By Carl Czuboka, M.D.
Many of us fell in love with our profession while watching famous TV “doctors.” Do you remember the episode when Dr. Marcus Welby talked about how he felt tired, overworked and burned out? Or the one when Dr. Kildare complained to his colleagues about the struggle to keep up with changes in healthcare technology or answer a seemingly endless stream of questions from patients?
Either episode ring a bell? No? It’s because they never happened.
In the 1950s, the average family doctor worked about 60 hours a week and was on call 24 hours a day, seven days a week. They regularly made house calls for those too ill to come to the office. (In 1958, only one out of 14 family doctors refused to make house calls.) On a typical day, most doctors treated an average of 26 patients in their offices and made rounds in the hospital before and after office hours.
Fast forward four decades. Physician burnout – often defined as emotional exhaustion, depersonalization and low personal accomplishment – has become a hot topic both in medical journals and the public media. It’s highlighted as an obstacle to patient safety, decreased job satisfaction, declining personal health, and even an increased risk of suicide among providers.
What does the research say? A recent study of more than 7,000 physicians published in the Archives of Internal Medicine found that:
• 46 percent of physicians reported at least one symptom of burnout.
• The overall rate of burnout among physicians was 38 percent, as opposed to 28 percent among other U.S. workers.
• Rates of burnout among Internal Medicine, Family Medicine and Emergency Medicine clinicians was higher than average.
This report is just the latest in a long series of studies demonstrating an upward trend of physicians’ growing angst, dissatisfaction or burnout:
• In a 1987 AMA survey of physicians over 40, 44 percent replied that were they given chances to do it all over again, they would not go into medicine. 
• In a 2001 survey of Massachusetts’s physicians, 62 percent were dissatisfied with the practice environment. 
• In 2002, a national survey by the Kaiser Family Foundation showed that 45 percent of physicians would not recommend that a young person should go into medicine. 
• In 2007, 77 percent of physicians said they are somewhat or very pessimistic about the future of the profession, while more than 84 percent believe that the medical profession is in decline. 
Then vs. Now
What has changed? Prior to the 1960s, physicians were perceived as having a monopoly on medical care, caring for a population with little knowledge about medicine. Physicians were rarely evaluated for productivity or quality outcomes. The concept of shared decision-making was in its infancy, and patients rarely questioned the “doctor’s orders.” The delivery of care was largely personal and depended on trust and authority.
Today, patients have access to vast amounts of medical information and rightly want to be involved in their own medical decision-making. This requires much greater levels of trust and discussion. However, there has been considerable pressure to minimize this element of the care process and transform physicians from unique agents to interchangeable units.
Physician leaders need to be aware of this growing issue and develop effective strategies to maintain a healthy workforce. We also must consider the current trends if we expect to be successful in creating care delivery models that render sustainable, affordable, high-quality care.
Causes of Burnout
The nature of our profession means that we often keep work and personal life more separated than workers in other fields. Striking an appropriate work-life balance, with quality time on each side of the equation, appears to be a bigger challenge for physicians. Other factors that lead to burnout include:
Reduced Patient Interaction. In many venues, the physician/patient interaction has devolved to one of customer and supplier – an individual negotiating and buying a service from a highly skilled tradesperson. One of the most fulfilling parts of our professional lives – delivering compassionate care – has been deemphasized in favor of productivity or the use of technology. Even the Patient Centered Medical Home (PCMH) model has evolved to the point where compassionate care is no longer a high priority – it is included as a subset under quality and safety. 
Business Pressures. Some pressure comes from the business side of medicine. Good physicians know that their professional responsibility often requires more time with each patient. Administrators, after comparing overhead and income, may encourage physicians to spend less time with patients. This constant tension and conflict can lead to frustration and burnout.
Higher Workloads. The sheer increase in workload is another contributing factor. Dr. Thomas Bodenheimer, professor at UCSF School of Medicine and a longtime analyst of the U.S. health system physician workforce, believes that the optimal number of patients for a physician practice panel is 1,800. The average PCP in the U.S. today is responsible for 2,300 patients.
