Stamping Out Physician Burnout

Physicians are trained to be autonomous problem solvers; enduring solitary, long hours on-call during internships and residencies. But that tendency to function independently can be a downfall when it comes to dealing well with workplace stress. Case in point: The rate of physician suicide is alarmingly high. According to an article in the Journal of Clinical Oncology, more than 400 physicians committed suicide in 2015. There are initiatives that have been launched to address the increasing stress that physicians - both those in training and in mid-career - find themselves under, but seemingly little headway has been made.

KrisEmily McCrory, an academic family medicine physician who practices in upstate New York at Ellis Family Medicine Residency, is frank about the stresses that she and her physician colleagues find themselves under. "I think the biggest challenge is that doctors are no longer in charge. But, at the same time, it is our licenses and our liability [at risk]. We get all the brunt when something goes wrong, but we really don't have any say to make sure things don't go wrong," she says. "It just gets to be really exhausting."

Yet that doesn't mean physicians are ready to throw in the towel. By any means. Eighty-four percent of 1,000 physician respondents said they like being a physician, according to Physicians Practice’s 2015 Great American Physician Survey, sponsored by Kareo. And when asked if they would do things differently, 56 percent of physicians, a slight majority, said they would choose the same career path as they originally did.

If you find yourself wondering how you can continue to experience the joy in practicing medicine without changing careers, here's how to protect yourself from soul-sucking angst.

CAN'T GET NO SATISFACTION

Ask most physicians and they will likely tell you that the practice of medicine has changed drastically over the last 10 years. Consider that the Health Information Technology for Economic and Clinical Health (HITECH) Act, responsible for creating the Electronic Health Record (EHR) Incentive Program, was signed into law early in 2009. While the promise of universally accessible and interoperable health IT is tantalizing, the reality is still a long way off. Yet, physicians have few choices when it comes to EHR adoption, as the government has moved into the penalty phase of Meaningful Use for nonusers. And even though the Office of the National Coordinator for Health IT has said Meaningful Use is officially "going away" fairly soon, it is really just morphing into another government program where physicians will need to meet a new set of quality metrics.

According to Catherine Hambley, an organizational psychologist and founder of LeapFrog Consulting, based in Monterey, Calif., the single-most noxious threat to physician satisfaction is the EHR. "I am hearing more physicians become completely demoralized by what [the EHR] has done to their ability to really provide the kind of personalized and quality patient care [they wish to give patients]," she says.

Another bane to physicians is that many government programs are essentially unfunded; falling on physician shoulders and straining their wallets. "Often unfunded mandates … are very challenging, particularly for solo or small practices," says McCrory. Take for instance, the government's requirement that physicians adopt and implement an EHR. Aside from the cost to purchase an EHR system - which may or may not be subsidized by the government or a hospital system - there are a host of staffing and work flow changes that challenge most physician practices both financially and through reduced productivity. "[The] overhead to just comply with Meaningful Use, it's a very burdensome program. There's no funding for putting in the infrastructure that you need to do it," notes McCrory.

The mountain of reports that physicians are required to generate as payers move toward value-based payment models are further distracting physicians and reducing the time they can spend with patients. As chief quality officer for Sheridan Healthcare, a national physician services company, anesthesiologist and critical care medicine physician, Gerald Maccioli is acutely aware of the increased reporting burdens on physicians. "The reporting requirements for both quality of care measures and revenue cycle management have become incredibly daunting to physicians," he says. "… We are seeing a tremendous amount of burnout and dissatisfaction [in healthcare providers]. And we know from numerous studies that burnout is associated with lower patient satisfaction, worse outcomes for patients, and possible cost increases."

PHYSICIAN DEPRESSION AND SUICIDE

If you think physician burnout is not a significant problem, consider these stats on physician depression and suicide in the United States from the American Foundation for Suicide Prevention:

• Three hundred to 400 physicians die by suicide annually in the U.S.

• Female physicians have a suicide rate equal to male physicians.

• The rate of depression for medical students is 15 percent to 30 percent higher than the general population. 

• Depression is a major risk factor in physician suicide.

• Bipolar disorder and alcohol and substance abuse are also risk factors in physician suicide.

• Physicians have a higher suicide completion to attempt ratio.

RECOGNIZING STRESS

Physicians have been under greater pressure to see more and more patients due to declining payer reimbursements, unfilled physician shortages, and newly insured patients who previously did not have access to healthcare. Quite often, they just dig in and work harder. But at a certain point, that strategy stops working. Like pain, people have varying tolerance to stress, and some stress is actually helpful and can increase performance. However, once you've hit the tipping point, according to Hambley, stress begins to lower performance and cognition.

