March 2019 Edition Vol.11, Issue 3

As Physician Burnout Becomes Endemic, Change is in the Wind

By Christina Bennett, MS

At an oncology group in California, a radiation oncologist sees his patients in the clinic during his workday and reserves all his electronic medical record (EMR) documentation for after hours. That way, he can go home and have dinner with his family on time. Then, he sits at his computer in his living room and works for two to three hours every evening filling out EMRs.

“That’s the only way he can participate in family life,” said Anthony Back, MD, medical oncologist at the University of Washington Medical Center, during a recent presentation at Developing and Sustaining an Effective and Resilient Oncology Careforce, a workshop hosted by The National Academies of Sciences, Engineering, and Medicine. “The administrative leader of that system said to me, ‘I am worried about him, and the [radiation oncologist] himself said to me ‘I don’t know how much longer I can do this.’”

“Who could do this?” Dr. Back asked, rhetorically. “It’s absurd.”

The story of physicians becoming burned out by the demands of the current healthcare environment is becoming all too common in oncology. While the overall prevalence of physician burnout has reportedly declined in recent years, the level remains higher among physicians compared with other professions.1

“It’s basically endemic at this point,” said Colin Champ, MD, radiation oncologist at UPMC Hillman Cancer Center. “I’m young in my career, but it seems like it’s worsening year by year.”

“I would be shocked if every physician doesn’t experience at least some element of burnout,” echoed Johnetta Blakely, MD, medical oncologist at Tennessee Oncology, a large community oncology practice. Being burnt out means experiencing at least one of the following: emotional exhaustion (having nothing left to give); depersonalization (treating patients like objects); and low personal accomplishment (feeling like my work doesn’t matter).

According to the 2019 Medscape survey of physicians across several specialties, approximately 4 in 10 oncologists experience at least one element of burnout.2

Women were found to have higher prevalence of burnout than men, in part, due to the difficulty of work-life balance women physicians face.2 Dr. Blakely said, “We were told as little girls that you can have it all—well, you can’t. When you are working hard, something else in your personal life is going to suffer,” she said. She felt there’s an unspoken rule that “you’re a little bit weaker because you take time for your kids’ stuff.”

Although physicians may not identify as burned out, they may be on the verge without realizing it. A study among general surgeons evaluated how well attuned they were to their risk of burnout by having them take a quiz to determine their risk and then comparing that risk to the surgeons’ self-reported risk.3 The surgeons were “totally inaccurate,” said Dr. Back. “They didn’t realize how close to burnout they were because we’ve all been trained to ignore all these things.”

With the threat of an oncologist shortage ahead, burnout among the upcoming generation serves only to exacerbate the looming shortage. A study found that when internal medicine residents completed their inpatient hematology-oncology rotation, their interest in pursuing a career in oncology actually declined and so did their empathy and resilience.3

“This is a tip of the iceberg of what we are dealing with in the culture of working in oncology now,” said Dr. Back.

Burnout Makes a Name

The concept of physician burnout dates back decades, but it wasn’t until 2012, when a study showed how high the prevalence of burnout truly was that the medical field paid attention: Nearly 50 percent of physicians across the United States identified themselves as burned out.4

“The prevalence became something people couldn’t ignore,” said Colin West, MD, PhD, co-director of the Department of Medicine Program on Physician Well-Being at the Mayo Clinic. He said that before the study was published, there was a sense of some “growing concern” that burnout was an event that was associated with negative outcomes, like medical errors, but “nobody had a great sense of how common this was.”

Research has tried to pin down the causes of physician burnout, and high on the list is the ever-growing burden of administrative work.

“It’s been an exponential growth over the past three years in paperwork,” said Brian Shimkus, MD, oncologist at Austin Cancer Centers, a small community practice in Texas. “Looking back 15 years ago, we literally scribbled a note in a chart, talked to the nurses, threw them a scrap of paper that had a chemotherapy regimen on it, and that was how things were done versus now we’re documenting if we put on a Band-Aid.” He said his biggest frustration is that while he’s spending “an inordinate amount of time” on documenting, he has patients waiting for appointments.

Sai Ravi Pingali, MD, Houston Methodist Hospital, expressed a similar frustration. He said that he must complete an “unbelievable” amount of paperwork to get funding from a society, or even insurance approval, to help pay for the cost of treatment for a patient. “That is something which we never thought about with all these new medications coming in,” he said.

Having too many bureaucratic tasks was ranked as the number one contributing factor to burnout in the Medscape survey. Following that was increased computerization of practice—that is, EMRs.2

“A large portion of our day is now in front of a computer,” said Dr. Champ. It’s not an odd day for him to look at his document queue and see dozens, if not over 100 documents that he has to sign off on by the end of day.

Although working longer hours was also linked to burnout, David Oubre, MD, President of Pontchartrain Cancer Center, a private practice group in Louisiana, said it depends on how those additional hours are spent. “If I’m spending my time talking to people about hospice or trying to help them with their cancer, I don’t find that that burns me out, but I don’t feel that way about filling out paperwork, and about clicking boxes on an electronic medical record.”

