and to go over the “problem list bullet points” that the nurses find, it could speed things up a bit. But also fracture care more… solutions are going to be difficult. At least we are starting somewhere with Obamacare. Now kids that were previously denied insurance because of an existing condition can get care. And 18-26 year olds can stay on their parents coverage until they get a good FT job with benefits.

  • Heather Franz Nichols

    seriously. I got yelled at so much from L&D nurses as a pedi resident. More than almost anyone else. Maybe that evil Neurosurgeon….

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