Editor’s note: On October 23, the National Academies of Sciences, Engineering, and Medicine (NASEM) released “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being” (see related article, Health Care System Takes Heavy Toll on Nation’s Clinicians, Study Finds). Health Care News asked physician policy advisors at The Heartland Institute, which publishes Health Care News, for their views on professional satisfaction and whether the recommendations in the NASEM report get to the heart of the matter.
Restore Physician Control
This report is a timely and important step in addressing an essential challenge in contemporary health care delivery. We have done an inadequate job of adapting training, workplace environments, management skills, and organizational cultures to accommodate the changed professional and employment status of our highly trained and dedicated physician workforce within what is now a heavily regulated, government-dominated health care system.
The bottom line is most physicians are now employees and have lost control over their work environments and daily activities. More than hours or the difficulty of the work, this feeling of lack of control or powerlessness is an essential element of the enhanced stress that directly leads to burnout.
—Roger Klein, M.D., J.D.
Put Doctors in Charge
Burnout exists because doctors are unable or unwilling to accept the new role they are being relegated to in this evolving health care system. They are viewed as a provider, no different from a nurse practitioner or physician’s assistant. They are diminished by hospital administrators who tell them they are not seeing enough patients or are ordering too many studies. They cannot spend more than seven minutes with a patient, and they are a slave to a computer that has become detrimental to patient care.
The solution to burnout is not teaching doctors better coping mechanisms. It is restoring doctors to the top of the health care mountain and freeing them from red tape and bureaucracy at all levels.
—Hal Scherz, M.D.
Burn Down the Bureaucracy
Bureaucracies, as Ludwig von Mises wrote, are not about excellence of service or production. They are about controlling people. Burnout in health care is created by bureaucrats.
NASEM proposes a program to deal with physician burnout. How about burning down the bureaucracy and going back to a value-based system that rewards performance and focuses on excellence and service?
—John Dale Dunn, M.D., J.D.
Listen to Doctors
“Moral fatigue” is a better label than “burnout,” to avoid the inaccurate labeling of toxic workplace conditions as mental pathologies of individual physicians. The six recommendations are to be commended. Physicians also need more robust and accessible mechanisms for reporting administrative error. There should be zero tolerance for retaliation against physicians who bring forward concerns about quality of care.
Also, the current system used to evaluate allegations of physician impairment needs reform. When physicians face stressful work environments, they will be more likely to seek help if they are assured their self-reports will not be used for stigmatizing, labeling, or coercive referral for psychiatric treatment.
—Robert Emmons, M.D.
Remove the Middlemen
The term “burnout” probably isn’t accurate. Physicians are generally a tough group of people. We are used to working 80-hour weeks for seven or more years in a row (aggregating medical school and residency).
In a literal sense, most of us gave up our twenties to practice medicine. Burnout implies we no longer want to work hard. A friend of mine effectively argues burnout should be relabeled “compassion fatigue.” When your work is hard but enjoyable, you continue to do it for as long as possible. I don’t think Tom Brady needs the money to play quarterback at this stage.
When your work is not rewarding, then you minimize it since the hours spent at work are not fulfilling. Clicking boxes to please a third-party payer for fifteen minutes after rushing out of the room five minutes into a patient visit is a recipe for unfulfilling work, and physicians will want to do as little of it as possible.
Physicians and patients are both to blame for this damaged relationship. All relationships fail without effective communication. Thus, the answer is surprisingly simple: ditch the third-party payer and communicate with each other again.
—Phillip Eskew, D.O., J.D.
End Assembly-Line Medicine
It is ironic that the report quotes Christine Cassell, who is probably just as responsible as any one individual for burnout problems because of the American Board of Internal Medicine’s Maintenance of Certification (MOC) program. MOC, which is mainly a cash cow for specialty boards, must be made truly voluntary, as the boards deceitfully insist it is, without loss of professional privileges for declining to participate.
A positive work environment is one in which the physician has authority commensurate with responsibility, control over the work environment, and the opportunity to develop patient-physician relationships instead of being the shift worker of the hour, enslaved to dropdown menus and counterproductive “documentation.”
A managed-care environment may be a guaranteed recipe for burnout. More and more physicians are finding fulfillment by declaring independence. The relationship between managed care and burnout is not coincidental. Working hours used to be longer, but burnout is recent.
—Jane Orient, M.D.
Let Doctors Be Doctors
The “solution” of having top-down wellness programs run by the very executives who are complicit in causing the problem adds to the oppression of physicians. “Being well” becomes a new task to achieve. Paying to enroll in a physician health program is a financial burden and subjects the physician to more rules.
Solutions directed at letting doctors be doctors and letting patients be seen as individual human beings, not points in an algorithm, would be welcomed.
—Marilyn Singleton, M.D., J.D.
Stop the Number Crunchers
The overlap between the “quality” industry and the “burnout” industry needs to be addressed. Many of the same players who invented, lobbied, and enriched themselves by forcing doctors and nurses to comply with untested, burdensome quality metrics and proprietary certifications at the core of this burnout crisis are the same ones now attempting to gain market share with burnout solutions.
—Meg Edison, M.D.