Every day, as people from all walks of life deal with burnout, they often turn to health care professionals for help. Yet the very people who dedicate their lives to keeping others healthy are the ones increasingly suffering from burnout. More than half of U.S. physicians report significant symptoms of burnout — that’s more than double the rates among professionals in other fields. If we want our nation’s health to flourish, we need to care for those who care for us.
Burnout is characterized by emotional exhaustion, depersonalization (which includes negativity, cynicism, and the inability to express empathy or grief), a feeling of reduced personal accomplishment, loss of fulfillment from work, and reduced effectiveness. It has serious consequences for the way that health systems function and the way they deliver care. Burnout has been a challenge for the medical community for decades, and the problem starts early. I saw it firsthand among my peers in medical school in the early 1970s.
Challenges to well-being are pervasive and affect every member of the care team, every workplace, and every career stage — from physicians to nurses and other clinicians, from solo practitioners to those in large hospitals or health systems, from trainees to experienced practitioners.
As many as 400 physicians commit suicide each year. That’s double the suicide rate in the general U.S. population. This is a huge concern for the grieving family members, friends, and patients who are left behind, and for all of us in the health care field. We recognize that suicide is rare and at the extreme end of a wide spectrum of clinician well-being, but it represents a devastating outcome.
These trends in clinician burnout are startling in and of themselves, but even more so when we consider their impact on patient safety. Studies have linked clinician burnout with increased rates of medical errors, malpractice suits, and health care associated infections. Clinician burnout also places a substantial strain on the health care system, leading to losses in productivity and increased costs. One longitudinal study found that the annual productivity loss attributable to burnout may be equivalent to eliminating the graduating classes of seven medical schools.
Fortunately, there is growing recognition that the problem of clinician burnout and suicide cannot be ignored. Many organizations are already doing great work to confront this crisis. But they are largely operating in silos. It is important to understand that clinician burnout is a systems issue stretching far beyond an individual clinician or a single workplace. There is a need to coordinate and synthesize the many ongoing efforts within the health care community and generate momentum and collective action to accelerate progress.
As a neutral convener, the National Academy of Medicine (formerly the Institute of Medicine), which I lead, is uniquely suited to bring together these many threads, uniting the organizations that are already developing solutions and bringing to the table other key stakeholders, including policymakers, insurers, and health information technology experts.
Nearly 20 years ago, the Institute of Medicine report “To Err Is Human” called the nation’s attention to the high rates of medical error in the United States. It helped launch the modern patient safety movement. The National Academy of Medicine now aims to perform a similar service for alleviating clinician burnout through our Action Collaborative on Clinician Well-Being and Resilience, which we recently launched in collaboration with the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education.
The goals of this collaborative are to raise the visibility of the problem of clinician burnout; better understand the challenges to clinician well-being; elevate evidence-based, multidisciplinary solutions that will improve patient care by caring for the caregiver; and monitor the implementation of these solutions.
The collaborative is currently made up of 55 core organizations and a network of more than 80 others, including clinician groups that span many disciplines and specialties, plus payers, researchers, government agencies, technology companies, patient organizations, and trainees. The collaborative is divided into four working groups that will meet over the course of two years to identify evidence-based strategies to improve clinician well-being at both the individual and systems levels.
These groups will produce a series of National Academy of Medicine Perspectives discussion papers, an all-encompassing conceptual model that reflects the domains affecting clinician well-being, and a common set of definitions. Another key resource the collaborative will launch in the coming months is an online knowledge hub — a user-friendly repository for data, models, and toolkits that will provide opportunities for clinicians and others to share information and build productive relationships.
Our health system cannot sustain the current rate of clinician burnout and continue to deliver safe, high-quality care. Yet I am optimistic that the tide is turning. The overwhelming response of more than 130 national organizations declaring their commitment to the collaborative’s work is a clear signal that clinician well-being is a growing priority for health care leaders, policymakers, payers, and other decision makers capable of bringing about system-level change.
Through collective action, we can tackle the multiple factors contributing to burnout, stem this epidemic, and promote well-being, thereby helping clinicians to provide the very best care to their patients.
Victor J. Dzau, M.D., is president of the National Academy of Medicine.
The study took a deep dive into the EHR problems to determine the root cause of burnout. According to the study:
Those reporting poor or marginal time for documentation had 2.8 times the odds of burnout.
Those reporting moderately high or excessive time on EHRs at home had 1.9 times the odds of burnout.
