© 2012 Dr. Dale Peterson & drdalepeterson.com

On August 20, 2012 the Archives of Internal Medicine published an online article titled “Burnout and Satisfaction with Work-Life Balance among US Physicians Relative to the General US Population.” It reported the results of a survey of physicians in the United States and compared them to those of a survey of the general U.S. population. The survey found that nearly half of the doctors surveyed were experiencing what is referred to as “burnout.” The percentage was even higher in those specialties on the front lines of medical care. Sixty-five percent of emergency physicians reported burnout symptoms as did fifty-five percent of general internists and fifty-two percent of family physicians.

The survey findings should be of interest to anyone seeing a physician, as burnout is associated with a loss of professionalism, a diminished quality of care, and a greater risk for making medical errors. Physicians in burnout are less likely to view those seeking their care as persons rather than objects and therefore they tend to view them with a high degree of cynicism. This is not a nurturing environment that is conducive to healing. Rather, it is a toxic environment that is a recipe for disaster.

Burnout has many characteristics including fatigue, exhaustion, inability to concentrate, depression, anxiety, insomnia, and irritability. Individuals who are experiencing burnout are more likely to abuse alcohol or drugs. They are also more likely to consider suicide. This explains why the suicide rate among male physicians is 40 % higher than among men in the general population and that of female physicians is 130 % higher than among women in the general population. The primary characteristic of burnout, however, is a loss of interest in one’s work or personal life and a feeling of “just going through the motions.”

Many factors that contribute to burnout have been identified. They include excessive workload, loss of autonomy, inefficiency due to excessive administrative burdens, a decline in the sense of meaning that physicians derive from work, and difficulty integrating personal and professional life. The authors of the article were able to look beyond the symptoms and identify the root cause of the physician burnout epidemic. “The origins of this problem,” they concluded, “are rooted in the environment and care delivery system rather than in the personal characteristics of a few susceptible individuals.”

In other words, the United States Health Care System (hereafter referred to as “the system”) is toxic. It has become dysfunctional, and it is destroying the lives of those working within its boundaries while placing those who are seeking care through it at risk of being harmed rather than helped. It is easy to predict that the situation will only worsen as the provisions of the Affordable Care Act take effect.

My personal experience is illustrative of how the current system of medical care has devolved to the point at which burnout is not only predictable, but inevitable for a majority of physicians. In 1999 I recognized that I could not survive if I continued to practice medicine within the confines of the system. I could drop out of the system or die. I chose to live, and today I find helping sick people become well more rewarding and satisfying than at any other time in my forty years as a physician.

I want you to understand the pressures your personal physician may be experiencing within the system. It should help you recognize whether he or she is at risk for burnout and whether your health may be at risk as a result.

One factor that leads to burnout is an excessive workload. I believe that this is one of the reasons that emergency physicians, general internists, and family physicians are at greatest risk of experiencing burnout.

The system has played a huge role in creating the excessive workload of front-line physicians. The stage was set by the creation of Medicare and Medicaid in 1965. Prior to the advent of those agencies there was a relative parity of reimbursement for medical services across medical specialties. While certain specialtists were able to earn more than others it was still possible to earn a respectable living as a general physician. Medicare and Medicaid, however, established a system of payment for medical services that favored the performance of technical procedures and significantly undervalued cognitive (thinking) and supportive (caring) services.

This created an income disparity between specialties that perform a significant number of diagnostic or therapeutic procedures and those that are devoted primarily to analyzing signs and symptoms and providing support to those under their care. Other third party insurers followed the lead of the governmental programs, which magnified the problem. Today the difference in earnings between front-line caregivers and those performing procedures is so great that it has become nearly impossible to interest medical students in pursuing a career in general medicine. In an ideal medical world a sizeable majority of physicians would be providing primary care to the population and a minority would be providing specialized services. In the system, however, a dwindling number of physicians are providing primary care to a rising number of patients. As the ability to obtain a same-day appointment to a general internist or family physician has decreased the number of people seeking care from emergency rooms has increased. The result is a system in which the doctors charged with providing first-line care to patients are overworked and underpaid – a recipe for burnout.

