“CAGED TIGERS” – The root cause of physician burnout

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In recent years, there has been an overwhelming discussion in the United States about cost containment in the era of the Affordable Care Act [1].

The pressures of reducing health care costs while increasing the ability to deliver the highest quality of care have paralyzed the profession medically and politically. The future impact on the delivery of healthcare is still yet to be determined. However, the measures that have been hastily imposed to justify a means to an end have already begun. What is clear is that burnout among physicians has insidiously reached epic proportions which are rarely acknowledged and not discussed openly. Burnout has been reported in the range of 25-60% of physicians and even up to 75% in published reports [2-6]. The "physician heal thyself" proverb, although based in religion (Luke 4:22), has been interpreted to assume that physicians by knowing the mind and body, can treat themselves from an arms-length perspective, perpetuating an unrealistic notion of self-preservation and invincibility that is unparalleled in any other profession.

Intriguingly, the concept of a “professional” is where this dialogue must begin. When I was interviewing for medical school about 30-years ago, the most memorable medical school interview was when I was asked, "Can you please define the meaning of a professional?" I recall that question very clearly in my mind because I knew there are so many ways to answer that question: the standard inclusive Merriam-Webster definition; the special ways that it pertains to ethical standards and conducts of individual in an autonomous profession; or the specific traits that really defines an individual who can succeed as a doctor. In fact, a professional is a combination of all of those definitions with nuances of each that are important to the ongoing dialogue.

Let us examine the nature and beliefs of these individuals who seek higher education in the medicine profession and that will, perhaps, shed light on the root cause of the burnout. It is an almost universally spoken and unarguable truth that health is of paramount importance in our lives. Sir Winston Churchill said, “Healthy citizens are the great asset any country can have” [5]. We care about it. We work to preserve it. We hope that we have it. We sympathize with those who succumb to the lack of it. Physicians, since the beginning of their profession, have always been the "healers" – the mortals who might provide solace and hope when one is suffering from illness. It is imperative to find the best and the brightest in our societies to enter this profession to perhaps shed light into the darkness of diseases that afflicts humanity. Science has been the foundation of knowledge, but the practical delivery of care demands the highest integrity, compassion, and understanding of the human spirit - the soul if you will. For this reason, no matter where you turn, medicine has always been the balance of the sciences and the art of healing - wisdom handed down to us from our predecessors in medicine such as Sir William Osler. Perhaps Osler said it best when he defined medicine as “the practice (of medicine) is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” Those who practiced medicine held this notion as the highest sanctity and is taught throughout medical schools everywhere.

In pursuit of providing the best healthcare in the world, we are now victimized by our successes. It was not long ago that the structures of DNA were elucidated and at that time, for our short memories, we can perhaps count on our fingers how many antibiotics were available to treating infections. The brilliant minds of scientists and all the research in medicine have taken us on a path of treating illness beyond what was imaginable just half a century ago. It has come to a point where we take for granted that premature babies can now routinely survive, most infections can be controlled, many cancers can be forever defeated, and even when organs fail, they can be replaced. I was particularly enamored by all these concepts, that of limited immortality - preserving life and maintaining wellness, that I went into organ transplantation as a career. Observing thousands of patients in my career who have life-threatening illnesses and yet emerge with healthy outcomes is enlightening; these experiences truly bring unimaginable job satisfaction. My mentor, Dr. Ben Cosimi, Emeritus Professor at Harvard, even once said, "Is death now optional?" The dignity of death and dying, thus balancing the science and art of medicine have risen to another zenith in our times.

This sophisticated healthcare system is not free. For that matter, nothing is. Indeed, medicine is changing rapidly from the initial higher callings of Sir William Osler where even the most solid fundamental and absolute pillars are rocked by time and the need for modernization. As healthcare dollars skyrocket to provide theoretical high-quality care, we have learned that almost a quarter of that amount is used in the last few years of our lives and not during the majority of our existence [7]. It became an important dialogue to discuss in what context are we making our economy sick while trying to heal ourselves individually. The measures of cost are benchmarked by some important observations for population healthcare indices such as infant mortality, life expectancy, the incidence of cardiovascular disease and so on. Despite the high cost of healthcare in the United States, garnering a higher percentage of the gross domestic product that any other sector, we are no better, but even behind, in overall health when compared to other first world countries. Staggeringly, in the World Healthcare Index of 2016, United States ranked number 35 in the world [8]. How could this be?

While observing parallel growth in other industries such as retail, airline, and manufacturing, health care experts noted that they were performing more efficiently with better outcomes than medicine [9]. These observations led to the rise of a new industry of checks and balances to model these “lean” production models. These barometers of quality are necessary for transparency and more importantly to understand what is happening in our profession. We have tasked with no longer using volume metrics as success but quality metrics as measures of improving delivery of healthcare in this country. With evolving roles of what doctors should concentrate on doing to provide great care to the patients, the concept of autonomy is also changing. Doctors provide great clinical care and are trained for over 15 years since high school to be competent physicians after passing rigorous clinical evaluations and clinical certifications. Because of these demands, isn't it better to leave all the complexities of running a practice to those who are educated to run a business instead? Conventional wisdom would say yes in a heartbeat, and our buy-in to this concept was immediate and universal. Almost most discussion of these new concepts began with the phrase, "The right thing to do is..."

