Nine Factors That Are Keeping Today’s Doctors Stressed, Depressed, and Disengaged
In his new book, Healing Physician Burnout, Quint Studer lays out the avalanche of industry changes that are crushing the life out of physicians. The good news? When you can understand what’s causing the problem, you can take the needed steps to address and alleviate it.
By Quint Studer
Survey after survey proves it: Physicians are feeling exhausted, dissatisfied, discouraged, helpless, and hopeless. Burned out, in other words. Statistics indicate that one out of every two physicians is, has been, or soon will be suffering from burnout. And in some specialties, this estimate is too low.
As a nation and as individual health systems, we can work with physicians to solve the burnout crisis. In fact, it’s even better than can—we will solve it. I believe the recent changes in healthcare have created the sense of urgency we need to finally put the needed energy behind the issue. The key is getting physicians aligned and engaged with the organizations they work with and for—but first we need to understand what’s causing them to burn out in the first place.
Healing Physician Burnout provides a solution to health system leaders and for physicians themselves. A good portion of the book is devoted to explaining the pressures that squeeze physicians from all sides.
In Healing Physician Burnout, I write: “Yes, there are many complicated and intertwined factors that are plunging too many physicians into a state of depression and burnout: uncertainty created by the ever-changing landscape of healthcare, a lack of control over their future, highly stressful jobs, time constraints that keep them from forming meaningful patient relationships, salary concerns, and the feeling of being stuck in a career they no longer enjoy.”
Here are just a few of the burnout factors covered in the book:
Coping with “big picture changes” is incredibly stressful. The Affordable Care Act (ACA) has forever altered America’s healthcare industry. And no one has seen more change than physicians. Many physicians have moved from solo practices or small groupings to joining ever-larger practices and systems. Employment has moved from solo to a group LLC to often a large organization.
What’s more, value-based purchasing increasingly ties reimbursement to clinical quality and patient experience outcomes. This is a major paradigm shift from “services delivered” to “outcomes performed,” and it includes both public and private payers, similar to when Richard Kimball Jr. of HExL talked about “The massive shift of the healthcare system from fee for service to value based reimbursement” from an article here. Not only does this new reality ramp up the pressures physicians feel to perform, it’s counter to their “rugged individualist” roots.
And if that’s not enough, a looming physician shortage is hitting at the same time that our aging population needs more and more care.
All of these changes have caused physicians to experience what they perceive as a severe loss of control. It’s taking a huge psychological toll. Studies show physicians feel greater professional satisfaction when they have more control over their work. In my view, physicians’ current frustration is not because they crave authority. It’s more that they crave respect for their ability to make decisions.
Physicians are experiencing too much change too fast. Besides the aforementioned paradigm shifts around how physicians get paid (and by whom) and the big demographic changes, there is also the need to learn new practical skills, which pulls physicians away from patient care. For example, the industry-wide move to electronic medical records (EMRs) is forcing physicians to learn time-consuming new systems—and while most agree this change will be beneficial in the long run, getting accustomed to the “new way” is far from easy.
The sense of feeling overwhelmed comes from having to move backward on a spectrum that describes the four phases of competency and change that all individuals go through when learning new things. (This model is usually attributed to Abraham Maslow as well as Noel Burch of Gordon Training International.) Essentially, people move from being Unconsciously Unskilled (where they don’t yet know what they don’t know) all the way up to Unconsciously Skilled (where tasks have become second nature and can be completed almost on autopilot).
Physicians are high performers. Imagine what it feels like when more and more change and responsibility are piled on them and they have to move backward to Consciously Unskilled, which means they know what they don’t know. This state doesn’t feel good to them at all, and they may express their discomfort by pushing back. Health systems need to be patient and have empathy for what physicians are going through as they strive to move themselves back up to Unconsciously Skilled.
Physicians are overworked and sleep deprived. The Physicians Foundation’s 2014 Survey of American Physicians found that more than 80 percent of doctors say they are “overextended or at full capacity.” Another study—“Burnout and Satisfaction with Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population,” by TD Shanafelt, et al, published in the Archives of Internal Medicine, 2012—reports that nearly 40 percent of physicians work more than 60 hours per week compared with only 10.8 percent of U.S. workers.
Ironically, very few physicians would recommend such an unhealthy, unsustainable lifestyle for their patients. Physicians are only human, and all humans need a certain amount of down time for their mental and emotional health. Like everyone else, physicians need and deserve time for a life outside of work.
