Will Reforming Healthcare Fix Physician Burnout, Too?

Fifty-four percent of American doctors report symptoms of burnout.

But, you say, they’re the best paid in the world. So, they should just keep quiet, get a grip, and do their jobs.

Hold on! They may be the best paid in the world. But they do work the longest hours. And, some explain, by working in an increasingly corporatized health system they have lost their souls and sense of purpose. From medical school on, they are abused by the system and, say many, abused by their own self-neglect and over-achievement drive.

What does healthcare reform have to do with any of this? And why should citizens and patients care? After all, it shouldn’t just be all about the doctors!

Let’s drill down.

First of all, the bad news about physician burnout.  One of its ravages is physician suicides — 40 percent more suicides among male physicians and 130 percent more among female physicians than in the general population. Physicians also experience exhaustion, insomnia, irritability, isolation, dread, loss of meaning and purpose.

How does this affect their patient care? A 2018 study showed an association of burnout with serious errors.  It is also associated with a loss of empathy towards patients and reduced overall performance.

A recent study seemed at first to challenge the association of physician work hours and errors.  The study showed that pediatric doctors in training made more errors when they were given shorter shifts, contrary to common wisdom. But on further scrutiny, the study noted that during those shorter shifts they were assigned a heavier workload of more patients – more work to do, and less time in which to do it.

What’s behind burnout? Many, many other factors besides workload – nights on-call, stressful patient interactions, moral distress, interruptions, loneliness.  And increasingly, electronic records sapping time and attention, all the while monitoring the doctor’s performance “metrics.”

The result is loss of autonomy, sense of competence (undermined by the computer’s constant “incomplete reminders”), and social relatedness. Paradoxically, paying physicians more, only makes things worse. In a 2020 survey, half the doctors said they would give up at least $20,000 in annual income in order to reduce their work hours.

What Does Burnout Have to Do with Healthcare Reform?

I will focus on four things:

• Connection between physician pay and workload
• Medical school student (physician) debt
• Racist underpinnings
• Burnout as a symptom of health system dysfunction.

First, the connection between physician pay and workload.  Dr. Ezekiel Emanuel wrote in the March 2018 AMA Journal:

The number (ie, “volume”) of physicians in the United States is comparatively low, thereby offsetting the effect of high salaries. In the United States, there are 2.6 physicians per 1000 citizens, whereas in Germany the ratio is 4.1/1000 and in Sweden 4.2/1000. Thus, even though US physician salaries are high, the per capita costs attributable to paying physicians is almost identical to that in Germany and $176 per capita higher than in the Netherlands, accounting for just 4% of the difference in per capita total health care costs. 

But this means that 2.6 American physicians are doing the same workload as 4.1 German physicians. American physicians work an average of 52 hours per week (thus, half of them work more than that). And 39 percent of physicians work more than 60 hours per week.

Fixing U.S. Healthcare blog has concluded that the cause of relentless cost rises and “GDP creep” are prices, although by Dr. Emanuel’s analysis physician payments are the least of the problem. This blog has also identified an “interlocking directorate” between politicians and healthcare that props up all healthcare prices. This arrangement is content to squeeze ever more volume out of physicians. Healthcare reform, like universal access via public option or even single-payer financing, would not directly end physician exploitation. But it would allow physicians to opt for less pay in return for less stress, overwork, and burnout.

Second, is the issue of medical school student debt.  76% of students graduate with debt. And while that percentage has decreased in the last few years, those who do borrow for medical school face big loans: the median debt was $200,000 in 2018. At private medical schools, 21% of students have debt of $300,000 or more, according to the American Association of Medical Colleges. It takes doctors an average of 14 years to pay off those loans. This turns doctors into “indentured servants,” and adds to their pressure to work harder and longer.  By contrast, medical schools in Europe are highly subsidized, costing as little as one-fifth as U.S. medical schools. On the other hand, since doctors there make much less income, they struggle just as much to pay off their medical school debts. So, this is not a uniquely American problem. Healthcare reform will not fix this aspect directly, either. But presumably it would bring the issue of physician training and supply more directly into public view.

Third, to the extent that Black and Brown students face financial and social challenges throughout their school years, they also face these systemic barriers to entry into the medical profession. And to the extent that racially based inequities are both the cause and effect of health disparities, fixing U.S. healthcare converges with fixing U.S. structural racism.  This blog has claimed that fixing healthcare would advance us toward our American ideal of an ever “more perfect Union,” and toward solidarity among fellow Americans for their mutual wellbeing – a vision for “a new Declaration of Independence, Constitution, and Gettysburg Address rolled into one!”

Lastly, it is tempting to “blame the victim,” that is to dismiss physician burnout as a problem for each individual doctor to fix on their own.  And it is certainly true that physicians and their training programs can help themselves to develop healthy wellness, mental health, and social-emotional practices. However, healthcare institutions are increasingly identifying their own contribution to physician burnout. Leaders at Stanford University and Mayo Clinic, for example, have developed institution-level strategies to mitigate physician burnout, focusing on practical issues like electronic health record design and soft aspects like incentive programs and organizational psychology enhancements.

Conclusion

Physician burnout is a troubling phenomenon. It is neither the cause nor the effect of U.S. healthcare’s cost problem, which is the focus of this blog.  But burnout is a symptom and result of the same underlying problem – a healthcare system in the grips of powerful forces that seek maximum profits and not health. Fixing U.S. healthcare could set the stage for addressing physician burnout more comprehensively.

Take Action

Now, take action!

 

Image Credit

Title:  Fortvilelse (Despair)

By:  Edvard Munch (1863-1944)

URL:  https://commons.wikimedia.org/wiki/File:Edvard_Munch_-_Despair_(1894).jpg

 

References

1. Hartzband P, Groopman J. Physician Burnout, Interrupted. N Engl J Med 2020; 382:2485-2487. DOI: 10.1056/NEJMp2003149

2. Committee on Systems Approaches to Improve Patient Care. Taking Action Against
Clinician Burnout. Washington DC: The National Academies Press, 2019 Link: https://www.nap.edu/read/25521/chapter/1#xv

3. Mata DA, Braun S. Preventing Clinician Burnout. Jacksonville FL:  InforMed, 2020.  Link: https://pa.cme.edu/CourseMaterials/2020%20Pennsylvania%20Medical%20Licensure%20Program~xb0g0yq0f5sgdp33rvlwktfo6-23-2020%202-18-41%20PM.pdf