Thursday, April 14, 2022

Burnout and depression in physicians: Not good for them or for the public's health

For some years now, there has been increasing emphasis in the medical community about “physician burnout”. While there different degrees and kinds of burnout, generally it refers to a feeling among physicians from having little or no enjoyment in their work to feeling unable to continue. At this far extent, it contributes to doctors leaving the direct practice of medicine for a less-stressful area where their medical background is useful (administration or insurance work or consulting) to leaving the profession altogether. It can be for a different career, or, if they are older and more financially able, early retirement. In the case of young physicians, particularly residents who are still doing their post-graduate training, working very long hours and getting paid relatively little – and since many have medical school debt exceeding a quarter of a million dollars, it can be actually little – burnout could prevent them from taking on a full career in medicine.

Of course, burnout can affect any profession, or any job, although that term is mostly used for professionals, who have historically counted on some degree of independence and control of their work lives. Feeling burned out, not interested, overwhelmed, and even resentful is common and maybe even normative in much non-professional wage work, where the assumption is often “of course you are alienated”, selling your labor to a boss whose only interest is in profit and to whom you are only a tool to generate it. It is a more recent phenomenon in the professions, particularly as professionals become essentially employees, and the profession I know most about is medicine.

Historically, physicians have worked very hard, long hours, often through the night, taking call to come in and see people (called, in medical terms “patients”), operate on people, deliver babies. In small towns and rural areas, where there were few other physicians with whom to share call, this was often particularly disruptive to home and family life, not to mention sleep. The compensating plusses were considered to be a good income, a high level of respect from the community, a sense of making a contribution and a difference, and some level of control of your practice. Although, often when coming in in the middle of the night, it might not seem like much control, many or most doctors were self-employed, and even when they became part of larger groups they were among the owners.

Over the last few decades, many things have changed in the practice of medicine, increasing the burdensome characteristics and decreasing the positives. These are mostly related to the increased size of medical enterprises and the corporatization of medical care. On the one hand, in the name of “efficiency” the practice of medicine has become routinized, less varied, less interesting, and sped up. Physicians often feel that they are on a treadmill churning patient visits as if they were widgets, not having the time that they would not only like but would be necessary to understand their patients as people, and to begin to meet their more complex needs – and people are complex, with every aspect of their lives affecting their health. They may be paid more, but they have much less control, and often seem to (and do) spend as much time completing their Electronic Medical Records (EMRs) as in patient contact, and it may feel (correctly) that the purpose of the work that they put into the EMR is aimed primarily at maximizing income and profit for their employers rather than maximizing the health of their patients.

The strategies which have been employed to attempt to address burnout have ranged from the individual (support groups, various therapies) to structural (changing the work situation). Many physicians are seeking to achieve more “work-life balance”, with more time for their families and other non-work life. The ameliorations include shift work (work hard but for a specified period of time, and know when you will be off and that you really will be off), limiting scope of practice, and, certainly, increased reimbursement. But because these “solutions” do not work as well for all specialties, burnout does not affect all specialties equally. Shift work is most effective in specialties in which continuity of care for an individual patient with an individual doctor is not seen as important; thus it works well for emergency medicine, anesthesiology, critical care, and a few other areas. It has also been widely employed in hospital work, with “hospitalists” who care for people who they do not see as outpatients working shifts (including for delivering babies), and has extended to generate yet newer specialties like "nocturnists” and “weekendists”. And has even renamed the doctors who do see people in the outpatient setting as “ambulists”. How well this works depends on who you ask; it is “efficient” for the employer, and the hospitalists know their hospital stuff, but for the patient, not only are you not seeing a doctor who knows you but your hospitalist may change every few days (and nights).

Salaries in medicine are still usually tied to how much the individual physician generates for the organization, which is heavily dependent on how insurers reimburse, and that is far more for surgery and other procedures than for “just” seeing, talking with and examining a person, reviewing lab and x-ray information, and coming to a diagnosis and treatment plan. So doctors who do the latter make less money (family physicians, general internists and pediatricians, psychiatrists) than do proceduralists. Thus, the physicians in the highest paid specialties (particularly those not just highly paid but that have the highest income/work ratios) are more likely to be successful in achieving work-life balance and avoiding serious burnout. And those who have to be most available for the greatest portion of time with the least support, rural family physicians, burnout can be highest. Although these doctors also often retain the most degree of autonomy, with time demands coming from their patients, not the corporations that employ them.

It is also worth talking about serious mental health issues that physicians confront, and especially the continued disincentives for them to receive necessary and appropriate care. A March 30, 2022 Op-Ed in the NY Times, ‘Why So Many Doctors Treat Their Mental Health in Secret’, by Seema Jilani discusses this, and in particular how employers and licensing boards feel free to ask about this, contributing to an atmosphere of stigma so that, in fact, many doctors do not treat their mental health issues at all. It would be outrageous for us to expect doctors to not treat their asthma, heart disease, cancer or myopia, but for mental health conditions this remains a real issue. It is one of the two great examples in medicine of the double-edged sword of “you should do this, but we may punish you for it”. The other is in the area of acknowledging mistakes (or even potential mistakes). There is excellent data showing that admitting and examining mistakes at the institutional level absolutely increases the overall quality of patient care (‘every mistake a jewel’, because we can learn from it; see W. Edwards Deming’s “14 points”). However, physicians who do so risk discipline, license loss or restriction, and even lawsuits. These punitive results (except for egregious cases) should not be there, and most of those who wrote letters to the Times in response to Dr. Jilani’s article (and I) agree that these punitive risks should not face physicians who seek treatment for depression or other mental health issues. Burnout and depression are not the same things, but may, and frequently do, co-exist.

Doctors are privileged workers; they are generally highly paid relative to most people, they still earn a great deal of respect, and they have the opportunity for great personal satisfaction through serving others. But they are often held to the standards of independent professionals while increasingly working for corporations, and they not immune from the stresses of overwork, lack of control, speed-up, and negative aspects of how capital treats its workers.

And they are certainly not immune from mental health issues, and should be able to receive appropriate treatment without inappropriate repercussions.


I did not address the issue raised by the recent conviction of a nurse in Tennessee for criminally negligent homicide for accidentally giving a patient the incorrect medication, but obviously this is entirely relevant to the issue of acknowledging errors, and the work situation for health professionals and thus issues of burnout and depression and, indeed incarceration.

A very good discussion of that case, 'Are All Medical Errors Now Crimes? The Nurse Vaught Verdict' appears in Medscape, and I would absolutely endorse this quote from one of the participants:

"A culture of safety is one in which the system that allowed the mistake to happen is changed, not one in which the individual is scapegoated. And a culture of safety correlates with better patient outcomes that we know. This verdict is the opposite." 

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