It’s not surprising these overworked physicians are also sleep deprived. This has always been the case for residents, but all the change we’ve experienced in recent years has made it true for physicians at all stages of their careers. Besides making mistakes more likely to occur, prolonged sleep deprivation almost inevitably results in burnout.
Physicians face downward pressure in compensation, coupled with heavy debt. Not only are physicians being asked to relinquish control over their own lives and to change many things about the way they’re used to working, they’re now hearing, “Oh, yes, now we want you to do this for less money, or at least the same money.” There is definitely a downward pressure on physician incomes, which represents a massive shift in the “social contract” physicians have always operated under.
This creates a feeling that the rules have been changed in the middle of the game. When rules are changed during a game, most likely people will feel “this is not fair.”
Also, it’s not unusual for new physicians to graduate with hundreds of thousands of dollars in education debt. The emotional weight of owing this much money on top of ever-rising living expenses cannot be underestimated. Once physicians take on a mortgage and possibly marry and have children, the burden can feel crushing. It can create the feeling of being a financial hostage.
Many physicians need additional skills beyond great clinical expertise. A recent Wall Street Journal article by Melinda Beck explains: “‘The fund of medical knowledge is now growing and changing too fast for humans to keep up with, and the facts you memorize today might not be relevant five years from now,’ says NYU’s Dr. Triola. Instead, what’s important is teaching ‘information-seeking behavior,’ he says, such as what sources to trust and how to avoid information overload.”
The additional skills needed today include: the ability to navigate electronic medical records, to consult a patient’s economic “big picture” when ordering tests, to work in teams with other professionals who aren’t doctors (and to be okay with not always knowing the answer), to communicate clearly, to engage patients as partners, and to know LEAN (process improvement) and cost-reduction strategies. Oh, and all of these new requirements are hitting at the same time.
What’s happening in healthcare is that we’ve moved from an episodic change culture to a continuous change culture. As John Kotter states, there is nothing more difficult for an industry, and it can implode a culture. It is like going from knowing you’re going to make Thanksgiving dinner one day a year to being prepared to make Thanksgiving dinner every day of the year.
We will eventually get there and adjust, but it means a huge overhaul of the processes and systems currently in place. Physicians and everyone else in healthcare are living and experiencing these changes now. Yet a physician can sometimes see the transition as more difficult because the decisions they make may save lives. This is a lot of pressure.
Patient needs and expectations are changing. As patients live longer, they often develop more and more health challenges. It’s not uncommon for a patient to have three or four or even five chronic conditions at the same time—say, obesity, congestive heart failure, hypertension, diabetes, and asthma. These patients tend to be on many different medications and are “prescribed” a certain type of diet and exercise plan. In other words, their care plan is extremely complex and demanding—and not surprisingly, they are often noncompliant.
Plus, because we now have so many treatment options that didn’t exist at all in the not-too-distant past, patients expect miracles. They believe doctors can solve any medical issue and save any patient—and obviously this is not true. Factor in the rise of the Internet, which means patients have more and more information at their fingertips (some correct and some not) and you have an incredibly tough and stressful doctor/patient dynamic.
Imagine having to deal with non-compliant patients, critically ill patients who have unreasonable expectations for recovery, patients who are deeply skeptical of your diagnosis or treatment because “That’s not what I read on the Internet.” It’s so tough. If physicians don’t know how to communicate with respect and empathy—and many are not trained to—they can alienate patients and negatively affect outcomes.
Consistently high quality operations are now a must. Above all else, physicians care about patient outcomes. They need to know their patients are well taken care of, and if they don’t feel this is happening, they’re going to be anxious and stressed. Providing consistent and exceptional quality care—meaning quality care that occurs with every patient, every department, every time—remains elusive for many.
The move to continuous change, transparency, and the need to cut costs while improving consistency can be difficult for health systems. All health systems can provide excellent operations from time to time, but too often cannot be sustained 24/7, 365 days a year. This is incredibly frustrating to physicians and may become a barrier to getting feedback from them. Physicians think, Well, I’ve told them before what they need to fix and they still can’t fix it, or they do but it doesn’t stay fixed. Why bother?
Physicians want to receive consistent performance feedback. According to an article written by S. Schoenbaum, et al, in The Commonwealth Fund, between 30 and 50 percent of physicians report they do not receive adequate or meaningful feedback on performance. This shortfall creates many problems. When physicians don’t know where they need to improve, it stands to reason that they can’t, and won’t, do so. This can negatively impact patient care, but it can also impact physician compensation.
