What's the true cause of physician burnout?

In June 2019, the World Health Organization formally labeled burnout a medical condition. I believe this to be a mis-diagnosis, as burnout is not an illness.

Rather, physician burnout is a symptom of a healthcare system broken by innumerable cracks, a system refusing to call attention to its disfiguration and failings. The public and lay press have latched on to the idea that physicians are burned out-with fatal implications of personal failing, exhaustion and shortcoming.

This is a distraction, a redirection away from the fundamental pathologies in our healthcare system. This dangerous paradigm of burnout runs the risk of eroding public trust in medical professionals, and avoids confrontation with the ultimate systemic failings that stoke the fire.

If the system is unwilling to identify its faults, I will vocalize those that have led me to huddle at my desk and cry to myself at night in an empty office. The first and most pervasive is the shift from the care of those in need to the business of medicine as a volume proposition for revenue generation. Bloated administrative salaries and unnecessary overhead parallel lavish marketing expenditures. Many systems have entered the sordid business of luring customers and seeking five-star reviews, as opposed to putting care of patients and communities first. There appears to be little to no accountability for the “non-profit” status so many systems carry.

What results are so-called “customers” that arrive to visits with increasing expectations of their time and experience. This is coupled with rising complexity of illnesses, rapid pace of change of evidence at the point of practice, and little or no additional time or resources for each patient seen.

Stolen autonomy

Ultimately, while many physicians don their white coat to care for those in need, they are confronted by a system that has stolen their autonomy and relegated them to the silent position of “provider.”

My symptoms of burnout in practice have come as a result of being overwhelmed with the extent of illness, of too many conversations about death, depression, addiction, and suicide on a daily basis. It is a feeling that I do not have the time to make the number of right and safe choices for my patients, or respond to the amount of care that they need in a given day.

It is often an impossibility for me to finish the day and feel ethically and morally satisfied. No duty hour rules can shield against such emotional onslaught.

The list of cracks in the system goes on. Much has been written about extensive documentation requirements that are unnecessarily cumbersome in outmoded EHRs. The ordering of unnecessary tests for the sake of liability not only compounds our untenable cost crisis, but undermines physician decision making and intuition.

Insurance companies play shell games with medication and medical bills, and prior authorizations add a superfluous and demeaning layer to patient care.

Too often the consequences of these failed machinations land on the shoulders of the physician at the point of care. This disrupts hallowed patient-physician relationships and wastes precious time that could otherwise be spent in caregiving and counseling.

Thankfully, in recent years we have witnessed some proactiveness in preparing trainees to recognize burnout. Likewise, our systems now provide new resources and counseling to respond to it.

These approaches are essentially bookends to the underlying condition but fail to fully confront the causes. In doing so, they unintentionally, yet implicitly, suggest that burnout is an unfortunate inevitability. Such an approach is akin to telling a young man that diabetes is a disease, and then sitting back until the first signs of elevated hemoglobin A1c. It ignores so many of the elements in the interim that can be influenced to prevent the outcome in the first place.

We treat burnout in much the same way, almost as if it is an expected side effect, a rite of passage or even a badge of courage.

Tweaks aren’t enough

Our healthcare systems fundamentally ignore the call for decreasing stress, offloading documentation burden, and restoring autonomy and joy to practice. Adding a suicide help line and an annual doctor’s day golf outing is far from a systemic cure.

One local health system formed a burnout committee in response to overwhelmed physicians, and the first initiative was a monthly wine night held on Thursdays. None of the primary care physicians I spoke to were able to attend, as they were all busy in the office working on documentation until after 10 p.m.

Many systems have added similar interventions such as lunchtime yoga sessions or coffee coupon cards for physicians. We respond to the symptoms of the disease, instead of working on preventive measures to address the problem at its core. These “treatments,” in other words, ignore the heart of the problem.

Unfortunately, the symptoms of burnout tend to beget more burnout. Much more than a spreading plague of negativity, compounded stress from a broken system has pressed physicians to bear the burden or pass it on to equally stressed colleagues. Neither responses are particularly healthy.

As physicians, we are far too willing to ignore our own health and humanity, and far too willing to transfer our own stress on to our colleagues.

Harming Each other

There is one area that I can speak to that is within our grasp as physicians to resolve: How we treat ourselves.

While I have witnessed acts of intense selflessness, compassionate camaraderie, and bonds among teams, I have also observed infractions of character, defamation, and belittling. Lost somewhere in our intense focus on doing no harm to our patients, we often neglect the application of non nocere to ourselves.

Yet, within the world of medicine, there is so much unspoken harm we do to one another. The overworked emergency room physician is berated by the overworked hospitalist for the tenth admission of the night. The attending surgeon belittles the intern for poor closure technique as the intern scrambles to fulfill the administrative tasks that are a hospital priority. The time-pressed primary care physician hastily sends a patient to the emergency room unnecessarily for something they could have addressed in-office with more time available. The specialist dumps a plethora of patient problems back to primary care. It becomes a vicious cycle in which, lacking time to deliver care in the right way, physicians pass patients like hot potatoes.

We burn each other with these repeated moral injuries, and instead of blaming the root cause of these actions, we instead scapegoat each other.

I am burned out on discussion of burnout. Incremental changes will only allow disparate inadequacies to flourish and become more prominent. As physicians we have our collective voices to call out the injustice inherent in these failures. But we also have the capacity to avoid self-harm, both to ourselves and to our colleagues. While we embrace the shift away from the discussion on burnout, and the coming necessary systemic changes, physicians need consider a broader application of their charge for non nocere and seek to do no harm to patients, colleagues, and yes, even ourselves.