In a way, we ushered in an era of “Wal-Mart mentality” to the delivery of health care [10]. MBAs, MPHs, healthcare managers, and mid-level providers all started to spring up in the field. Physicians gladly ceded control of their practice to others that we employed who appropriately tasked to help us make our professional lives better. As we started to believe more and more that we were best at doing what we were trained for, our lives were managed by our "handlers." We have little or no management training as a result [11]. It seemed that the tables turned overnight. The autonomy of physicians has now disappeared. Our practices are now regulated by clinical guidelines, practices and protocols, efficiencies and measures of perfections. We are now trapped by the logical processes we have created [12]. Perfection is demanded. Mistakes are outlawed. Appointments need to be always available. Communications need to be open, inclusive, and even omnipresence in today's digital media. Electronic medical records need to be comprehensive and without error. Items of history and physical demand to be documented which, subsequently, are counted by coders and billers. This system was to ensure our professional accountability – because doctors can cheat, right? We have no escape in a system that we, ourselves, created, given up control, and agreed to being essentially a worker. We are now in an era of making widgets on an assembly line. We provide care with interchangeability as evidenced by having our clinics covered by colleagues or advanced practice providers in case we are out with fatigue, sickness or personal reasons.

With other goods and services in our everyday lives, compensation is determined by expertise. If you want better-tailored clothing, food, legal services, or financial services, you will pay more and wait in line. The notion of getting something better is not the case in American medicine [13]. Our generation demands that our profession is the same exact quality wherever you go. Even the most junior physicians are supposed to provide the same care as the most experienced in the field. Not only that, allied professionals such as nurse practitioners and physician assistants are grouped together with physicians, in the spirit of inclusivity, as “healthcare providers”. I distinctly recall that during 30 years of practice in medicine, this was a profession where we chose the best and brightest to enter the field. Now we cannot even be recognized as "doctors" but relegated to the generic “healthcare providers”. However, care is not uniformly equal among all “healthcare providers”. It takes years to hone those skills and newly graduated physicians will further develop their experiences over the first few years of being in practice despite years of medical school and residency training.

When doctors are considered as generics and consumables, there is a distinct and palpable erosion of autonomy. We need great doctors to administer great healthcare. We need to start with a premium seed, mature it in the right soil, and harvest it as a final product. This is not unlike mass production of food in this country. As an analogy, we are longer can we be "free range" -- we are now raised in chicken coops and systematically matured in 45 days from hatching [14]. With no disrespect to others, candidates are chosen for the medical profession because of who they are; how they think independently and creatively; and, ultimately, hope and promise that they can bring healthcare forward to a better place. We foster and breathe those ideals. However, it has been a steady erosion of that promise and those ideals as a result of “industrialization” of the medical profession. Look no further. This is the root cause of burnout. In hindsight, a Professor of Medical History 30-years ago said during the first week of my medical school class, “You will soon see that you are put on a conveyor belt and spit out on the other end in four years.” He was so ahead of his times and, ironically, he was a historian.

The problem that we face today is how we bring new generations of bright young medical students through this complex system. Prospective medical students that I have interviewed for the past eight years always come with outstanding credentials of academic brilliance, extracurricular talents, formidable leadership qualities, and a wide breath of social consciousness and equity. These medical students are the future leaders in medicine with their unwavering demonstrable will and nobility that defines the profession – almost trust on first sight. We want them to succeed because we chose them for the lack of a better colloquial analogy, like the "pick of the litter." These are students who could have become successful in any field such as law or finance but are selecting medicine as a profession for the reasons Osler so eloquently stated. Now they are destined for a protocol-driven life, not allowing them to grow and develop the novel thoughts we need truly need in medicine. The current system we have set up for them will undoubtedly fail them. It is a system of bait and switch. These dissatisfactions are evidenced by the high rates of resident burnout, and depression is high, but even more so the rates of suicide are increasing [15]. These bright young minds are leaving medicine in droves to more lucrative fields such as finance, biotech, venture capital firms.

Many medical societies and professional organizations are beginning to look at physician dissatisfaction and burnout. Is it the demand of filling out electronic medical records? Is it the lowering of payments to doctors? Is it the stress of working too many hours a week? Is it because the training is too long? Is it the high burden of student loans? Is it because the balance of family and profession is getting harder to manage? Of course, these are contributing factors [16-22] but knowing from a study that electronic medical records contribute to dissatisfaction with a significant p-value doesn't help on a practical level. It is naive to think that these will be the elements of illumination that will resolve physician burnout. Solutions generated to help us with electronic health records by employing medical scribes, which now is becoming popular, only adds to more complexities and needed oversights on documentations. These missions are, indeed, trimming the flowers off the dandelion and not getting the roots out. These do not do away with the loss of our profession's autonomy. The fact is, we were the tiger cubs that were born to be at the top of the food chain. We are now simply the caged tigers in a circus. Even Ringling Bros. and Barnum and Bailey's circus recognized that change is ultimately necessary! 

By Dicken S. C. Ko, MD, FRCSC, FACS1 with contributions from Julianne Ip, MD2 and Garry Choy, MD, MBA3

1Chief Medical Officer and Vice-President of Medical Affairs, Steward St. Elizabeth’s Medical Center, Boston, MA
2Associate Dean of Medicine, Brown University, Providence, RI
3Chief Medial Officer, Q bio – Health Informatics & Technology Venture, San Francisco, CA

References:

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