Physician Burnout - How Are You Doing?
Robert E. Van Demark, Jr., MD
SDSMA President

Earlier this year I met an old friend at a Hand Society meeting in Denver. He practices Orthopedic surgery in Summit County, Colorado. After we had talked about our children and what they were doing, he asked me if I had any retirement plans (he is a few years younger than me). I told him that I hadn’t thought much about it and that I still like taking care of patients. Peter told me that he also likes working but it is all “the other stuff” that drives him crazy. We commiserated about our respective electronic medical records (EMR) and how the EMR is number 1 on his “the other stuff” list (sound familiar?).  He is not alone. Several of my friends have retired recently for the same reason.

What is Burnout? 

Burnout is a syndrome characterized by exhaustion, cynicism, and reduced effectiveness. Physician burnout has been shown to influence patient care, patient safety, physician turnover, and patient satisfaction. Burnout also leads to broken relationships, alcohol use and suicidal ideation. (1,2) 

Who is Affected?

In a recent study from the Mayo Clinic and the American Medical Association, approximately 50 percent of physicians in the U.S. are suffering from some degree of burnout. This has increased approximately 10 percent from a previous survey done in 2010.3 All specialties are affected with the primary care specialties (family practice, internal medicine, pediatrics and emergency medicine) having the highest rates of burnout.(4) In that same study, after adjusting for physician age, sex, specialty, practice setting and hours worked, physicians who used EMRs and computerized physician order entry (CPOE) were less satisfied with the amount of time spent on clerical tasks and were at higher risk for professional burnout.(4,5) Burnout has also been reported in medical students, residents and residency program directors. (2,6-8)

What are the Causes?

The reasons for burnout are variable and complex. Some physicians feel that the widespread use of EHR, electronic prescribing, electronic patient portals, and computerized physician order entry (CPOE) has led to information overload, interruption/distraction, and a dramatic change in the content of professional work.(4)  A 2015 study showed that high-stress environments (odds ratio, 13.7) and poor work control (odds ratio, 4.3) correlated with high burnout rates. The factors include chaotic clinical environments, insufficient time for documentation and use of EHR at home, short visits for complex patients, organizational ambivalence toward physician support and a need for work-life balance.(9) 

Sinsky et al. reported on a time and motion study in four specialty practices (family medicine, internal medicine, cardiology and orthopedic surgery). During office hours, physicians spent 27 percent of their time in direct clinical face time with patients and 49.2 percent of their time on the EHR and desk work. With patients in the exam room, physicians spent 52.9 percent of their time on direct clinical face time and 37 percent on EHR and desk work. Twenty-one physicians completed an after-hours diary and reported an additional one to two hours of after-hours work each night, devoted mostly to EHR tasks.(10)

A recent article described a surge in “desktop” medicine (practicing medicine on your desktop computer). The authors studied physicians’ time spent with EHR transactions. Thirty-one million EHR transactions were recorded for 471 primary care physicians who were involved with 765,129 visits. The physicians logged an average of 3.08 hours on office visits and 3.17 hours on desktop medicine every day; 34 percent of the logged time was spent doing progress notes.(11)

A recent paper in Clinical Orthopedics and Related Research entitled “Clinical faceoff: physician burnout – fact, fantasy, or the fourth component of the triple aim” discusses physician burnout. One of the phrases used in the article is “the triple aim.” The triple aim suggests a redesign of the health care delivery system to do the following: (1) Improve patient outcomes, (2) increase patient satisfaction, and (3) decrease overall cost. The authors suggest adding a fourth component to the triple aim: provider well-being. The most crucial cog in transforming health care is the practitioner, without whom the delivery of care is impossible. With the dramatic changes in health care today, the effect on health care providers has been largely ignored. If the System is transforming for the better, why are we seeing an epidemic of early physician retirements, career changes, and burnout? (12)

There are many suggestions on what to do but these are not easy for physicians to accomplish. Because of the relationship between distress and the quality of care, we first need to promote physician well-being.(2) We will discuss possible solutions next month’s editorial.

Book of the Month: For all of the golfers, I suggest Every Shot Counts by Mark Broadie, a professor at Columbia University. He finally explains the concept of strokes gained.

References


1. Shanafelt TD, Dyrbye LN, West CP. Addressing physician burnout: the way forward. JAMA. 2017;317(9):901-2. 
2. Ames SE, Cowan JB, Kenter K, Emery S, Halsey D. Burnout in Orthopaedic surgeons: a challenge for leaders, learners, and colleagues:  AOA critical issues. J Bone Joint Surg Am. 2017;99(14):e78.
3. 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):1600-13. 
4. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91(7):836-48. 
5. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among american surgeons. Ann Surg. 2009;250(3):463-71. 
6. Saleh KJ, Quick JC, Conaway M, et al. The Prevalence and Severity of burnout among academic orthopaedic departmental leaders. J Bone Joint Surg Am. 2007;89(4):896-903. 
7. Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: causes, consequences, and proposed solutions. Mayo Clin Proc. 2005;80(12):1613-22. 
8. Dyrbye LN, Thomas MR, Huntington JL, et al. Personal life events and medical student burnout: a multicenter study. Acad Med. 2006;81(4):374-84.
9. Linzer M, Poplau S, Grossman E, et al. A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) Study. J Gen Intern Med. 2015;30(8):1105-11. 
10. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016;165(11):753-60. 
11. Tai-Seale M, Olson CW, Li J, et. Al. Electronic health record logs indicate that physicians split time evenly between seeing patients and desktop medicine.  Health Aff (Millwood). 2017;36(4):655-62.
12. Wuest TK, Goldberg MJ, Kelly JD. Clinical faceoff: physician burnout-fact, fantasy, or the fourth component of the triple aim? Clin Orthop Relat Res. 2017;475(5):1309-14.