Message from President

Gregory W. Rouan, MD

doctor exhaustion

Message from President Gregory W. Rouan, MD

Navigating the Local and National Waters of Healthcare Delivery

academy of medicineWith the realities of our current health care delivery system, there exists a fundamental tension that physicians are at risk of becoming patients themselves.

“. . . it (is) clear to me that to reduce physician burnout and re-enchant medicine we need to reestablish the importance of the relationship between patient and physician. Therein lies the magic.” This is a quote by Dr. Lydia S. Dugdale from Yale in a recent JAMA perspective piece called Re-Enchanting Medicine in the Physician Work Environment and Wellbeing Section of the Journal.1 She went on to state, “Medicine has become defined by metrics and efficiency. But our patients do not suffer efficiently.”

The Academy of Medicine has chosen to prioritize "the health and wellness of physicians in their personal and professional lives" as part of our strategic plan. We are reaching out broadly to all physicians, health care systems, and the community at large to do so. We have already implemented several initiatives in an effort to address this agenda.

Burnout is a syndrome of exhaustion, cynicism, and decreased effectiveness at work and home. This is the simplistic definition used by Dr. West from the Mayo Clinic.2 The burnout syndrome was only described in 1974, though obviously existed as an entity prior to that time.3 It not only affects health care workers but also others who are involved in intense interactions with people. Burnout occurs when resources do not meet demand. More definitively there are five issues that lead to physician distrust and burnout: (1) excessive work effort, (2) subpar work efficiency, (3) interference of work on home life, (4) a poor sense of meaning and lack of flexibility, and (5) lack of control and autonomy.

One might ask why has a physician professional society, whose membership holds providing the highest patient care delivery as its ultimate mission, chosen to seemingly instead focus on health and wellness of physicians. The literature supports the fact that physician burnout negatively affects the quality of care provided in the US health care delivery system. For example self-reported errors, turnover, and increased patient mortality in hospitalized patients.4

Health care delivery, and broadly the field of medicine, continues to evolve and become more complex. The systematic and rapid implementation of electronic health records (EHRs) and the proliferation of pay-for-performance metrics – at a minimum – have resulted in significant deterioration of the physician’s experience, and thus, have negatively affected their professional and ultimately personal lives. In most areas technologic advances enhance efficiency. However EHRs typically increase clerical burden for physicians in large part due to the focus on physician and hospital billing instead of adding value to patient care.

Doing too much and doing so inefficiently with too little control and without a sense of purpose results in burnout in doctors more often in this scenario than for those who are in an environment that is supportive and conducive to efficient practice. The Maslach burnout inventory is the three-prong test measuring: (1) emotional exhaustion, (2) depersonalization, and (3) personal accomplishment.5 Finding meaning in one's job proves challenging in large part due to aspiring to practice good medicine, not confined to narrow constraints, and at least to include higher-quality and better outcomes.

Broad categories of interventions include an individual focused approach to organizational solutions. Physician centered tactics such as mindfulness, stress reduction, resilience training, and small group communications are examples of the former. Health care systems and their leadership must take responsibility from an organizational standpoint.6 Panagioti described controlled interventions to reduce burnout in physicians, which is a JAMA systematic review and meta-analysis focused on the adoption of organizational directed approaches.7

Allowing for honest conversations about emotional exhaustion, depersonalization, and a low sense of personal accomplishment positively impacts physician work and home lives and already is a best practice that has been established in other professions.

Why should hospital systems and their physician colleagues who experience burnout be mindful of the syndrome? A survey from the American Medical Association demonstrated that the prevalence of burnout in 2011 was 45% and in 2014 was up to 55%. Such an increase is in large part due to bureaucratic tasks being performed by physicians, extensive work hours in the schedule, computerization in health care systems, and limited compensation. Burnout also results in lower work satisfaction, disrupted personal relationships, substance misuse, depression, and suicide. Every year 300 to 400 physicians in the United States commit suicide. Female physicians are three times more likely to do so. Overall, the rate is 1.4 times higher among physicians compared to the general population.

Definitive interventions include developing multidisciplinary teams thereby allowing less costly support staff to perform much of the work not requiring physician expertise. In addition, reducing unnecessary interruptions and the stress those cause is advantageous. Lastly, paying attention to personal professional well-being, adjusting physician schedules, and ensuring they have adequate training for their clinical competencies to be maintained are also key.

Substantive progress requires alignment of government, professional societies, health care organizations, leaders, and individual physicians. The recently announced National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience is such an approach to addressing this matter.8 Though the cooperation at every level is required, the Academy of Medicine is taking ownership by sponsoring the Southwest Ohio Regional Update in Internal Medicine in a collaborative fashion with many in our community.

In closing, perhaps a wish that we might all have is that the Academy succeeds in improving the personal and professional lives of physicians in our community. As Atul Gawande9 has described, relationships with physicians benefit the health of patients. Patients live longer and are hospitalized less. But what Gawande does not mention is that strong relationships with patients also benefit the health of physicians.1
The strategic journey of the Academy through the waters of the local and national health care environment may be a bit choppy. However, with our current and future leadership and their commitment to our priorities, we are on course to succeed.

1. Dugdale, LS, Re-Enchanting Medicine. JAMA Internal Medicine. 2017:177:1075-1076.
2. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281.PubMedArticle
3. Freudenburger H. Staff burnout. J Soc Issues. 1974;30(1):159-165.
4. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613.
5. Maslach, C., Jackson, S.E, & Leiter, M.P. MBI: The Maslach Burnout Inventory: Manual. Palo Alto: Consulting Psychologists Press, 1996.
6. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374(9702):1714-1721.
7. Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177:195-205.
8. National Academy of Medicine. Action collaborative on clinician well-being and resilience. https://nam.edu/initiatives/clinician-resilience-and-well-being/. Accessed September 8, 2017
9. Gawande A. The heroisim of incremental care. The New Yorker. January 23, 2017. http://www.newyorker.com/magazine/2017/01/23/the-heroism-of-incremental-care. Accessed August 20, 2017.