Medscape’s most recent physician burnout and depression report¹ reveals a number of alarming statistics regarding the incidence of these conditions in physicians of all ages. The document shares significant gender differences when it comes to burnout, with female physicians affected more than males, as well as differences among specialties and incidence at unique periods of the professional life (see also a report on HCP Plife outside of work). The bottom line is that close to 45% of physicians acknowledge being affected by burnout and at least 12% by depression.¹
In terms of depression, the percentage of physicians impacted compares very unfavorably to the incidence in the United States population at large, where fewer than 7% of individuals are affected, according to Medscape. The report does not offer specific statistics on burnout among other medical professionals, including the ancillary healthcare personnel working in the office setting, hospitals, or other healthcare institutions. No comparison statistics are offered for allied clinicians, such as psychologists or dentists. In this regard, it is my hope that there may be future studies to evaluate the incidence and prevalence of burnout and depression in a number of pertinent vocations, as well as in the US population as a whole. The more knowledge we have, the better will we be able to tackle the issues at hand.
Acknowledging Physician Burnout
The medical definition of physician burnout refers to a complex set of physical symptoms including fatigue, or rather, a feeling of exhaustion and difficulty managing daily professional tasks, as well as depressive symptoms, most often related to the practice of medicine today. This short commentary—fueled by 35-plus years of experience in medicine, the available literature, and colleagues’ input—is meant to be an eye-opener and, ideally, may lead to a better understanding of the many facets of this subject. The data presented in the Medscape report deserves serious consideration.
The Hidden Realities of Practicing Medicine Today
It goes without saying that physician burnout is hardly new or unifactorial. In the great majority of cases, the condition resembles the legendary Medusa and the frightening snakes emerging from her head. Physicians exposed to our healthcare system for a long period of time are bound to be affected by it—we are, after all, human beings. The toll medical practice takes on clinicians also seems to get worse year after year.
Perception & Respect
There are no specific ways to address physician burnout in an ordinal mode, as most issues overlap. One factor that immediately comes to mind and to the minds of my older-generation colleagues is that we entered the field at a time when the title and position of “physician” was respected across society. This distinguished role seems to be fading.
Today’s healthcare system seems to provide insurance companies, administrators, lawyers, politicians, and related professionals with an opportunity to purvey our diminishing reputations. Aside from being paid lip service, physicians have very little, if any, say in the protocols they must follow. Our years of work and exhaustive board certifications no longer hold much value.
Insurance companies, for example, call us “vendors” or, at most, “providers.” Many of my colleagues have heard themselves referred to as “cows” by healthcare administrators, implying that physicians are only there to serve the institutions at play. And some lawyers have another name for us, one I will not use here. A number of physicians work in the pain-related fields of disability evaluations, and while many lawyers state that they prefer physicians to be objective, as the specialty requires, some thrive on seeking out physicians who will do their bidding as expert witnesses.
As a further consequence of our dismembered healthcare system, patients are no longer encouraged to know or be known by a physician, slowly unraveling what was once a strong knot of confidence, trust, and respect. In fact, more and more patients opt for generic care offered by entities such as express emergency clinics where the physician and patient establish no bond and conditions are treated without knowledge of the patient’s full medical history. I realize that many patients may counter this point, arguing that they would prefer to have a quality relationship with their physicians, but the insurance companies’ reimbursement schedules have forced physicians to spend less time with each patient, thereby chipping away at this important aspect of healthcare.
Training
Today’s medical education system plays a contributing role in physician burnout. Discussions around physicians and society, and the need for professional respect, are hard to come by within a typical medical school curriculum. More importantly for pain practitioners, physicians are often encouraged to substitute the word “discomfort” for “pain,” and they are only given barebones training in the field pain management, as well as in preventive medicine and clinical nutrition.
Family & Finances
At home, many physicians of my generation feel that they are often unable to spend time with their spouses or watch their children grow. With a typical 50- to 70-hour workweek, and the beeper/phone ringing during “off-hours,” a good standard of living does not replace quality time with one’s family. I strongly believe that this factor alone is consciously or subconsciously a prime underlying cause of burnout and depression. Patients often question me after taking a rare few days off, and I am sure that I am not the only one to be subjected to this guilt.
Financial pressure is another factor cited in the Medscape report¹ and in the literature. Today’s physicians work more for less. For example, in 1986, I received approximately 93% reimbursement from insurance for medical bills submitted according to their own tariffs. Today, the percentage is below 50%.
While expenses continue to increase on a monthly basis, physicians’ income in all fields has decreased consistently over the past decade and the trend has no end in sight. I am told that the down-slope figure is 16% per year. We are probably the only profession in this predicament. No regular business can stay afloat in such circumstances.
Bureaucracy & Workflow
In the past few years, physicians have had to switch, under the threat of financial penalties, from paper filing to a variety of electronic medical record (EMR) systems. Unfortunately, the systems do not talk to each other and there is no unified system on the horizon. While there are benefits to using EMR, the time factor can be detrimental. Completing daily records may take 30% longer with an EMR system compared to a traditional system, for example. Furthermore, the systems often cost between $25,000 and $100,000.
The administrative and financial reality behind this new workflow is another crucial factor behind burnout. General physicians do not receive this type of practice management training in medical school and often admit that they tend to be poor financiers.
Easing the Burden
There is urgent need for serious studies about the personality characteristics and coping skills of physicians who face burnout and/or depression versus those of colleagues who work in similar circumstances and tolerate the same hardships without reaching those consequences. Once the etiology(ies) are found, we can work to formulate solutions, such as biofeedback, wellness training, exercise therapy, and so forth. The path may be arduous, but I am an eternal optimist.
Enhanced Curricula & CME
At the same time, it is important for future physicians to be selected by the medical faculty authorities based not only on their academic achievements but also on a number of social and psychological criteria. Furthermore, medical students (and the parents who may be footing the tuition bills) should be made aware of the realities of medical practice. New physicians enter practice with average school debts in excess of $100,000.
Medical school curricula should include more detailed practice management, from a paperwork and financial perspective, as well as an overview of the expected lifestyle.
Solid college grades and above-average MCAT results alone cannot overcome the burdens of a physician’s professional life. Just as our society tests and trains pilots using a variety of criteria, medical schools should provide students and residents with all the information they need regarding their career choice and treat them with the utmost respect.
Recognizing burnout, preventing it, and treating it should be part of the standard medical school curricula as well as residency programs. Moreover, this subject should be a compulsory annual continuing medical education course, with a pertinent number of credits for maintaining a medical license. If this condition affects nearly 50 percent of physicians, it must be treated seriously.
Follow-up Counseling
Back on the home front, as well as in the office, counseling and training in coping strategies need to be made available for the physician, her/ his family, and staff.
Once physician burnout and depression are recognized, one should be able to attend a rehabilitation program. The American Medical Association and state boards should study the issue and direct the formation of serious programs and follow-up across the nation.
Graduated Workweeks
It is clearly stated in the Medscape study that physicians are much happier outside the scope of practice.¹ One overall solution, therefore, may be the reduction in the number of working hours or pattern of practice. Since the peak of burnout is in the mid-life, perhaps physicians over age 50 should gradually reduce their workweek and/or hours spent in the office per day.
For too long, the motto of invincibility was dominant, and physicians were considered “great” when they went for days and nights without sleep, surviving on hospital quality coffee. It is time to re-dimension practitioners in our society to a position where they can live and practice their profession for a long number of years without succumbing to burnout and depression. Let us take these conditions seriously and study properly the issues at stake. Only then, can we effectively address them for everyone’s benefit.