Those who agreed that EHRs add to their daily frustration had 2.4 times the odds of burnout. Read More:
https://blog.curemd.com/physician-burnout/
Very Nice Article! Thanks for sharing
After posting my prior comment on 2/19, I wanted to check out my concerns about this curious term “potential impairment.” It’s a phrase that is frequently referenced in both FSPHP and FSMB literature. It is also the same phrase that is used in one or more state’s laws in their statutes (Medical Practice Act) defining medical licensing board (MLB) and Physician Health Program (PHP) functions and the legal authority for their actions.
It’s one of those phrases that seems reasonable as you unconsciously say “oh, that must mean drunkenness, or drug dependence, or dementia or, you know ….” And one generally doesn’t further demand clarity. Right action is presumed of those who hold such authority. And until recent times, it had been a reliable maxim.
But I’ve been unable to obtain a clear definition of what constitutes a “potential impairment” or a “potentially impairing illness.” (And incidentally, there are profound implications to the subtle shift in focus from an individual with a possible impairment to an entire class of illnesses which are “potentially impairing” and therefore immediately implicate as potentially impaired all those who have those illnesses.)
And when there’s no clear definition, there’s no means of adjudicating what it means apart from courts telling plaintiffs that a) a board and PHP can say it’s whatever they determine it to be; and b) you can’t sue a state agency or an instrumentality given sovereign immunity. With that, there’s now a huge opening for one party to exercise inordinate freedom of interpretation on no objectively studied basis.
In other words, such loose terminology of potential impairment combined with unchallengeable authority sets the stage for abuse of discretion. And the burden on an individually charged / diagnosed-as-ill-and-impaired physician to prove abuse of discretion is impossible without demonstrating an agency pattern. But conversely, showing such a pattern is impossible because such individual cases never prevail. In other words, legally, one is stuck in an endless judicial loop.
My review of FSPHP Guidelines (the last official version is 2005 – see https://www.fsphp.org/resource/2005-fsphp-physician-health-program-guidelines) and FSMB impaired physician policies (http://www.fsmb.org/globalassets/advocacy/policies/physician-impairment.pdf) provides no clear definition of “potential impairment.” So, when you get right down to it, the drowsy inattentiveness from a bad head cold could be considered a “potential impairment.”
Now, one would presume most reasonable regulatory entities surely wouldn’t abuse this definitional discretionary power. But as I documented earlier, in the absence of any internal or governmental oversight, one state’s PHP violated the due process rights of 1,140 physicians over a ten year period. And evidence available in multiple cases reveal that fraudulent diagnoses were made knowingly, and done with impunity, in the context of governmental complicity in systematic denial of due process and denial of request for investigation by its oversight bodies.
So, my concern about this loose language of impairment and the unclear definitional criteria of burnout is that, when apprehended by regulatory licensing and fitness-for-duty assessment agencies which are neither overseen nor provide any means of grievance, a physician can be thrust into a veritable Kafkaesque nightmare. And at the end of it, s/he will be broke, broken and will find their careers permanently derailed.
Even independent of its consideration as a depressive illness, once burnout is allowed to be assigned official terminology referring to it as a condition which potentially impairs, then regulatory and PHP-wise, the stage is set. Now, not only will such a ubiquitous stress phenomenon officially authorize the compulsory submission of that physician to a non-overseen, non-medically licensed, non-impartial sovereignly immune PHP assessment entity. It will ensnare them in a PHP “preferred” for-profit treatment complex from which there is no escape.
But perhaps even worse. On close reading, some medical boards – and FSMB itself – maintain that it is a physician’s ethical duty to report to the board a physician whom one suspects may have a “potential impairment.”
State medical boards and PHPs are participating in this NAM collaborative and, on one level, their participation might be welcomed as their acknowledgement of the inordinate stresses facing licensed physicians today. But I’ve closely examined their positional statements and they are heavily laced with “potential impairment,” “potential for impairment” and “potentially impairing illness” phraseology. And that worries me greatly. I urge NAM to examine this inadvertent assignment of judicially reference-able language that might contribute to even worse consequences for the clinician already grappling with the anguish of burnout.
I have previously reached out to both FSMB and FSPHP to engage in a dialog about these concerns and have even offered to present at one of their meetings. I received no response. I would welcome FSMB’s and FSPHP’s comment here in STAT addressing these concerns. I’m willing to bet that the 50% of practicing physicians in the US today who might discover that they’ve been reported to their board and ordered to submit to a PHP assessment of their potentially impairing condition would also.
I read this article blind – that, is without reading the comments first. It was after reading that I found my response matching the major themes reflected in the commentary below. I will attempt to avoid too much redundancy.
