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." 

How to prescribe a glucometer – or why I can’t support Medicaid-for-All

This is a guest post by Seiji Yamada, MD, MPH.

A shorter version recently appeared on the KevinMD blog, http://www.kevinmd.com/blog/2017/09/heres-glucometer-turned-doctor-medicaid.html

In a recent Vox interview, Senator Brian Schatz of Hawaii announced his plans to sponsor a bill to allow individuals without insurance to buy Medicaid coverage for themselves.  As a family doc who cares for patients on Medicaid in safety net clinics in Senator Schatz’s home state, I cannot support such a plan.

While private insurance companies offer supplemental insurance, Medicare continues to be run largely by the federal government.  In contrast, while Medicaid programs receive federal funding, they are largely run by state governments.  In a trend known as Medicaid managed care, in recent decades, states have been contracting out Medicaid to private insurance companies.

Prior to 1994, Hawaii’s state Medicaid system was run by HMSA, Hawaii’s Blue Cross/Blue Shield.  During the Clinton presidency, the buzzword was managed competition, the idea being that insurance corporations would compete on price to provide publicly funded health insurance.  Thus in 1994, the State of Hawaii devolved to managed care Medicaid and started farming out Medicaid to other corporations besides HMSA.  In 2009 Medicaid managed care was extended to the aged, blind, and disabled.

Medicaid also generally reimburses at lower rates than Medicare or private insurance.  (Senator Schatz proposes to fix this.)  However, low reimbursement is only one reason that physicians in private or group practice take few Medicaid patients today.  Another reason is the administrative hassles to care put up by insurance companies as well as the difficulties of dealing with multiple insurance companies.  Thus, Medicaid patients have relatively restricted networks of providers from which to choose.  Many are therefore seen by safety net providers such as Federally Qualified Health Centers (FQHCs) or training clinics.

The modern practice of medicine is complicated enough, but the different requirements and different formularies of different insurance companies complicates it to Kafkaesque levels.  I believe that the powerlessness and helplessness induced by this nightmarish bureaucracy is a major cause of physician burnout.  I want to give just one example.  Let us say that one of our patients has newly diagnosed diabetes.  Let us say that he has Medicaid.  Just to prescribe him a glucometer, I have to go through the following:

Patients on Medicaid must enroll with one of the following:  HMSA, AlohaCare, Ohana (WellCare), United Healthcare, and Kaiser.  I need to go to the insurance section of the patient’s Electronic Health Record (EHR) to find out which insurance corporation is responsible for this patient.  Then I go to The Prescribing Guide (http://prescribingguide.com/), a cheat sheet developed and maintained by my family medicine faculty colleague Chien-Wen Tseng, MD.  The prescribing guide tells me which brand of glucometer to prescribe.

Each insurer contracts with a different glucometer manufacturer, so I can’t just prescribe a generic glucometer.  I have to figure out whether to prescribe Freestyle, or OneTouch, or AccuChek.  Because the contracts are continually re-negotiated, the preferred brand can change every six months.  If you enter the wrong brand, the pharmacy will reject it and tell you to get a prior authorization.

Next, I have to identify the ICD-10 code that corresponds to the highest complexity of the patient’s diabetes.  Does she have nephropathy, or neuropathy, or ophthalmopathy?  I often have to review the patient’s labs to see if the creatinine/GFR is abnormal.  Am I going to place the patient on long-term insulin?  Because if I am, I can justify asking for test strips for more than once a day testing.  The number of times per day the glucose is to be measured, the ICD-10 code, and whether or not the patient is on insulin has to be on the prescription.  If not, the pharmacy will reject it.

Now that I have prescribed a glucometer, I can now start working on prescribing a diabetes medication.

And I’ve yet to address the fatigue, the blood pressure, or the back pain for which his friend’s oxycodone worked real good, Doc.

. . .

