By Tom Lacock
Wyoming Medical Society
Betsy Spomer, MD still thinks about the day a deal for her new physician office fell through. She had been practicing in Powell for about 12 years before modifying her practice plan into something that would allow for what she thought was more balance in her life. The new office was key to that plan, but the deal fell through.
She should have been disappointed the deal didn’t happen.
Instead, there was nothing.
Just the realization that this graduate of Hot Springs High School in Thermopolis (she was Betsy Snook back then) and Creighton Medical School in Omaha, was burned out on her dream job as a Wyoming physician.
“The building fell through I began to wonder, why am I not more upset about that?,” Spomer asks. “My husband and I had a heart-to-heart at that point and decided to have me stay home for a while until we figure out what the next step is. He was suffering right alongside of me through the burnout.”
Burnout is now the norm
Good news if you are a physician feeling burned out – you are completely normal.
The bad news is you are… well… feeling burned out.
Perhaps few in the country have studied the issue of physician burnout as much as a team led by Tait Shanafelt, MD, and Lotte N. Dyrbye, MD, MHPE of Mayo Clinic in Rochester, Minn. Shanafelt’s research team concluded that 54.4 percent of the 6,680 physicians who completed surveys (over 35,000 docs were invited to participate) reported at least one symptom of burnout in 2014, compared with 45 percent on a similar study in 2011. There are multiple reasons for the burnout, everything from the business of healthcare resulting in more paperwork, to less time being spent on work related to why physicians got into medicine.
“There is not a lot of meaning when you are filling out multiple pre-authorization forms every time someone needs a walker,” Dyrbye says. “We have a lot of challenges related to that. A lack of social support too. Even for those of us who work in large academic centers it is easy to work a whole day and not see a colleague. Those working in remote areas can struggle in getting the needed social support from colleagues.”
The Mayo Clinic has been researching physician well-being since 2004 and Shanafelt traced the idea of physician burnout all the way to residency. Shanafelt did a study during his time at the University of Washington looking at burnout among residents and how it impacted the chances a physician was likely to engage in sub-optimal patient care. Since then, Shanafelt has joined forces with the Mayo Clinic and Dyrbye, who says she first got involved with the subject of burnout in 2004 while looking at the prevalence of burnout, depression, and alcohol use among medical students in Minnesota.
While research suggests medical students actually start medical training with mental health profiles better than the average college graduate, that changes quickly as they get acculturated to medicine. Soon they are developing more burnout, depression and a worse quality of life than college graduates at the same age.
“The seed was planted in the early 2000’s and we have really been watering it over the years, trying to understand the epidemiology,” Dyrbye says. “We are trying to understand the drivers and the consequences so when you start talking about consequences people really start to pay attention. Now, we are at the stage of what do we do about this? How do we mitigate this? How do we turn the tide around?”
Kathy Gibney, PhD, is a psychologist and the director of the Center for Physician Well-Being at Adventist Health Systems Florida Hospital. The program was started in 2003 and has recently expanded its mission to include burnout prevention education and consultation.
“Physicians are taught to work and work, and work and they are told over and over again that the patient must come first, even at the expense of their own health,” Gibney says. “In the past, physicians focus was on the patient and physician relationship and they were paid for the important work they do. More recently, incomes have been dramatically reduced and time with patients is shorter and subject to the intrusion of technology leaving physicians feeling less satisfied with their work and the meaning they bring to their patients’ lives.”
EHR’s contributing to burnout
For every physician who has said it seems like they spend twice as much time working on electronic health records as they do seeing patients, Dyrbye says research validates your feeling. According to a 2016 study by Christine Sinsky, MD printed in the American College of Physicians’ Annuals of Medicine, for every hour physicians provide direct clinical facetime to patients, nearly two additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another one to two hours of personal time each night doing additional computer and other clerical work. It suggests physicians now spend 33 percent of work hours on direct clinical work and 49 percent completing clerical tasks and interfacing with EHRs.
According to the findings of the study, “unlike many industries in which advances in technology have improved efficiency, EHRs appear to have increased clerical burden for physicians and can distract some physicians from meaningful interactions with patients.” The study goes on to say it is unclear how this compares to the amount of time physicians used to spend handwriting notes, ordering tests and locating patient records, or lab results.
