The Elephant in the Room

Carolyn H. Kreinsen, MD, MSc Susan G. Krantz, MD, ScM

Being a physician has always been difficult, fraught with responsibility, intellectual challenges and stress. Physicians often enter the profession with altruistic goals to help other human beings and to lessen the burden of illness and pain. They may pursue medicine to address complex diagnostic challenges, to make contributions through education or research or to serve the greater good through volunteerism. Given the nature of the work, no one embarks on a career in medicine expecting routine hours and predictable work days; however, for many physicians, the current realities of the job barely resemble the profession for which they trained.

Burnout is widely defined as a long-term occupational stress reaction characterized by depersonalization, emotional exhaustion and a sense of low personal accomplishment. Burnout is not a new concept, having been described over the past several decades in physicians, other healthcare professionals and other individuals in myriad work environments. In 2019, the National Academy of Medicine reported burnout had reached “crisis levels” among the U.S. health workforce, with 35-54% of nurses and physicians and 4560% of medical students and residents reporting symptoms of burnout [1]. Since then, mounting pressures in the U.S. healthcare environment, in addition to severe stressors and staffing shortages associated with the COVID pandemic, have only exacerbated problematic imbalances. Demands on physicians consistently exceed the available resources to support their efforts within the existing infrastructure [1]. Burnout not only results in high personal cost for individual physicians, but also negatively impacts patient care with substantial economic and societal costs. It has been estimated that burnout costs the U.S. healthcare system at least 4.6 billion dollars per year, with the greatest burden attributed to physician turnover and work hour reduction [2]. A recent Massachusetts Medical Society (MMS) survey reported an alarming level of physician burnout currently impacting the physician workforce in Massachusetts, with overall 55% of physician survey respondents experiencing symptoms consistent with burnout. Their data indicated that a large number of Massachusetts physicians have already reduced or intend to reduce their clinical effort, with approximately 1 in 4 respondents planning to leave medicine in the next 2 years [3]. These alarming statistics may actually underestimate the true scope of the crisis; many physicians do not reveal their symptoms of burnout due to personal and professional reasons, and often suffer in silence.

While many different contributors to burnout have been described, the widespread implementation of the electronic health record (EHR) and often ill-conceived performance metrics have been consistently identified as underlying drivers [4]. Rather than supporting clinicians in delivering care more effectively and efficiently, existing EHR designs essentially manage physicians and how they do their work, with prioritization of billing functions [5]. Instead of spending time and attention on meaningful work that prioritizes utilization of their unique clinical skill sets and training, physicians today are frequently burdened by a high volume of irrelevant and rote administrative clerical tasks. Those would include time consuming documentation and EHR clicks that do not require physician-level expertise and are unrelated to clinical care [4].

Practicing physicians today often experience a disheartening lack of autonomy reflected in limited control over their time, attention, content of patient encounters and structure of the related documentation [6]. One qualitative study of 57 practicing physicians in several different ambulatory specialties reported that every hour of direct clinical time in the ambulatory setting generated nearly 2 additional hours of EHR and desk work within a clinic day. The authors also documented that the studied physicians routinely spent an additional 1 to 2 hours of personal time each night, outside of office hours, addressing unfinished EHR and other clerical work [7].

Initial proposed solutions for the burnout epidemic approached this as a “physician problem” and targeted the individual clinician with interventions such as exercise classes and mindfulness/relaxation techniques. There was emphasis on increased efficiency and maximization of productivity as a means of reducing stress. However, while burnout exerts detrimental effects on the individual, the problem in reality is collective and macroscopic in nature. Targeting the individual physician fails to address the actual underlying causes existing within the larger healthcare system. Realistic solutions to address the physician burnout epidemic and to support physicians in delivering high quality care must examine the multifaceted contributors to burnout at all levels of the healthcare infrastructure - local, organizational and governmental. Interventions could include efforts to optimize EHRs and to utilize innovative and appropriate AI approaches to support physicians in patient care activities. Further initiatives must reduce the burden of overwhelming unnecessary administrative work, adopt reasonable expectations for physician clinical workloads and schedules, and prioritize adequate clinical support staff capable of handling non-physician issues.

The current clinical healthcare environment has left many excellent physicians exhausted and disillusioned. Given the multitude of competing demands facing the healthcare infrastructure at all levels, it remains imperative to keep the issue of burnout in the forefront. The current exodus of physicians and other healthcare professionals from medicine is a serious crisis. Rather than merely scrambling to supplement clinician availability with non-physician providers when physicians leave their jobs, effort must go towards nurturing and retaining the committed, experienced and very capable physicians who have already been functioning as integral forces within the healthcare system. The elephant in the room permeating the healthcare system looms large and must be addressed; facing and solving the issue of physician burnout is critical and necessary to ensure a robust and sustainable healthcare system today and in the future. +

References:

1. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being.Washington (DC): National Academies Press (US); 2019 Oct 23.

2. Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med 2019; 170(11) 784-790.

3. Massachusetts Medical Society. Supporting MMS Physicians’ Well-Being Report: Recommendations to Address the On-Going Crisis. March 2023.

4. Hartzband P, Groopman J. Physician burnout, interrupted. NEJM 2020: 382:2485-2487.

5. Detmer DE, Gettinger A. Essential electronic health record reforms for this decade. JAMA 2023;329(21):1825–1826.

6. Khullar D. Burnout, Professionalism, and the Quality of US Health Care. JAMA Health Forum. 2023;4(3):e230024.

7. Sinsky CA, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med 2016; 165:753-760.

Carolyn H. Kreinsen, MD, MSc is Assistant Professor of Medicine at Harvard Medical School. She has been a long-term Associate Physician at Brigham and Women’s Hospital with appointments in the Division of Women’s Health and Department of Medicine.

Susan G. Krantz, MD, ScM is Instructor of Medicine at Harvard Medical School. She previously worked as a primary care physician at VA Boston Healthcare System for more than 25 years.