Burnout has been an insidious part of many professions for decades, manifesting itself anew in today's ever-changing economy. As the workforce changes because of industrial downsizing, weak economic growth and corporate reorganizations, those Americans who still have jobs report expanded workloads and responsibilities, longer hours and stagnant or reduced compensation.
The result, American workers say, is reduced productivity and increases in absenteeism, health care costs and personnel turnover. Burned-out workers report they have little say about how to do their jobs, often with requirements imposed by higher-ups with limited understanding of what their jobs entail. With the virtual elimination of mid-level management, there is often no training, direction or mentoring. The feeling of never being caught up becomes overwhelming.
Physicians are not immune. Based on a recently published study by the Mayo Clinic, nearly half of the nation's doctors (45.8 percent) suffer at least one symptom of burnout. As more and more baby-boomer doctors retire, as the population ages and as fewer physicians choose primary care, the problem is growing and the impact on patient care is significant.
The sheer administration of a medical practice today continues to strip away the satisfaction that physicians otherwise experience when they care for patients. Regulations, paperwork and electronic data-gathering erode the physician's autonomy to make medical decisions and impose an onerous burden on the physician's time -- at the expense of time spent with patients. Doctors don't have enough time with patients to understand and sort out treatment options and create the kind of relationships that for decades have contributed to early interventions, improved compliance with treatment plans and other critical aspects of quality care and patient satisfaction.
The Mayo Clinic study estimated that the average time spent annually on insurance pre-authorizations alone in the 1,310 practices that responded to its survey was three weeks for physicians, 23 weeks for nursing staff and 44 weeks for clerical staff.
Physicians also report that most required pre-authorizations for tests and diagnostic imaging are approved in the end and that diagnostic coding has been refined to the point of being meaningless. This major and costly contributor to physician and patient frustration appears to have no demonstrable benefit in terms of patient care or in the ability of insurers or employers to manage costs.
Physicians often must invest in expensive technology and hire staff solely to process required forms. The Journal of the American Medical Association, in an article titled "Physician Burnout: A Potential Threat to Health Care Reform," reported last year that this problem is likely to grow under the Affordable Care Act (Obamacare): "Infrastructure expenses required for compliance with new regulations, such as those expenses associated with reporting quality-based measures, will be an additional ongoing expense" -- and these expenses will not be fully covered by subsidies. (Teachers might see parallels to "No Child Left Behind.")
Also looming large over the profession is the ever-present threat of malpractice litigation. The defense of malpractice cases -- founded or unfounded ---- take their toll in time, expense and the demoralization of already-beleaguered health care providers.
Physicians report feeling more isolated. They spend less time with patients, less time with their families and less time with their colleagues sharing knowledge and expertise gleaned from day-to-day practice.
Health care reform, with its goal of insuring an additional 30 million Americans, brings the issue of physician burnout into even sharper focus. Many of these new patients are expected to suffer complicated illnesses that have been neglected over time. They are likely to be older and more frail as well.
Some say "physician extenders" -- nurse practitioners, physician assistants and others -- are the answer and are stepping up to fill the void. Last month, for instance, the Post-Gazette published an opinion column by Joyce Penrose, a nurse practitioner and adjunct professor at the University of Pittsburgh, titled "Providing Primary Care for the Poor: Nurse Practitioners and Physician Assistants Stand Ready to Meet the Challenge, Again." However, a survey of professional literature suggests that these and other health professionals -- including nurses, social workers, dentists, emergency staff, mental health providers and speech and language pathologists -- are at risk of burnout as well.
Physicians acknowledge the important role physician extenders play, but as Ms. Penrose states, "New models of care delivery, utilizing teams of physicians, nurse practitioners and other health care professionals, are needed as we face new challenges."
A critical examination of how best to integrate these professionals along with a broad examination of the impact on cost and care in the long run is warranted. A physician's eight to 12 years of training and clinical experience will remain a pillar of health care -- they produce finely honed instincts that can avert or ameliorate serious illnesses and manage the multiple conditions likely to be seen in the newly insured.
Are current levels of training for physician extenders adequate for an expanded role with presumably older, sicker patients who have not had routine medical care due to a lack of insurance? If not, as these professionals assume more and more responsibility and a greater patient load, not to mention the attendant legal liability, burnout in medicine will grow and spread. As primary-care physicians are left to care largely for the sickest of patients, commensurate support -- physical, emotional and financial -- will have to be factored into health care reform.
Most physicians still find personal satisfaction in the practice of medicine, but they recognize the effect these factors have on patient care and their own work/life balance. As a result, they modify their caseloads and lifestyles. They seek out mentors who can teach them coping skills. More and more are choosing to work for hospitals or hospital-owned practices to minimize administrative tasks in favor of spending more time with their patients.
We all have a vested interest in the future of medicine. We urge readers who share these concerns to advocate for change with insurers, legislators and regulators by posing this simple question -- how does what we are doing really benefit patients?
Dr. Rajiv R. Varma is president and Dr. Lawrence R. John is chair of the Primary Care Coalition of the Allegheny County Medical Society (www.acms.org).