“It is a lot of boxes to check,” Dyrbye says. “EHR’s have been built for the purpose of billing, not built for the purpose of outstanding patient care. It is incredibly cumbersome and not very meaningful to sit and click boxes and spend a lot of time engaging with the EHR. We didn’t go to med school to spend all that time looking at a computer screen clicking boxes.”
Other Systemic issues to be addressed
Dyrbye says the best hope for battling burnout is a mix of systemic and personal changes. Among the systemic changes is the need to streamline documentation and work on EHRs. Her group points out in an opinion piece in the Journal of the AMA that there needs to be clarification and guidance on what tasks, forms and documents can be filled out by trained non-physicians and points out payers can also help burnout with more streamlining of policies.
“Requirements by insurers that physicians perform and document unnecessary elements of care to justify billing codes but that do not contribute to good medical care should be eliminated,” the team writes. “Payers must also develop a more efficient pre-approval process for tests, medications, and procedures.”
The authors of the study suggest more physician input into required documentation as required by meaningful use of EHRs, maintenance of certification requirements, and questions on licensing board applications regarding diagnosis or treatment for mental health conditions. Dyrbye asks that state licensing boards inquire about current impairments due to a mental health condition rather than a past or current diagnosis or treatment.
The Mayo Clinic is now working on the concept of social support as a deterrent for burnout. It has performed a randomized control study in which physicians meeting with a trained facilitator to talk through curriculums in how to deal with medical errors, work-life programs, and self care strategies. The results have been positive. Although expensive, it did get physicians into a room and give them a topic to talk about for a lunch hour, resulting in decreased burnout and more work and career satisfaction.
“Those sorts of groups are now in place for physicians at Mayo across the entire enterprise,” says Dyrbye. “We have over 1,100 physicians engaging in these groups and we think it has been a real positive change.”
Meanwhile the Adventist Health System, Florida Hospital has been using teaching mindfulness living which includes gratitude practices, inquisitive inquiry strategies and meditation, (which Mayo agrees can be helpful), as well as encouraging physicians to take a leadership role in their organization to improve relationships with administration.
“Administrators and doctors are really trained differently,” Gibney says. “Administrators and doctors have the patient as their primary focus, but they are looking at that focus from two distinct world views. Administrators are concerned about patient satisfaction, how happy the patient is about their care and physicians are concerned about patient outcomes, how well the treatment was related to standard of care. Therefore they are often looking at different measures of success. I encourage them to have deeper conversations about how to meet all the needs of the patient and to appreciate their unique perspectives and build bridges. We need everyone on the same page to fix the system. Otherwise we will find more physicians burning out.”
Practical ideas for Physicians Battling Burnout
Gibney says her most powerful story of working one-on-one with a physician on burnout issues involved a physician three years out of his fellowship with a young family and long hours at the hospital. Gibney said she encouraged him to do something to transition between the hospital and home to emphasize he was off work. She suggested something as simple as a shower and a few minutes intentional time with the kids.
“The day after he started the transition where he showered and spent five minutes with each kid individually, he was amazed at what took place the next day when he returned home from work. That day when he arrived home, his six year old daughter came running to him and said, ‘daddy, daddy, would you be the daddy you were last night.’ That just broke him.”
While the suggestion of inserting a transition between work and home is a common one, Gibney says she also suggests looking for treasures in each day. In one case she told a doctor to go as far as being thankful for something as simple as a working ice machine at work for a cold drink. When the physician shot back the ice machine was broken, things looked bleak. However, the next week Gibney said the doctor told her his son suggested life’s treasures are sometimes found outside the workplace, it changed his outlook and reminded him he was no longer asking his patients about their families. Once he reengaged with his patients at that level he felt the joy returning to his work, and his son was happy to be a good part of the success.
“They are a challenge,” says Gibney about physicians. “They are well-defended from all the emotion they experience. In training they are told they need to be thinking and not feeling. That is not necessarily the best advice we should be giving. These are talented people they should have access to all parts of themselves.”
The Adventist Health System, Florida Hospital is also offering counseling for its physicians, which Gibney says is fulfilling for most after a day spent listening to the needs of others.