So how do you know if you've hit that point? Well, sleeping less, loss of appetite, and a persistent flat or negative mood are clear signs that something is up. Rising stress levels can also mean a decline in cognitive function, which is particularly concerning for physicians who need to be on their A-game at all times.

"When one gets more stressed," says Hambley, "your memory becomes more impaired, your ability to collaborate well with others and see their perspective begins to decline, you are frequently more irritable, and you are not making as good decisions. That's purely a brain function."

Add to that a physician's propensity to operate as a lone ranger and you've got a recipe for disaster. "Physicians have a tendency to almost suffer in isolation, if you will. It's interesting, I've known lots of people who are physicians who don't see the physician themselves," says Maccioli. 

* If you are interested in learning about strategies to tame the inner beast, try reading these articles by Hambley: "Strategies to Help Physicians Build Stress Resiliency" bit.ly/build-resiliency, "Motivate Medical Practice Staff by Being Positive" bit.ly/positive-staff-motivation, and"Preventing Physician Burnout"bit.ly/prevent-burnout-2.

PHYSICIAN HEAL THYSELF

Given that physicians feel like they have little control when it comes to payer rule changes, government reporting requirements, or those last-minute emergency patients on Friday afternoon, what options do they have to reduce their stress levels?

Sue Jacques, a medical and corporate professionalism consultant based in Calgary, Alberta, says it boils down to making a conscious decision to change. "As a result of [greater patient demand] I see that medical practices are becoming overwhelmed by trying to fit people in, having longer hours, staying late, and dealing with more than one medical concern at a time …," says Jacques. "There are four decisions that medical practitioners need to make today to begin to lessen their load to enhance their level of satisfaction so they don't feel burned out …"

Jacques calls these decisions the "four Ds" and says that physicians can approach these changes

• Delegate. This can be a tough one for independent physicians, but it is absolutely vital if they don't want to stretch themselves too thin. There are several areas where physicians can delegate responsibilities to others. The first is to staff or colleagues. "[Physicians] can have a nurse practitioner or physician assistant help them out by doing things like the history, the initial exam, and follow up," Jacques says. "A lot of time can be saved by delegating those tasks to someone who is qualified and trustworthy."

Another important area to delegate is to patients. Jacques says it is important that physicians let their patients know they should come prepared with a written list of symptoms and requests. "It can be very frustrating interviewing a patient and trying to get the history and the physical done when they are vague and trying to remember things," she notes.

• Diversify. It's important to reexamine the way you do business periodically and not be afraid to be innovative or stretch your boundaries. Jacques says diversifying can mean many things, but one example is setting up a specialty clinic like a flu clinic that is ready to go when needed. Plan out schedules, budgets, and assign providers and staff members ahead of time, so that once the flu season hits you are ready to deploy your team.

• Decline. Simply put, learn how to say no. "To obligations, to opportunities, to committees, to all the things that physicians as good hearted people tend to overcommit," says Jacques. She also points out that it is just as important to say no to patients as well, when warranted.

• Decompress. Setting aside time for yourself is just as important as treating your patients. Jacques recommends that physicians should actually schedule time to get away and do something for themselves. "If that is meditation, if it's running, if its family outings, window shopping through the mall, going for a drive, whatever it is. It's so important to find that time to decompress and to be actually able to breathe," she says.

*To read Jacques Physicians Practice Pearls column on how to say no, visit bit.ly/how-to-say-no-p2.

CHANGE UP YOUR WORK ENVIRONMENT

Another way that physicians can reduce their stress, say experts, is to change the way their medical practice operates. Here are three possibilities to get you started:

Use medical scribes. Most physicians struggle with inputting patient notes into the EHR, largely because the data fields and check boxes are not user-friendly and don't follow the natural flow of the patient visit. Rather than spend extra time dictating a long patient note, or struggling with the EHR, Jacques suggests offloading that task to a medical scribe.

Join a group practice or physician organization. Maccioli feels the best way to reduce the stress of over-regulation and complying with government mandates is to achieve economy of scale by merging with another practice, joining a larger organization like a healthcare system, or becoming an employee of a physician management company.

Convert to a concierge or direct-pay practice. Once an option that was scorned as elitist, concierge practice and direct-pay practice are becoming more acceptable to physicians and patients alike. One of the greatest benefits for physicians is the elimination of insurance contracts with their restrictive rules and declining reimbursements. "The reason that the doctors who have [converted to direct pay] really like it is that they don't have to deal with the red tape, bureaucracy, [and] filling out prior authorization forms…," says McCrory. "Which means that instead of having 15 minutes to spend with your patient, you can have 30 minutes with your patient."

Erica Spreyis associate editor for Physicians Practice. She can be reached at erica.sprey@ubm.com.