When Sparks Stop Flying: How Is Clinician Burnout Tied to Patient Outcomes?

My worst month as a resident was one of my last months in the Coronary Care Unit (CCU). I had matched to an excellent cardiology program a few months before, and I was eager to sharpen my cardiology skills. Back then, the CCU was a q3 overnight rotation, and I rarely slept during those nights on call. I eagerly spent my nights running codes or greeting patients with STEMI in the emergency department to prep them for the cardiac catheter team.

The experience was as exhausting as it was rewarding. But what finally got me wasn’t the long hours, the very sick patients, or the lack of sleep — it was the unspoken political drivel that often plagues the medical profession.

In one instance, I withheld a nonteaching attending physician’s order at 2 AM because I felt it was unnecessary — and more importantly, unsafe.

Yet when my attending physician arrived and I told him what I had done, he began screaming, telling me how inappropriate it was to override an attending physician’s order. He scolded me and threatened to contact my program director to report the “inappropriate” behavior. This was not the first time I had been yelled at, but the few times it had happened before, I understood that I was being taught a lesson. This was different; there was no lesson. I had been shouted at for doing what was in the best interest of my patient.

The political backlash from my actions that night triggered an all-out war that was out of my control. I was simply the catalyst that set off a fire primed to ignite. I was not privy to the details of that battle, but my colleagues and I were routinely scolded postcall for “[expletive] with the politics.” Clearly, something was happening behind the scenes that did not involve us, but we became the scapegoats because of our dissent against what we viewed as bad patient care.

Two weeks into that CCU rotation, my colleagues and I were destroyed. I felt disappointed with an entire healthcare system that seemed to oppose my efforts to provide the best possible care to patients.

Despite my professional and personal successes, l suddenly felt unaccomplished, disillusioned, and terribly afraid that the flame that had called me to medicine had burned out. It took nearly my entire fellowship to get it back.

The events of that month did not in and of themselves lead to burnout; however, they did take away the only coping mechanism that I had for dealing with physical and emotional exhaustion. I was driven by a set of ideals that helped me focus on providing high-quality patient care. When I suddenly found myself trapped in a system that did not share those priorities, it was as if the rug had been pulled out from under me.

In 2012, the Archives of Internal Medicine published an analysis of 7288 physicians.^1,2 The authors found that 46% of physicians reported at least 1 burnout symptom.² Similarly, the Agency for Healthcare Research and Quality reports that in some studies, the number of physicians experiencing symptoms of burnout exceeds 50%.³ The issue of physician burnout has gained traction as a public health concern because more and more physicians are leaving medical practice altogether, resulting in decreased patient access and continuity of care.³ Furthermore, there is a growing body of evidence suggesting that depression and burnout in physicians contributes to medical errors.⁴ As if those weren’t enough reasons to pay attention, one often-cited and infrequently acted on statistic is the alarmingly high physician suicide rate, which is approximately twice as high as in other professions.⁵ I know of at least one medical school classmate who was lost to suicide and several friends-of-friends who have committed suicide.

One possible explanation for this high burnout rate is that physicians work longer hours. Yet compared with other highly educated professionals who work similar hours, physicians still lead by a significant margin in their rates of depression, burnout, and suicide.¹ Moreover, the marked reductions in resident work hours over the past several years have done very little to improve the rates of burnout and depression among residents.⁵ One argument is that the work hour reductions came along just in time for a sudden influx of insured patients into our healthcare system. Without more physicians to provide care, the decreased work hours resulted in markedly increased patient loads.⁵ Maybe, though, long hours and increased patient volume are not the problem; rather, perhaps it is an environment that is plagued with cynicism, hypocrisy, and profiteering under the guise of “good” patient care.

These frustrations are further exacerbated by an inefficient and wasteful insurance system, an increase in tasks that are not reimbursable and often nonsensical, numerous dysfunctional electronic medical record systems with lousy-to-no interoperability, a frivolous malpractice system, revenue-focused hospital administrators, decreasing physician salaries, poor peer support, and increasing familial responsibilities. Is it a surprise that such a chaotic healthcare system that fails to care for its doctors also fails to produce better outcomes than occur in other industrialized nations?⁶

So, what is the solution?

Clearly, the system must change, but progress will take time and we cannot simply wait around in the meantime. If physicians expect improvements, then physicians need to be the source of that change. First, we need to change perspectives. Older generations need to stop reminiscing about a healthcare system that no longer exists — it does not help future generations to belittle their concerns. Likewise, young physicians need to reconnect with their patients. Medicine is not about discharging patients and getting people out the door as quickly as possible. We need to refocus and prioritize ourselves and our families over our pride and our salaries. If we cannot lead healthy lives and spend quality time with our families, then we have already lost the battle with our patients.

Physicians often agonize in isolation, as if we are the lone victims of this dysfunctional system. Yet we know better — 50% of our colleagues are experiencing at least one symptom of burnout.³ In our inability to mentor and support one another through tough times, we are complicit in promoting the hostile environment that leads to physician burnout, depression, and — unfortunately — suicide.

During my career, I have had the pleasure of meeting some of the greatest minds in cardiology today, including Eugene Braunwald, MD, chairman of the TIMI Study Group and professor at Harvard University, and Valentin Fuster, MD, PhD, director of the Zena and Michael A. Wiener Cardiovascular Institute at Mount Sinai Hospital. The most important message I took home about their respective successes was about the importance of good mentorship. Yet good mentorship nowadays seems hard to find because everyone is too busy struggling. Maybe we need to start struggling together and treating one another with a bit more of that humanity we aim to offer our patients.

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References

1. Schattner E. The Physician Burnout Epidemic: What It Means for Patients and Reform. The Atlantic. https://www.theatlantic.com/health/archive/2012/08/the-physician-burnout-epidemic-what-it-means-for-patients-and-reform/261418/. August 22, 2012. Accessed April 26, 2018.
2. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-1385.
3. Agency for Healthcare Research and Quality. Physician Burnout. https://www.ahrq.gov/professionals/clinicians-providers/ahrq-works/burnout/index.html. July 2017. Accessed April 26, 2018.
4. Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. 2008;336(7642)488-491.
5. Klass P. Taking Care of the Physician. The New York Times. https://www.nytimes.com/2017/11/13/well/family/taking-care-of-the-physician.html. November 13, 2017. Accessed April 26, 2018.
6. Davis K, Stremikis K, Squires D, Shoen C. Mirror, Mirror on the Wall, 2014 Update: How the US Health Care System Compares Internationally. The Commonwealth Fund. http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror. June 16, 2014. Accessed April 26, 2018.

 

This article originally appeared on Medical Bag