I found that the concerns expressed by Dr. Dzau as well as his proposal and reports of action being taken looked like a duck, but did not quack like a duck, or perhaps, visa versa. Either way, it did not seem to meet the basic criteria necessary to convince me we actually have a duck here. If not a duck then, I must then wonder what is is we DO have. Thoughts on this have been in the many comments below, and perhaps, above. The problem of “burnout” is NOT that difficult to address – not with working professional in general – not with physicians or other healthcare professionals in the specific. “55 core organizations … a network of 80 others” … plans for the production of a series of NAM discussion papers … an “all-encompassing conceptual model “ … 130 national organizations …”? I mean, are we going to screw in the lightbulb or not?
My take away from this article is that it is TRAGICALLY disingenuous and unbecoming of intelligent persons. Others are speculating as they should – and must – why this is, because the most substantive part of this article is that a group of “could-be” game changers are putting in a VERY concerted effort to piece together an illusion of grand action rather than expending 1/100 of the energy on actually accomplishing a very simple task. Beyond this, the substance of this article can be reduced to a 3 word paraphrase which is “Burnout is bad.” That’s sad and not good enough. People are DYING – both doctors and patients, due to this “burnout” which is simply not that hard to address. Dr. Dzau’s tears? Spare me.
Christian Wolff, MA
Psychologist Associate (Inactive)
Healthcare Alliance for Regulatory Board Reform
harbr-usa.org
There seems to be a trend in healthcare professions-in the patients that see doctors, mid levels, counselors etc-in the providers themselves to some extent-and in the corrupt and money hungry boards that regulate them. That common trend is the expectation that they should be perfect. That they never have a bad day. That they never make a mistake. That they never fall subject to a drug or alcohol addiction. That they never say a cross word with their staff or patient. That they never speak to a romantic partner in a general way about a specific patient or client, that they maintain perfect, clean sterile lives. And that they do so in a method that some other nonperfect regulatory group has deemed “perfect.” (Even though its subjective bullshit at best). No wonder there is burnout. They started with one goal. To help and care for others. In the end what they got was more regulation, demanding litigious patients, managed care demands, and threat of total loss of career if you don’t play by an increasingly Orwellian set of rules. Even though the gatekeepers don’t follow their own rules governing their own behavior with NO OVERSIGHT in most all cases. Can a provider survive and thrive in an environment run by a government sanctioned mafia? No. They will burn out. Period. It’s past time for change. Put an end to corruption and greed in the system and see it thrive once again.
I concur with Manion.
At a time when employment rights for employees in all sectors have become more limited; and when laws passed with lobbying support from medical groups have produced laws (the Health Care Quality Improvement Act and Patient Safety and Quality Improvement Act) that have made it much more difficult for physician-employees to obtain due process against a hospital-employers’ peer review; investing in burnout and wellness interventions, without addressing the obvious, seems disingenuous.
Creating a burnout/wellness task force, conducting burnout/wellness research, and investing in burnout/wellness programs does not mean you care about physician wellbeing, and is not a substitute for employment rights. Employers should also not play doctor to their employees, not in this field, or anywhere else.
At a time when everyone else is talking about employer harassment and discrimination against employees in the workplace, why are we talking about corporate wellness programs and burnout interventions?
Nicholas D. Lawson, M.D.
Former psychiatry resident and incoming law student
Georgetown University Law Center
In reading Dr. Manion’s response to this article I was struck by how his expressed concerns reflect the real life horror stories of many physicians. Most professionals I have spoken to relate that the multiple stressors of their career pale in comparison to the trauma of dealing with their boards. These boards answer to no one, not even the governor, and have absolute power to make career and life altering decisions for dedicated physicians and psychologists. It is past time for these boards to be scrutinized and held to federal requirements including being supervised and acting on behalf of the public versus as gatekeepers to those they perceive as potential competitors.
As an internal medicine resident at a NYC hospital for 1969-70, I had the opportunity to attend our union’s leadership meeting regarding the affairs of our Committee of Interns and Residents UNION. Bargaining for an employment agreement is complex given the Federal rules that apply. You can bargain for salary, benefits and some working conditions. You can not negotiate for nursing staffing or hospital leadership priorities. Physician “burn-out” would not be solved by any collective bargaining process. When you don’t have any avenue to experience Trust, Cooperation and Reciprocity in the affairs of how your work environment is maintained, the occurrence of any level of social capital as a basis for employment would be highly remote.
I would affirm the thoughts of Kernan.
I attended NAM’s excellent clinician wellbeing conference last year and heartily applaud this broad reaching initiative.