Physicians benefit (as does the organization) from clearly defined and very specific goals that are aligned with the organization’s larger goals. Physicians also need relevant, objective metrics built into their feedback. Physicians like facts and figures, and it will be a struggle to engage them in collaborative dialogue if one can’t cite “the numbers.”
Ultimately, physicians are just like everyone else in that they a) appreciate clarity around whether or not they are meeting expectations, and b) know exactly what needs to happen in order for them to meet expectations. Vagueness in either area results in uncertainty, which results in stress. Clarity and directness dissolve stress.
Many feel they spend too little time with patients…and too much time doing everything else. Physicians want to spend most of their time with patients. That’s why they went into medicine in the first place. Yet for a variety of reasons, physicians find themselves forced into frustratingly short appointments. A satisfied physician is a physician who feels confident their patients are getting the best possible care. A physician who feels rushed may not have that confidence.
Much of the problem, of course, is all the other tasks that have sprung up demanding physicians’ time and attention. The AMA-sponsored Rand Corporation report “Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy” notes that: “…many physicians—especially those without large numbers of dedicated allied health professionals and support staff—described spending a significant amount of time performing tasks that did not truly require a physician’s training and that ‘crowd out’ those that did. For example, such activities as filling out forms, typing and correcting automated transcriptions, dealing with multiple EHR order entry screens, and other ‘secretarial’ duties were reported as occupying a significant share of physicians’ time.”
None of this is to imply that we can’t overcome or at least mitigate many of these factors. Health systems and physicians, working together, can accomplish great things. And the key is to win over physicians’ minds and hearts. When that happens, the rest will take care of itself. As I write in the conclusion to my book:
“Over the past several decades, I’ve learned a lot about human beings in general and about healthcare professionals in particular, and one of the things I’ve learned is this: When people believe strongly in something and are fully invested in it, they can do amazing things. That’s why I am so certain that engagement and alignment are the keys to solving the physician burnout epidemic. Why? Because when physicians really buy into and get excited about an organization’s mission, they will put the full force of their passion, intelligence, and caring behind that mission. When that happens, miracles can occur.”
# # #
Physician “Burnout Busters”:
Five Tools Organizations Can Hardwire Right Now
To understand why health systems want to help physicians avoid and heal from burnout, just consider the definition of the word. Psychologist Christina Maslach said that burnout has three dimensions: emotional exhaustion, cynicism, and ineffectiveness. Each of them is antithetical to the mission of our industry—and each of them prevents patients from receiving the best possible care.
That’s why it’s crucial that organizations take steps to get physicians aligned and engaged (both before they burn out and after they’re already showing signs of this epidemic). And these steps should be grounded in the four physician drivers: quality, efficiency, input, and appreciation.
Physicians need to feel that their patients are receiving great clinical care and having a great experience. They want to maximize efficiency so they can spend as much of their limited time with patients as possible. They want a seat at the table when decisions are being made. And, oh, yes—a little appreciation wouldn’t hurt, either.
Following are a few tools that impact these four physician drivers, increase alignment and engagement, and fight burnout—and that health systems can put into practice right away.
TOOL #1: Physician Quadrants. This tool was created to provide organizations a more structured way to assess alignment. The first step in using this tool is to identify the physicians who have the most influence on operations (based on their role, their impact on revenue, etc.). Then divide this group into four quadrants based upon their level of alignment with the organization. (Keep in mind that alignment is different from performance, although performance does factor in.)
Next, label the quadrants as (1) “Loyal”; (2) “Want to Be Aligned”; (3) “Skeptical”; and (4) “Naysayer.” Alternately, you might follow the lead of one organization that chose to change the labels to (1) “Always”; (2) “Often”; (3) “Sometimes”; and (4) “Never.” Finally, place every name on your “influential physicians” list into one of the four quadrants. Once you’ve done this, you will need to take appropriate action to get each quadrant of physicians aligned and on board.
For physicians in Quadrants 1 and 2 you’ll basically want to thank them, ask them what you do well and what you might do better, and so forth. Do the same for Quadrant 3 physicians, but also have frank discussions regarding operational issues that can’t be fixed at all or in the time frame they would like. For Quadrant 4 physicians you’ll want to take similar actions—but just be aware that you’ll probably never make believers out of them. Fortunately they are only a small percentage of the medical staff.