“All the world's a stage, And all the men and women merely players” -Shakespeare

Was this theater of the absurd composed by Alfred Jarry?  Samuel Beckett?  No, this play was composed by the layers of business administration types that have piled onto the health care system over the past couple of decades to bring corporate-style efficiency to medicine.  Insurance companies limit their costs by imposing roadblocks.  By making it so time-consuming and so frustrating to get anything done, we physicians throw up our hands and decide, no it’s not worth the hassle to order a different medication or sophisticated tests.  Perhaps my patient gaining weight on a sulfonylurea would benefit from a glucagon-like peptide 1 receptor agonists or a sodium glucose transporter 2 inhibitors instead.  But the prior authorization form requires me to list the dates that the patient has taken every other diabetes medication she has ever been prescribed . . .

For those physicians who are employed by hospitals or other institutions, we are finding that our employers are engaging in an arms race with the insurers by hiring their own army of coders and billers.  These coders and billers find our documentation lacking in order to maximize return.  So now we are told to write addenda to chart notes entered months ago - in order to justify higher reimbursement.  These coders and billers shake their heads sadly and say to themselves, “Dr. Yamada, you are such an idiot.”

. . .

The new interns started in July.  When they were medical students, I taught them about the pathophysiology of diabetes, about the evidence base of what treatments have been shown to improve patient outcomes, about how to discuss lifestyle measures, about the social determinants of the development of diabetes.  Now that they’re interns, though – all of that goes out the window.  Now that they’re managing real patients, I teach them how to enter billing codes into the electronic health record, and how to get a glucometer covered by insurance.

They look at me with incredulity.  They are dumfounded by how irrational and Byzantine our health system is.  They realize that I am no longer teaching them medicine.  Because there is no time for that now.  There is only throughput.  Treat ‘em and street ‘em.

 “Welcome to the desert of the real,” I say.  “Get used to it.”

. . .

The MBAs who manage us physicians say, “It’s not about throughput.  It’s about quality.  We’re not going to pay you for throughput any more.  We’re going to pay for performance.  We don’t care how many times you see the patient.  We only care about their A1cs.”

OK, then, tell me how you get better outcomes with a patient with diabetes without seeing them every once to talk with the patient about diet and exercise, to prescribe a glucometer so they can learn how diet and exercise affects their glucoses.  What is the point of telling the homeless patient to bring down their A1cs by eating more fresh vegetables?  What use is the A1c when the patient has cancer?  What does the patient dealing with domestic violence care about her A1c?  To measure the quality of care provided by a physician through A1cs is like the drunkard searching for his keys under the streetlight because that’s where the light is.  The A1c is easily measured.  Other aspects of medical care are not so easily assessed.

. . .

Insurance companies and their corporate mind-set have so thoroughly taken over American medicine that we can hardly see the forest for the trees any more.  EHRs, essentially designed for reimbursement purposes, define the patient encounter – such that physicians look only at their screens.  I can’t afford to make eye contact with my patients, or I’ll fall hopelessly behind.  Was there a time that we used to eat lunch?  Nowadays, lunchtime is for finishing with charting or dealing with phone calls.  Dealing with medication refills, or lab or x-ray results?  Planning for the patients on tomorrow’s schedule?  We do that in the evenings or weekends by remote access to the electronic health record.

Though Senator Schatz’s proposal would make Medicaid something like the public option that didn’t make it into the Affordable Care Act, it would likely leave intact insurance company-run Medicaid managed care – with its restricted networks and administrative hassles.  As a practicing physician, I would like to get corporate profits and the layers upon layers of bureaucrats out of medicine.  The American physician is in a predicament like that of Josef K in Kafka’s The Trial.  The rules are obscure and seem to be constantly changing.  We are never told what crime we committed to justify our being treated the way we are.  The sense of a lack of agency and helplessness induced is one major cause of physician burnout.  The practice of American medicine needs to be rationalized, so that we health workers can go back to focusing on the medicine.  Medicare for All is what we need.  Not all the inefficiencies and irrationalities of the modern practice of medicine will be fixed by Medicare for All – but patients and doctors need a way out of this Kafka novel.