Physicians are leaving the field in relative droves in recent years. Some retiring early, many taking very extended maternity leaves, many reducing hours, others going off into different fields altogether. There has been a growing sense of disillusionment, really, more so probably than burnout, among physicians. “Burnout” is what occurs in training, the combination of exhaustion and depression that leaves one too beaten down to resist. Disillusionment is what occurs after one manages to gather a few wits back about oneself. Enough to stop and say, as the Talking Heads put it so pithily, “My God! What have I done?!”
Being a doc just ain’t what it used to be. Administrators rule the boardrooms. Nurses rule the hospitals. Insurers rule the universe. So what happened? Certainly, the Digital Age happened, the birth of the algorithm, the “checklist manifestoes” that dumbed down medicine enough to allow non-medical types to take over. But physicians have colluded, and they, we, allow the situation to go on. Not because physicians, as a group, desire this way of being, but more as a consequence of their training. A training that has not changed much while the rest of the universe has been rocketing by. Unfortunately, one of the consequences of the soul-numbing process of becoming a physician is the general sense of humility (beaten down-ness?) it brings to most (not all). This is something utterly foreign to the training of most other health care-related professions and jobs, and absolutely foreign to the administrative side. This is also why physicians have no effective common leadership. We are trained to be doctors, after all, not corporate cogs.
Still, to read the “Action Plans” of various administrative bodies in attempts “to address the issue” — an issue of “retention” as they see it, certainly not of compassion — one would think this is a fairly sudden crisis, coming to popular attention as health care in general has been dramatized in the popular media.
As a typical example, according to the American Medical Association’s recent "Stepsforward" plan to “Creating the Organizational Foundation for Joy in Medicine” (even George Orwell could not have made this stuff up), seven “action steps” should now be taken by “physician organizations” and “organizations that employ physicians” to address the mounting crisis of burnout. These steps are:
- Create a central well-being committee.
- Celebrate successes and share updates.
- Consider every member of the care team.
- Enhance visibility and sharing between groups.
- Offer administrative and managerial support.
- Acknowledge the contribution of adverse events.
- Follow through, revise, and refine.
As my 7-year-old daughter would say, “Seriously?”
In addition to the head-scratching recommendations from the AMA, other unproven solutions endorsed by some of the mightier healthcare megaliths include the encouragement to seek out meditative practices, the providing of “wellness apps” and wellness websites that allow you to rate your level of burnout on a daily basis (in order to track your “progress,” or “regress,” I suppose), the encouragement to seek mental health support without fear of stigma (i.e. the ubiquitous cocktail of stimulants and benzoes), and of course the Sisyphean push to “recognize” the "work we do.”
All critical thought aside (we are talking boardrooms, after all), this is a topic of interest to me and my colleagues. And should be of at least passing interest to anyone who utilizes the services of physicians.
But first, an economic caveat:
Physician-hood, it should be remembered, is different from all other corporate-professional fields in that there is no real path to advancement. Once you’re a doctor, that’s it. You’ll stay where you’re at, professionally, for the next 30 years or so, male or female. Except in a tiny percentage of floating corporate-ivory palaces, there is no corporate ladder. There are no promotions other than the ubiquitous quasi-academic titles that come with no corresponding pay increase. You are what you are, and though the salary is above average, you will start years later than your colleagues, and you will start at well below poverty. Your pay will also not increase significantly as the years go by. This is a critical, if inconvenient, piece ignored in all these discussions around “burnout.”
That said, and after lengthy discussions with colleagues, across specialties, I have come up with an even simpler (i.e. concrete) “action” plan than those steps listed above.
Here is my own seven-step program (some of which have been urged in other contexts, but bear repeating), and I would challenge anyone to find me a physician — one who actually sees patients, that is — who would not agree with the spirit of it. These are listed in no particular order:
- Dismantle the state boards of registration in medicine and any and all “maintenance of certification” requirements. There is considerable evidence that these requirements exhaust and provoke chronic anxiety among physicians, subsequently, ironically, leading to poor self-care, which typically translates into poor patient care. There is zero evidence that the increasingly onerous and expensive requirements for maintaining one’s board certification improves patient care. This should be a state and/or federal legislative effort as the financial conflicts of interest among professional organizations, hospitals, and the boards is too great to allow for self-policing.
- Make prior authorizations for hospitalizations, procedures, and/or medications of any kind flat-out illegal, not punishable by fines, but by allowing malpractice suits without limits against insurance companies. Insurers reportedly base their clinical decisions upon the expert opinions of their own medical staff, i.e. they operate substantially like a “health care” system, and they, not individual physicians, need to bear the appropriate lion’s share of the responsibility for denials and delays.
- Eliminate “value-based” incentives, as there is no meaningful definition of “value” in medicine. All “incentives” to physicians are thinly-veiled incentives to Big Insura, which means that all “incentives” to physicians are measures that conflict with good patient care. For example, I am rewarded for cutting down on face-to-face time with patients. I am rewarded for prescribing less effective medications. I am rewarded for paying less attention to detail. It’s time to call a spade a spade, and be done with it. Pay people for the job they do.
- Criminalize online reviews of physicians. Our services are not like other services. There is often a world of difference between appropriate care and what the patient wants. This is social media coercion, often to dangerous ends — i.e. demanding inappropriate prescriptions lest I drag your name through the mud — and this constant worry in the digital age contributes significantly to “burnout.”
- Decrease documentation requirements. And more complex and expensive electronic health records (EHRs) are not the answer. Much like technology in the classroom has been shown to make children dumber, so the more advanced EHRs have been shown only to increase the amount of time physicians spend on documentation — in fact, creating dangerously useless levels of documentation (i.e. a hundred or so note for a three-day admission for an appendectomy) — and decrease time on patient care. (Related to this, there are far too many useless electronic “quality improvement projects” foisted upon us by our own colleagues, subsequently making the rest of our lives hell.) Fewer templates and smartphrases; more dictation services and scribes.
- Provide national amnesty for all medical school loans. The tuition charged is criminal; the loans provided are criminal. New York University, with its new policy of tuition-free medical education, if nothing else has just shown us how little these institutions rely on income from tuition. Only banks profit from this. Compelling people to live in debt is medieval and barbaric. It is institutional torture. This may be the single biggest burnout contributor for newer physicians especially.
- Pay more. This simple, absurdly commonsensical step can work wonders in reducing burnout.
There you have it. If we want to improve doctors’ lives and be happy, and we should all want our doctors to be happy, that’s the basic recipe.
Elliott Martin, MD, is a board-certified adult and child psychiatrist at Newton-Wellesley Hospital, as well as the Director of Consultation and Emergency Psychiatric Services at Newton-Wellesley Hospital, and Assistant Clinical Professor of Psychiatry at Tufts University School of Medicine. He is a 2018–19 Doximity Author.