The system is committed to enlarging this problem. It is estimated that the Affordable Care Act will add sixteen million recipients without adding a single provider. A speaker at a meeting I attended shortly after the bill was passed likened it to a large city deciding to provide free bus service to its citizens. Announcing the new program the mayor said, “I have good news and bad news . . . the good news is that everyone can now ride the buses for free. The bad news is that we only have three busses.”

Loss of autonomy is another recognized factor leading to burnout. Lack of perceived control is, in fact, the leading indicator of physician burnout. Over the past several decades the system has been methodically undermining physician autonomy. A number of examples can be given.

When I first entered medical practice I worked in offices that enjoyed the freedom to provide services efficiently and cost-effectively. That changed abruptly with the passage of CLIA, the Clinical Laboratory Improvement Act of 1988. CLIA placed restrictions upon the ability of physicians to perform laboratory tests in their private offices. In many cases this meant that procedures that had been routinely performed on site now had to be referred to an off-site reference laboratory, a process that was not only much more costly, but which adversely affected patient care.

Urinary tract infections (bladder and kidney infections) are one of the most common challenges seen in a primary care office. Prior to the passage of CLIA a patient suspected of having an infection could provide a sample of urine in my office. If it appeared that an infection was present the specimen could be placed immediately on a culture plate and incubated overnight. By the next morning the organism(s) causing the infection could be placed on a larger culture plate onto which were also placed disks containing various antibiotics. By the following day I would know which antibiotics would effectively treat the infection and which would not. The process was efficient and the cost was nominal.

When CLIA took effect urine cultures and sensitivities could no longer be performed on site. Doing so would have required installation of industrial exhaust systems that were well beyond the resources of a physician office practice. Not only were the equipment specifications beyond our reach, the law required that a colony of every potential infecting bacteria be kept growing in the laboratory continuously! The incubator space required would have been larger than our entire laboratory.

Office urine cultures and sensitivities rapidly became a thing of the past in my practice. Because the urine sample had to be sent to a reference laboratory for processing it could no longer be plated and placed in an incubator immediately. Even though the specimens were refrigerated prior to transport bacteria, contaminants in the sample would multiply and compromise the results of the test. The results were no longer as clear-cut as they had been on site, and the cost was prohibitive for many patients. Autonomy was lost and patient care suffered as a result.

CLIA was but one of many ways the system attacked physician autonomy. Insurance companies began aligning themselves with specific physicians and hospitals. I had become accustomed to referring patients to specialists I knew well. I could usually match the specialist’s personality and practice patterns to best fit the individual whom I was referring. A significant part of the art of medicine was lost when the ability to choose the physicians to whom I would refer patients was taken away. The requirement that I refer someone to a faceless name found in an insurance company manual was another means the system used to remove my autonomy and take control of my medical decision making.

To a great extent the system has taken decision making out of the hands of those in the trenches and given it to bureaucrats sitting in sterile offices far removed from direct patient care. Those decision makers are less concerned about the best interests of patients than they are about the insurer’s bottom line.

When I entered practice I had the authority to determine when someone required hospitalization and when they were well enough to be discharged. Both of those critical decisions were later usurped by the system.

The decision to hospitalize an individual is often not an easy one. There are times when it should be dictated by a general impression rather than by a specific diagnosis, but the system refuses to recognize a principle I learned in my first year in private practice. I recall sitting in our rural hospital emergency room one evening when an older, wiser colleague happened by. I apparently looked perplexed as he asked me what was wrong. I explained that I had been called out to examine a woman who appeared ill, but whose initial examination and test results had failed to reveal a cause. The older doctor advised me that he had learned over the course of his career that it was best to hospitalize such individuals, as very often a serious problem would present itself over the next 24 to 48 hours. He was absolutely right, but today a patient must have a diagnosis the system recognizes before hospitalization will be approved.

I also remember speaking with an insurance company employee in Minneapolis, Minnesota about the need for one of my obstetrical patients to stay an extra day. The delivery had been complicated and the woman had hemorrhaged severely. Her insurance company’s policy stated that mothers were to be discharged on the day following the delivery. In this case, the new mother was too weak to stand up without assistance. I appealed to the system to allow her to stay an extra day, but my request was summarily dismissed with the words, “In Minnesota we send patients home on the day after delivery routinely and you can learn to do the same in Oklahoma.” Once more the system’s removal of physician autonomy had resulted in a loss of quality of patient care.