Estimates suggest that a primary care physician would need to spend 21.7 hours per day to provide all recommended acute, chronic and preventive care for a panel of 2,500 patients.[6-8] This drives physicians toward shorter patient visits, less time for evaluation and, most importantly, less opportunity for engaged dialogue between patients and their most trusted partner in health – physicians.
Loss of autonomy. The past decade has seen a significant decrease in the number of physicians in solo practice, small groups and physician-owned practices, while those working in hospital-owned practices, integrated delivery systems and larger group practices have grown. Currently, 60 percent of American Academy of Family Physicians members work in employed positions rather than private practice. This shift means that many physicians are adjusting to life as an employee, rather than calling the shots in their own practice.
Payment Systems. Some physicians argue that our payment system is flawed and is a leading cause of burnout, especially for outpatient internists and family physicians. However, simply providing more financial incentives is, according to Dr. Richard Gunderman, a columnist for The Atlantic and vice-chair of the Radiology Department at Indiana University “a self-fulfilling prophecy of cynicism”
“The more we treat physicians as though they were self-interested moneygrubbers, the more we de-professionalize them,” he says. “And a de-professionalized physician is inevitably a demoralized and burnt-out one.”
Effects of Burnout
Burnt-out physicians are likely to be less productive, make more mistakes and generally deliver lower-quality care than their fully engaged colleagues.
Some physicians withdraw from their practices, reduce their workloads or leave medicine entirely. Others become less engaged with their patients and suffer a decline in the quality of their work. Still others turn to unhealthy and even self-destructive habits, such as alcoholism, abuse of prescription drugs or use of illegal substances. Some consider suicide.
We’re often counseled to cope with stress focusing on the “reduction of stress.” While beneficial, reducing stress can only go so far. Increasing the ability to cope with the unpleasant parts of the medical practice should be coupled with accentuating the most fulfilling elements and making full use of our knowledge, skills, innate abilities and talents.
Treating the System
Unfortunately, the decreasing number of physicians entering adult primary care means that workloads are expected to increase, particularly as more people have insurance coverage and seek access to primary care. The pressure to be more productive (often defined as “seeing more patients in less time”) will mount.
Who is looking out for physicians? One might think that medical societies, foundations interested in improving health and healthcare, accreditation organizations and academic medicine in general would all be interested in addressing the causes of physician dissatisfaction and burnout. There is, however, scant evidence of significant action in this area.
The way we select and train the next generation of physicians can help prevent burnout, particularly for those who may be most susceptible. Some medical schools now feature wellness curricula, and duty hours limit the degree of exhaustion associated with training.  We can also encourage training programs to develop and reinforce a healthy work-life balance and model it ourselves as we interact with residents.
Our practice models may also need to change. For some physicians, a concierge-style practice, caring for a panel of less than 1,000 patients, may be the answer. However, it isn’t scalable – there are not (and likely will not be) enough primary care clinicians in the United States to meet this standard.
Another approach, the “Organized Team Model,” distributes responsibility for patient care among an interdisciplinary mix of team members. This allows physicians to practice high-quality care with a reasonable workday and a large – but manageable – panel size. All team members must perform at the top of their skill level, and many tasks currently performed by primary care clinicians are safely and effectively delegated to non-clinicians or delivered through health information technology. 
Payment systems must evolve to reward clinicians whose practice is patient-centric and promotes health literacy and good health choices. Properly run Patient-Centered Medical Homes and Accountable Care Organizations will provide incentives for patient engagement and allow physicians more time with patients when necessary.
Physician burnout is an issue that we must all face – and solve. By refocusing on what truly matters, we can begin to create an atmosphere that supports and reinforces the reasons that we chose this noble profession.
In his role as Area Chief of Ambulatory Medicine for The Southeast Permanente Medical Group, Carl Czuboka, M.D., oversees a team of internists who care for more than 240,000 Kaiser Permanente members. Dr. Czuboka received his bachelor of science and M.D. from the University of Ottawa School of Medicine and completed his residency in Family Medicine at McGill University in Montreal. He joined TSPMG in 20XX after serving in private practice and as an assistant professor at McGill University.
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