Physician burnout is increasing at an alarming rate. According to a January 2017 AMA Wire report, physician burnout rate has increased from 2013 to 2017 across every specialty in medicine. Greater than 50 percent of primary care providers are burned out. Therefore, every patient at the entry point of medical care is, more likely than not, going to be treated by a burned out physician. The question is why are we so burned out. Self-determination theory (SDT) offers a plausible answer.
According to SDT, we all proactively seek to gain mastery over internal and external forces in our lives in order establish our own well-being. Toward this end, we have three basic psychological needs: competency, relatedness, and autonomy. Competency refers to our desire to be good at something, which positively impacts our world. Relatedness occurs when we feel connected within a community of caring people. Autonomy is our craving for freedom to act according to our own values. When these needs are met within our social environment, we are capable of intrinsic motivation and healthy integration of regulations, which establish a framework for good mental health and well-being.
We physicians begin our training with a dream, an intrinsically motivated goal to live sacrificially in order to cause a positive impact in the lives of others. As we strive to competently provide better healthcare for society, we in healthcare sense a relatedness to each other and to our patients. Prior to the era of modern American healthcare, most physicians would agree that our three basic psychological needs, which nourish our intrinsic motivation, were met by a physician-friendly environment.
The Affordable Care Act (ACA) transformed our physician-friendly environment into an era of physician as adversary. The federal government along with hospital and insurance bureaucracies have relegated physicians to being nothing more than troublemakers, who spend too much, care too little, and must be watched with great scrutiny. To facilitate control of physicians, several programs were implemented that have manipulated us into using an electronic health record (EHR) to the satisfaction of the federal government’s demands. Compliance comes at an exorbitant cost, both financially and mentally. A time-motion study by Dartmouth-Hitchcock Healthcare System found that physicians spend nearly half of their workdays on EHR data entry and other desk work. In a workplace where nearly everyone’s eyes are on an EHR or a smartphone, a physician is unlikely to feel connected to her colleagues or her patients. Relatedness seems impossible to find. Autonomy is lost, and competency is constantly under attack. We may be burned out, but we are not the adversary.
Some burned out physicians turn to extrinsic goals as a substitute, e.g., acquiring wealth or escaping through alcohol, drugs, and/or sex. These rewards are temporary and lead to ill-being. The physician becomes like a rodent on a hamster wheel, striving but never obtaining contentment. The external reward becomes the controlling motivator. Autonomy is lost, and mental health declines. In fact, if one’s efforts towards these goals outweighs one’s pursuit of intrinsic goals, then anxiety, depression, narcissism, addiction, and low self-esteem can result. Conversely, when intrinsic motivation outweighs extrinsic, then good mental health, greater well-being, and more effective functioning occurs.
If only we could integrate the ACA and EHR regulations into our value system and make them a part of who we are, then maybe we could find a new autonomy, relatedness, and competency. But, we did not spend 10 to 15 years of medical training to do data entry for the federal government. Certainly, it is to our benefit as providers to look for the value in regulations and try to integrate them. Integration brings well-being. Some regulations are good and easily integrated, but the majority represent intense micromanagement, which enslaves us and questions our competency to practice effectively. Physicians have become pawns in the hands of the government, insurance, and hospital bureaucracies, and so we walk with our heads down, passively complying while suffering anxiety and guilt for not integrating the system’s regulations.
Simply put, our social environment does not trust us to behave out of the goodness of our calling and the excellence of our training in the art and science of medicine and surgery. Our dream, our intrinsic motivation, and goals have been thwarted. We are fragmented for lack of integrating burdensome regulations. To be honest, our basic psychological needs of competency, relatedness, and autonomy are far from being met, and that is why we are burned out. Ask any physician, and you will find the solution to the increasing rate of burn out is fairly simple: deregulate our use of the EHR.
David E. Hockman is an orthopedic surgeon.
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