TOOL #2: Stoplight Report. This tool allows organizations to keep their “wins” at the forefront so that physicians and others can see and feel good about what has been accomplished.
It’s a simple yet powerful tool that organizations can use to show the status of suggestions physicians have offered and the action being taken. The stoplight report is divided into three columns: Green = “Done”; Yellow = “In Progress”; and Red = “It Won’t Happen.”
You can tell how good an organization is at fixing things by looking at the colors. If there is a lot of green, a good amount of yellow, and just a little bit of red, the organization is moving forward. Physicians see this progress and appreciate that their input is appreciated and implemented. And it’s fine if a suggestion goes into the red column from time to time—physicians have told me they’d rather hear a solid no than to feel they’re just being glad-handed.
TOOL #3: Professional Development Feedback Systems. Sometimes when a physician graduates from medical school, they are seen (erroneously) as a “finished product.” Yet today, physicians are expected to have much more knowledge of teamwork than ever before. An organization decides to implement Lean, and physicians need to be experts on patient flow. They need to have technology skills for the new electronic medical records. They’re asked to use problem-solving skills in ways they never have before. That’s why I suggest putting systems in place to help physicians master these vital skills.
There seems to be an understood need for ongoing development in clinical advancement, so let’s also focus on other needs. It would be really exciting if time was taken with physicians on a regular basis to create a professional development plan to track their progress and performance—much like other industries do for their elite performers. It doesn’t make sense that development plans are created for almost everybody else in the healthcare system, but not for physicians.
If a physician makes $200,000 a year with benefits, over a five-year period that comes to a million dollars. That’s a major investment. Once physicians are part of the healthcare team, opportunities to help them continue to perform at a maximum level should be provided. This is done to enhance their professional life. Their personal life also benefits. When both areas are working well together, physicians are far less likely to burn out and far more likely to thrive.
TOOL #4: Focus, Fix, and Follow-Up. This tactic can be used in conjunction with leader efforts to round on physicians or as a standalone. (Healing Physician Burnout explains more about rounding, but basically it’s about making a human connection and asking three questions: What’s working well today? Do you have everything you need to provide excellent care to patients today? Anybody to reward and recognize?) Focus, fix, and follow-up ties into the concept of input, efficiency, quality, and appreciation.
For physicians, a key issue is the feeling of losing control. Physicians think, I want quality of care for my patients. I want efficient, effective operations. I want input, and it wouldn’t be bad to be appreciated, either. While all tactics hit one or more of these drivers, focus, fix, and follow-up hits all four of them solidly.
FOCUS: Focus on what the physician is saying. (Input)
FIX: Fix it so the physician can have more efficient/effective operations and better quality of care for patients. (Quality and Efficiency)
FOLLOW-UP: Follow up so the physician is communicated with and is appreciated for identifying the issue. (Appreciation)
TOOL #5: A Focus on Physician Health and Wellness. Wellness programs have become a more common component and employee benefit in our workplace today with organizations requiring yearly wellness visits for every employee. However, this is not as common with physicians. In fact, it is not unusual for physicians to self-diagnose and to treat themselves.
A large hospital system in Texas implemented a requirement that all employees have a wellness check with their primary care physician each year. After a few years, they realized they were not requiring the same for employed physicians. So they are implementing a wellness check requirement for physicians as well. They actually found that a number of physicians did not have a primary care physician but were instead acting as their own physicians.
The system feels these wellness checks for physicians is an important part of overall health and wellness for their physician staff and will be able to screen for issues such as burnout, anxiety, stress, and depression that might otherwise go undetected. They are even tying these wellness checks to their payroll and incentive measures.
# # #
About the Author:
Quint Studer is the founder of Studer Group®, a recipient of the 2010 Malcolm Baldrige National Quality Award. Inc. Magazine named Quint its Master of Business, making him the only healthcare leader to ever have won this award. Twice Modern Healthcare has chosen him as one of the 100 Most Powerful People in Healthcare. He is the author of numerous books. There are currently 700,000 copies of his BusinessWeek bestseller, Hardwiring Excellence, in circulation.
About the Book:
Healing Physician Burnout: Diagnosing, Preventing, and Treating (Fire Starter Publishing, 2015, ISBN: 978-1-622-18020-2, $28.00) is available at bookstores nationwide and from major online booksellers.