Who’s to blame for physician burnout?

As large hospital systems and medical societies attempt to address physician burnout, at the end of the day, much of what they recommend puts the onus on physicians to fix the problem. From implementing team-based care to time banking, peer support groups, and introducing more mindfulness into practice, it would seem that the only viable solution is: physician, heal thyself.

But does it have to be this way? What if we considered the myriad of systemic issues that may be causing burnout? Perhaps then, physicians can get back to the source that called them to this profession in the first place.

It may come as no surprise that, in a 2017 survey released by the American Medical Association (AMA), 75% of medical students, residents, and physicians reported that “helping people” was one of the primary motivators for entering the field of medicine.

The same AMA survey revealed administrative burden, lack of time, and long hours to be the principal contributors to physician stress and exhaustion. The message is clear: When excessive administrative tasks pull providers away from their patients, professional satisfaction and, thus, patient care tanks. Let’s take a closer look at some of these issues.

Electronic health records (EHRs)

While most physicians believe in the concept of EHRs, many agree that the current interface needs a major overhaul. Turns out, the EHR system was developed piecemeal over time, and interoperability was never taken into consideration.

As Carla Pugh, MD, professor, Department of Surgery, and director, Technology Enabled Clinical Improvement Center at Stanford University School of Medicine, Stanford, CA, wrote in a 2019 editorial commentary published in Annals of Translational Medicine: “Physician workflows and the ability to access information from these siloed, independent systems during the process of care was not taken into account. Moreover, there were no avenues that could enable a physician to unify the data they had and the data they needed.”

In addition to poor design, physicians must address numerous regulatory and insurance requirements within the EHR system. These tasks add administrative complexities, including time-consuming data entry and documentation, that ultimately detract from patient care. The American College of Physicians (ACP) is working to combat these systems-based issues by promoting a strategy known as “patients before paperwork.” Through this initiative, the ACP is working with regulatory agencies and insurance companies to try to eliminate nonessential tasks that draw physicians away from patients and cause stress. According to their website, “ACP has long identified reducing administrative complexities or burdens as a priority. ACP works to advocate for changes in our health care system that simplify excessive administrative burdens that put a strain on physicians and patient care.”

Another tactic some physician practices have taken to overcome the nuisances of EHRs is to employ scribes for data entry. According to Dr. Pugh, “The use of scribes is one example of a foundational, far-reaching change that would have had no place in medicine 20 years ago but is now being held as the savior of physician burnout and doctor-patient communications.”

Excessive workloads, work-life balance, and clinical autonomy

Not surprisingly, many physicians have reported poorer work satisfaction and higher rates of burnout when they work long hours, have to see more patients in a day, and are frequently on-call overnight and on weekends. Work-life balance is also key. Burnout increases when providers have to take work home and when their practice leaders offer little to no schedule flexibility to accommodate family obligations.

In a review article published last year, Colin P. West, MD, PhD, professor, Department of Medicine, Mayo Clinic, Rochester, MN, and colleagues outlined what the scientific literature says about these issues: “Multivariable analyses of data from cross-sectional studies of physicians have reported independent relationships between burnout and work hours (a 3% increased odds of burnout for each additional hour per week), night or weekend call duties (3-9% increased odds for each additional night or weekend on call), time spent at home on work-related tasks (2% increased odds for each additional hour per week) and work-home conflicts (greater than doubled risk of burnout when present).”

A survey conducted by MDLinx showed a whopping 75% of physicians have at least one chronic disease, and 74% attributed their conditions to added workload and work-related stress. In addition, the prevalence of some chronic conditions that are usually exacerbated by stress is higher among physicians than the average US adult. Read the full survey results.

In addition, Dr. West et al reported that the quality of practice leadership is directly proportional to physician stress levels. “How well leaders engage their constituents and seek input from, inform, mentor, and recognize individuals for their contributions relates to burnout and career satisfaction amongst the physicians they lead,” the authors wrote.

They added: “Large national studies of physicians also suggest organizations and leaders that provide physicians with increased control over workplace issues are more likely to employ physicians with higher career satisfaction and lower reported stress.”

Pay structures and income

Additional barriers to professional satisfaction revolve around insurance payment models and physician compensation. The American Hospital Association reports that payers are moving from a fee-for-service model, which is based on service volume, to a model based on the value of those services, which includes value-based care and alternative payment models (APMs).

What this boils down to is—physicians have to take time away from patients to learn about and implement more complex pay structures in their practices. With the fast-paced shuffle of payment models, physicians and other professionals in the healthcare field are “calling for a ‘time out’ to allow them to better adapt to current APMs,” according to a 2018 AMA-sponsored study conducted by RAND Health researchers, led by Mark W. Friedberg, MD, senior policy researcher, RAND Corporation. In their report, Dr. Friedberg and colleagues also recommended the simplification of “APMs to help practices focus on improving patient care as the preferred strategy for earning financial rewards.”

Speaking of financial rewards, providers who receive a salary now report far lower burnout rates than those who are paid on performance- or incentive-based models. To avoid receiving various incentives from multiple payers, some practices have chosen to affiliate with hospitals and large delivery systems; smaller, independent practices that have chosen not to join large health systems have reported feeling pressured to do so. In another AMA-sponsored study conducted by RAND Health researchers that was also led by Dr. Friedberg, the investigators noted: “When implementing new and different payment methodologies, the predictability and perceived fairness of physician incomes will affect professional satisfaction.”

While efforts to curb burnout within these larger issues may take time, some experts are asking questions like: Are health systems and larger practices the only way to go to adequately get resources for practice improvement? Can physicians receive stable income while transitioning to payment models that are not based on fee-for-service? How will income shift over time between primary care and subspecialty care?

Burnout rates are nearing 50% among physicians and physicians-in-training. Given the factors outlined here (and many more in the literature), we should continue to question the systemic demands placed on providers, and challenge the adage that physicians alone are responsible for their healing.

When we look at the big picture, all of us have been—or will be—patients in the system who seek the high quality of care that physicians want to provide. It seems clear that rooting out systemic problems, in the end, will benefit everyone.