Not only does documentation and clicking through EMRs take up time, but these tasks are often viewed as meaningless and don’t improve patient care. A 2016 study found that physicians across a variety of specialties who used EMRs were significantly less likely to be satisfied with the amount of time they spend on clerical tasks and had higher levels of burnout. Only one in three physicians in the study believed that time spent on such tasks were directly related to patient care.5

An example of meaningless work, according to Dr. Shimkus, was the mandatory switch from ICD-9-CM to ICD-10-CM codes in 2015. “The amount of documentation that [ICD 10-CM codes] requires is maddening because, from a physician point of view, there is a lot that does nothing to contribute to patient care,” he said.

Administrative burden and documentation are just one piece that leads to burnout. Other aspects, such as the threat of a malpractice suit, lack of respect from administrators, colleagues, or staff, and insufficient reimbursement contribute to burnout.2

Government regulations is another reported reason,2 and because of changes in regulations, Dr. Champ says he finds himself in “so many” meetings, often with administrators who may not understand his day-to-day schedule. “You will get scolded for running late to a meeting, yet, you’re saying goodbye to a patient who’s going on hospice to go home and pass away, and who you’ll never see again in your life,” he said.

The decreased collegiality and socialization among physicians may be another contributor. Hospitals used to have areas where physicians would eat together to discuss patients and those are “all pretty much gone,” Dr. Champ said. “Little things like that, over a broad spectrum, all add up to this massive thing called physician burnout,” he said.

Affecting Change

About a year ago when Dr. Blakely was experiencing elements of burnout, her group’s chief medical officer asked her to attend a weekend conference on physician burnout. She was hesitant, after all it meant more time away from her family when she was already burned out, but she went anyway. “I came home saying, ‘Oh my god, everybody has to hear this,” she recalled. Her mindset changed from looking at situations in a negative light to seeing them as an opportunity. “Sometimes I think we forget that we can only control our reaction to the environment we are in,” she said. “I feel, at least internally, a lot calmer than I used to.”

Studies have found that interventions can help decrease physician burnout. For example, a systematic review and meta-analysis showed that individual-focused strategies, such as stress management training alleviated physician burnout.6 Also, a single-institution study showed that an intensive educational program in mindfulness, communication, and self-awareness improved the well-being of primary care physicians and resulted in lower burnout.7

Given the success of the conference, Dr. Blakely tried to bring in experts to talk about burnout to the rest of the practice, and while the group approved, getting buy-in from the other physicians has been a struggle.

Large health systems are also trying to address burnout but with something new called: chief wellness officers. The position would have the authority, budget, and staff to implement an ambitious agenda according to an article in Health Affairs.8

However, whether chief wellness officers will help has yet to be seen as organizational science is not very well developed in the area of well-being, said Dr. West. In addition, there’s the risk of putting someone in a position with a title, but not linking that position with any authority or role to contribute to actual policy. If this happens, he explained, the position “serves only to increase mistrust and cynicism for rank-and-file physicians within an organization” and “can be perceived as leadership giving lip service to the problem.”

For chief wellness officers to be effective, the position must be associated with meaningful impact. Dr. West explained that physician well-being is not commonly a direct part of conversations among leadership and the overall goals of a health system. Chief wellness officers, however, could be effective if they were directly in those conversations. For example, when setting a higher net operating margin as the goal, organizations would have to consider the cost to physician well-being. They would have to ask, would this financial goal lead to higher burnout among their staff?

Beyond the external solutions, the medical field may also have to look inward and change the way physicians are trained to practice. Historically the attitude has been that training is supposed to be hard, but the tough enough mantra is being re-examined. Organizations are starting to ask pointed questions about the learning and practice environments within which physicians work. According to Dr. West, “All of these battle analogies, I think are being questioned.”

Editor’s Note: The Association of Community Cancer Centers (ACCC) released the results of their “2018 Trending Now in Cancer Care” survey on March 1, 2019 as OBR went to press with this article. Respondents listed “workflow inefficiencies,” “heavy workload,” and “lack of work-life balance” as top concerns that may contribute to burnout. Also, most respondents (70%) said EMRs lead to longer workdays and more than half (59%) feel EMRs have had a negative influence on physician and staff well-being. The survey also revealed several ways in which burnout is being addressed, including staff recognition programs, staff team-building activities, and monitoring of professional well-being.

References

  1. Shanafelt T, West C, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017 [published online February 22, 2019]. Mayo Clin Proc. doi: 10.1016/j.mayocp.2018.10.023.
  2. Medscape National Physician Burnout, Depression & Suicide Report 2019. https://www.medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056?src=ban_burnout2019_desk_mscpmrk_hp#1. Published January 16, 2019. Accessed February 28, 2019.
  3. Shanafelt TD, Kaups KL, Nelson H, et al. An interactive individualized intervention to promote behavioral change to increase personal well-being in US surgeons. Ann Surg. 2014;259(1):82-88.
  4. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-1385.
  5. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91(7):836-48.
  6. West CP, Dyrbye LN, Erwin PJ, and Shanafelt TD. Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281.
  7. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-1293.
  8. Kishore S, Ripp J, Shanafelt T, et al. Making the case for the chief wellness officer in America’s health systems: A call to action. https://www.healthaffairs.org/do/10.1377/hblog20181025.308059/full/. Published October 26, 2018. Accessed February 28, 2019.

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