There are two crucial and interrelated concerns about NAM’s initiative that immediately leap out. They pertain to an emerging and misguided conceptualization of burnout and to involvement of some of the regulatory organizations supporting this endeavor and I feel both must be addressed with high priority. The first is that burnout is being mistakenly equated with clinical depression and therefore with “mental illness.” The second is that Medical Licensing Boards (MLBs) and Physician Health Programs (PHPs) are actively involved in conceptualizing the burnout phenomenon while they may play a conflictual and, in the case of PHPs, potentially self-interested role in assessing, treating and referring those grappling with it.
Burnout is an occupational stress syndrome; it is not the same as the diagnosable mental condition known as depression. Treating burnout as an inevitable preamble or equivalent to depression is not only not supported by the research, such may be iatrogenically harmful. It is also a very slippery slope of pathologizing normal human behavior. That one experiences stress that may overwhelm one’s coping does not connote illness.
The optimal approach to a stress syndrome is stress management which has two core elements: stressee management, i.e. optimizing how one deals with that stress and manages one’s stress response; and stressor management, i.e. taking an active role in identifying and fixing what is causing the stress. This latter often entails recognizing that there are certain stressors (e.g the EMR, toxic leadership, “productivity” demands; threat of litigation etc.) that are out of one’s individual capacity to change and require the efforts of a group of people who share the same stressor and can collaborate effectively to implement actionable solutions. In the fragmented healthcare ecosystem that we currently have, the concrete vehicles to accomplish this don’t exist at the local community hospital level.
Labeling burnout as a clinical syndrome necessarily leads to the sufferer, now the “patient,” being assigned some variation of a mental illness diagnosis. This has profound and even dangerous implications for physicians for numerous reasons. Perhaps the most important consideration is that being given a “mental illness” diagnosis, no matter how seemingly benign and rote for the treating clinician (for example, assigning the lowest level reimbursable diagnosis of “adjustment disorder with depressed mood”), such is nevertheless a DSM-coded “mental illness” diagnosis. And the fact of getting or even having remotely gotten “treatment” for a “mental illness” may be considered mandatorily reportable by a MLB and have profound consequences on medical licensure.
Many medical licensure boards (MLBs) still routinely ask deeply invasive and in fact legally impermissible questions of physician applicants such as whether they have ever had a mental illness or been hospitalized or treated for same, regardless of the benign counseling nature of the psychotherapy, the appropriate use of prescribed psychotropics or the absence of any behavior or report suggestive of impairment. Such acknowledgement is sufficient to set the pretext for MLB demands for utmost confidential records of an intimately personal nature which are rightfully private and protected by law. That MLBs or PHPs may not have qualified licensed specialist personnel on staff to review such records and handle such matters with discretion is of course an alarming consideration but one which will not be explored here.
Worse, a positive answer almost guarantees mandated referral to the MLB’s affiliated Physician Health Program (PHP) for what amounts to an involuntary de novo psychiatric diagnostic assessment. And what happens there can be deeply – and irreversibly – problematic. PHPs may then conduct a highly invasive, binding forensic “fitness for duty” psychiatric evaluation, compel immediate submission to unwarranted and humiliating laboratory testing, and then make legally incontestable and irreversible diagnostic determinations of the nature and severity not only of that original MLB reason-for-referral mental illness, but perhaps arrive at a new psychiatric diagnosis, and then “recommend” treatment or further costly assessment at one of its “preferred programs.” And MLBs, by nature of their affiliation, then invariably mandate compliance with the sovereignly protected PHP’s recommendations.
In one state, responding to multiple senior psychiatrists’ concerns about erroneous diagnoses emanating from MLB-mandated PHP evaluations, the State Auditor found that over the course of the preceding decade, that PHP violated the due process rights of 1,140 physicians in the diagnostic evaluations it conducted, at a minimum by refusing them a copy of its diagnostic evaluation report, by refusing to acknowledge results of a qualified concurrent independent diagnostic evaluation which may have challenged the PHP’s findings, and by refusing all means of grievance. Its virtual board order (requiring targeted physicians to report out of state to one of its “preferred programs”) was not only incontestable but also non-litigable as that PHP’s determinations were not only deemed infallible by the MLB but both its findings and the subsequent MLB orders for immediate compliance with that PHP’s “recommendations” – under threat of immediate license revocation – were covered under the state’s sovereign immunity. That PHP is one of this NAM initiative’s supporting organizations.
Understandably, a MLB may have a legislatively granted right or even duty to screen licensees for a potentially impairing mental illness. “Potentially impairing” already affords way too much latitude. But burnout now as a mental illness or potentially leading to one which might cause “impairment?” I believe MLBs’ mandatory referral of physicians and other healthcare professionals to their affiliated PHPs for non-impartial diagnostic assessment and recommending a specific course of “treatment,” or “referral” to one of their preferred programs for the newly established “mental illness” of burnout to assess its “potential for impairment” poses a frightening spectre. Further, seeing that the prevalence of burnout is approaching 50% of all practicing clinicians, the magnitude of career jeopardy and the Kafkaesque regulatory legal nightmare this would subject physicians to is simply mind-boggling.