A third factor leading to burnout is inefficiency due to excessive administrative burdens. As in the case of loss of autonomy, CLIA provides an excellent case in point. In order to continue to perform on site testing we were required to develop a set of laboratory manuals describing each test in detail and providing an in depth discussion of the steps involved in performing the test. It mattered not to CLIA that our medical technologists held professional degrees demonstrating that they had been trained in correct laboratory procedures and that those procedures were readily available in standard textbooks, nor did it matter that the information was included with each test kit we purchased. The techs spent endless hours preparing the manuals and I, as the laboratory’s medical director spent hours signing each page as required by the CLIA regulations. The chore was never-ending, as I was required to review and initial each page annually, a task that took the better part of the first Saturday in January each year.

OSHA added its own administrative requirements, as did the EPA. Keeping abreast of the endless rules and regulations was an impossible task. The EPA, for example, determined at one point that urine samples could not be disposed of by flushing them down the drain. The portion of urine that went directly from the patient to the toilet bowl could be flushed, but the portion that was caught in the specimen cup was immediately and magically transformed into a biohazard that was to be placed in barrels and taken to a toxic waste facility. Some physician offices were fined $10,000 per occurrence for flushing urine specimens rather than paying a hazardous waste company to dispose of them in an acceptable manner. Fortunately clearer heads finally prevailed and routine urine specimens are no longer considered biohazardous waste.

The system has also been instrumental in removing the sense of meaning that physicians derive from their work. The system refuses to recognize doctors as physicians and chooses to refer to them as “health care providers.” The designation has more than semantic significance.

Webster’s Ninth New Collegiate Dictionary defines a physician as “A person skilled in the art of healing; specifically: a doctor of medicine. One exerting a remedial or salutary influence.” It defines a provider as one that provides.

A physician is an artist whose very presence can exert a healing effect. A provider is a technician performing those duties the system requires. A physician has a calling; a provider has a job. A physician cares; a provider goes through the motions.

Is it any wonder that people who enter medicine with a sincere desire to help relieve the suffering of others have difficulty finding meaning in carrying out the dictates of an impersonal system dedicated to its own interests rather than those of hurting individuals? Is it surprising that they become cynical as they find themselves under constant scrutiny by third parties who are charged with modifying their behavior?

It has been over thirteen years since I opted out of the system. In doing so I reduced my workload to less than a third of what the system demanded. I regained my autonomy; I’m free to make recommendations based solely upon what I believe to be in the best interest of the person consulting me. I eliminated over ninety percent of my administrative burdens. Most importantly, I became a physician again rather than a health care provider. As a result I’m reminded every day how rewarding and meaningful helping sick people become well can be.

I write this article to help you understand why the physicians you encounter may be less personable than you’d like. I write it to help you appreciate why the treatment you receive, which is largely dictated by the system, may not effectively address your health challenges. I write the article to make you aware that at some time you too may need to step outside the system to effectively address your health challenges.

While it’s not possible to identify a burned out doctor with certainty during a brief office visit there are some signs that suggest that burnout exists or is imminent. One is the length of time you are required to wait before being seen. Since the complexity of medical problems can’t always be anticipated and because medical crises arise without warning there will be times when your physician will get behind and you’ll find yourself waiting to be seen beyond your appointment time. If long waits are the rule rather than the exception, however, it’s a sign that your doctor’s workload is excessive and that burnout has occurred or will follow.

Another sign that your doctor is experiencing burnout is a failure to be heard. A doctor in burnout will often appear distracted or will be focused on your chart rather than what you are saying. He or she may avoid direct eye contact and the visit may feel mechanical rather than personable. If your doctor doesn’t listen to you it’s time to find another.

Physicians in burnout don’t want to prolong visits. They are more likely to dictate a treatment plan rather than present options and discuss them. If your doctor doesn’t explain what your choices are and take time to respond to your questions move on.

A burned out physician is often incapable of searching for answers when they aren’t readily apparent. It then becomes easier to dismiss symptoms as being due to depression than to an as yet unidentified cause. If you don’t feel depressed but your doctor insists that you start taking an antidepressant seek a second or third opinion.

Burned out physicians are no longer capable of providing meaningful care and support to their patients. If you suspect that your physician is experiencing burnout take whatever steps are necessary to find one who is not. Doing so may ultimately save your life.

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