“Physicians are the ones making huge decisions, life and death decisions.” Gibney says. “It weighs heavily on them. I encourage them to try to live mindfully. Before going into a room, take a big breath and let it out. Really try to remember this is the person I am talking to, and encourage everyone to stay in the moment as much as possible.”
The Role of Medical Organizations in Burnout
University of North Carolina Hospitals Physician Richard Wardrop, MD, is on the Governor’s Council of the state’s American College of Physicians (ACP) chapter. North Carolina’s ACP as well as the state’s medical society are making physician wellness a priority.
The North Carolina ACP offered a physician burnout workshop over the past two years concentrating on evidence-based practices to fight off burnout. Wardrop admits he wasn’t sure what to expect from the series when it was first proposed.
“I thought nobody would come and those who didn’t would label us as complainers and whiners,” he says. “It turns out a lot of people came and I found out in that interaction that people were really hurting. I thought it was really heartfelt and genuine that people felt willing to open up. The discussion got emotional. It monopolized the conversation – things like EMRs, hospital systems buying up practices and different forces that are dissatisfiers.”
He says where the state societies have begun the conversation, it continues at the County Society level where issues and solutions are discussed.
“I think a medical society could offer a list of resources for physicians and allow them access to the Mini-Z (the AMA’s physician burnout survey) or things like that for practices or staff and adopt AMA steps forward methodology for physicians and be a link on the website.”
The national offices of The American College of Physicians (ACP) is dipping its toe into the physician burnout waters. In an April 17 opinion piece in The Annuals of Internal Medicine The ACP considered the AMA’s Joy in Medicine Research Summit to develop a national agenda to battle burnout.
The summit resulted in five recommendations: 1: Further establish links among physician burnout, well-being, and healthcare outcomes. 2: Estimate the economic cost of physician burnout. 3: Develop a cohesive framework for intervention with individual and organizational components. 4: Share best practices. 5: Build alliances to address physician burnout; and use common metrics.
I feel like I Lost My Edge…
In retrospect Spomer says she was a classic case of physician burnout. She would use comments like, “lost my edge,” and says she felt cynical and jaded. She says she stopped seeing her patients as human beings and felt irritated that sick people kept coming through the door. She left full-time practice in 2013, though she does still offer coverage for physicians in Powell, including at the Express Care clinic at the hospital in Powell.
Spomer says she did her residency training at North Colorado Family Medicine in Greeley, Colo. to be a rural doc capable of doing everything for her patients and began practicing in Powell in 2001. Her reputation solidified in obstetrics and she describes the experience as, “everything I ever wanted,” pointing out she had great mentorship, partners, and practice.
After having her first child in 2003 her life got busy, and with the assistance of a personal life coach, she began making the necessary changes in her practice that allowed for a better work-life balance. These changes kept her going for the next eight years of practice, but the stress continued to mount due in part to a second child and husband who began running his own company.
Over the years she continued to modify her practice, removing men from her patient panel completely and then taking a hard look at whether she could keep up with practicing OB.
“It is crazy, but as much as I loved OB, it was killing me at the same time,” she says. “It was just this unwritten rule in Powell at the time that you delivered your own patients whether they came in on your call night or not. The babies seemed to come when I wasn’t on call. I felt compelled to have back-up childcare every night when my husband was out of town.”
Spomer is also an adjunct professor at the University of Washington through the WWAMI program, and says she would love to see more emphasis throughout medical training in the areas of self-care including work-life balance, personal boundaries and wellness – as well as the development of strong leadership and communication skills.
“Doctors in Wyoming are their own unique breed,” she says. “Not only are they smart, but they are often perfectionists and have high expectations for themselves. Not to mention they are also from Wyoming, so you cowboy up and figure it out and there is not a lot of compassion for the weak. I bought into that.”
“I didn’t even know how to manage my own cell phone when I left my own practice four years ago,” she says. “I had been taken care of. That is what happens, you get caught up in the system, it takes care of you in many ways and it can chew you up unless you are tapped into the answer to the question, ‘why am I doing this in the first place?’”
“Although there is a great deal of burnout among our physician population, we also have people dedicated to finding ways to support them in the current dysfunctional healthcare system while we all work to find ways to build a better system,” says Gibney.