It’s certainly welcome and commendable that MLBs (here FSMB) and PHPs (both FSPHP and multiple state PHPs) express these first signs of compassion for the profession they regulate by acknowledging the epidemic of burnout and endorsing NAM’s broad-reaching ameliorative efforts. But their absence of government and external ethics-compliant oversight and the lack of explicit clarity in distinguishing their regulatory licensing and potentially self-interested “preferred referral” roles from their expressed altruistic physician wellbeing concerns raise large red flags. I think examining the extent of MLBs and PHPs active participation in shaping the dialog around the hypothesized clinical nature of burnout and its natural pathway to coerced diagnostic assessment, “treatment,” and lengthy “monitoring” ought to be a high priority, both for NAM and for physicians as a whole.
Kernan Manion, MD
References:
“Collective action needed to stem burnout and restore clinician well-being and resilience” By Victor Dzau, STAT News, February 15, 2018 https://www.statnews.com/2018/02/15/clinician-physician-burnout-resilience/ (last accessed 2/18/2018)
National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience – https://nam.edu/initiatives/clinician-resilience-and-well-being/ (last accessed 2/18/2018)
State Of North Carolina – Performance Audit – North Carolina Physicians Health Program. April 8, 2014. Office Of The State Auditor, Beth A. Wood, CPA State Auditor http://www.ncauditor.net/EPSWeb/Reports/Performance/PER-2013-8141.pdf (last accessed 2/18/2018)
How can a highly competent physician, “burn out”, when they are subjected to the draconian methods practiced by the “chemical dependence counselors’ at the PHPs who hold only an associate’s degree and have a PMH + for drug &/or EtOh abuse?
As a physician/coach/consultant who has been dedicated to preventing physician burnout since 2010, I welcome all the new found attention. The challenge for academic organizations will always be to stop studying the problem and actually make meaningful changes.
In our practice, we have found over 235 ways to prevent physician burnout
https://support.thehappymd.com/physician-burnout-prevention-matrix
And conditions for front line doctors in the majority of US healthcare organizations are deteriorating by the week, unfortunately.
Dike
Dike Drummond MD
CEO and Founder TheHappyMD(dot)com
Dike you won’t fix anything for these docs with the present system in place. Medical Boards and the Federation of State Medical Boards have destroyed the ability to practice medicine. Medical Boards have no oversight and they are the investigators, judge, jury and hangman. They use their position of power to remove competition, Integrative Medicine docs, docs who stand up for their supposed Constitutional Rights and Due Process rights, docs who try to “explain” themselves to the the Board or just anyone they don’t like. Docs are in constant fear of psychological and financial abuse by these boards who seemingly are run by psychopaths and sociopaths.
Here in Oregon it is out of control. Kathleen Haley is the Exec. Director of the OMB. Warren Foote is the AAG who oversees 5 different healthcare boards including the OMB. They openly use their positions of governmental power to engage in perjury, ex parte contact with ALJs who oversee hearings which are simply facades of justice, hearsay, no allowance of cross examination of supposed witnesses, individuals portrayed as experts who simply aren’t, the trashing of any Due Process, witness intimidation, etc. All this has been documented, but the Oregon State Bar has basically refused to investigate these claims and the supposedly “progressive” politicians we elect in Oregon will not look into it any further even though they openly express their dislike of the OMB.
The courts, at least the Oregon ones and the Ninth Circuit, have given these bureaucrats absolute immunity from any State or Federal laws as a result of the HCQIA of 1986.
You can’t fix broken Dike. Few docs are happy. My son certainly won’t go into medicine where satisfaction is in the high 30s and low 40s percentiles. He will be going into engineering where all satisfaction ratings are above 85% overall – none below 80%.
Respectfully
Eric Dover, MD
drdovervsomb.weebly.com
You need to understand the abuses of power that the state regulators engage in under the plume of “sovereign immunity”. No oversight exists. In Washington, the Attorney general’s minions prosecute cases. prosecutorial misconduct is routine. I ran into our former AG, who supervised the assistant Ams who went after me, at the grocery store here in Olympia, Wa. She has NO clue of the misery she has wrought!
Erik is correct. Washington is no different than Oregon. The state employees of the regulatory agencies routinely measure their “success rate” by the number of physicians they prosecute (persecute).