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Physician Burnout Is a Social Disease
Physician burnout has gone from an occasional issue to a national epidemic over the past 20-30 years or so. Doctors have always worked a lot of hours but, in general, we work fewer hours now than we did before. So why the sudden surge in burnout? Physician alcoholism, drug abuse, and suicides are at all-time highs and continue to grow.
Wendy Dean, MD, has an interesting theory. Dr. Dean spent time as a psychiatrist in the military and noticed a similarity between the PTSD she saw in soldiers and the “burnout” that so many physicians are struggling with.
She avoids the term “burn out” and describes this phenomenon of exhaustion, demoralization, and depersonalization among physicians as “moral injury.” Dr. Dean delineates the root causes of this condition: “Moral injury … describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control.” She explains that physicians are “… increasingly forced to consider the demands of other stakeholders – the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security – before the needs of our patients.”
Aristotle would understand this. It’s not that doctors are working too hard at their job. It’s that they’re being prevented from doing their job in the way that they believe it should be done. This creates inner conflict that is a slow-acting poison to the soul.
The best physicians are the ones who give a crap – the ones who really, really care about their patients. And unfortunately, those are the ones most affected by this phenomenon, as you might expect. So our best doctors quit or burn out. Which leaves the rest of them.
You can understand why doctors who really care about their patients struggle with modern medicine:
Each patient is going to the doctor because something very important is wrong, but they’re herded through like cattle. They’re treated like a number, not a neighbor that we care about. The doctor orders a test to find the diagnosis, and gets a message on his computer screen the next day telling him that the test was either denied, or requires additional meaningless paperwork, after which it will be denied. By a nameless, faceless somebody who has never met the patient. So he guesses, and writes a prescription to treat the disease he suspects the patient has, and gets a message on his computer screen the next day telling him that the prescription was either denied, or requires additional meaningless paperwork, after which it will be denied. By a nameless, faceless somebody who has never met the patient. And so on and so forth.
He does this thousands of times a year. And his natural human compassion that drove him to medical school years ago starts to feel a little numb. On a bad day, with a difficult case, he’ll reach inside for that personal compassion that he needs to care for someone, and be unable to find it, for some reason. His brain feels overfull of tasks regarding Medicare compliance and HIPAA regulations, but his soul feels strangely empty. He’s still functional, he tells himself. Just a little numb, for some reason. Eh – it’ll pass.
The numbness leads to pain. Alcohol helps convert the pain back into numbness, which is sort of an improvement. But only for a while.
Sometimes it gets worse. It never gets better.
He yearns for sufficient apathy to keep him, well, mostly functional. The inner drive and personal compassion that made him an outstanding physician now make him a below-average bureaucrat, clicking boxes on his EMR, filling out more forms that he doesn’t understand or care about.
This gradual process of depersonalizing our most compassionate profession is regrettable. But if you’re a sick person, it’s terrifying.
Modern leftism is partially based on the diffusion of responsibility. You feel guilty when you don’t volunteer at a homeless shelter or when you see a child in need and you keep walking. But you absolve your guilt by voting Democrat. Hey – it’s not my problem, it’s our problem. It takes a village. Government is the name we use for things we do together. When someone is hurting, government must act. Cooperation is nice, right? We can all come together to achieve Utopia. People gradually defer their responsibility for one another to the collective. Diffusion of responsibility sounds good – it’s so tempting. Which leads to stronger, more centralized power structures.
The individual starts to get sort of lost in the complexity of the ever-growing government. And people gradually become depersonalized.
Their responsibility for their neighbor becomes diffused to the society as a whole, meaning government. Loving their neighbor becomes more of a chore. After all, she’s really not his problem. I don’t need to walk across the street to say hello. I’ll just “like” her post on Facebook. Didn’t her husband just lose his job? Can’t remember. Not really my concern, anyway. That’s why we have unemployment benefits. It’s nice that Elizabeth Warren wants to help the unemployed. I’m voting for her. That makes me nice, too. A little numb, maybe. But nice.
The moral injury of demoralization and depersonalization that Dr. Dean describes may be more exaggerated among physicians, because of our personalities and the nature of our profession. But I think it’s more widespread than just among doctors.
Much of society suffers from this affliction, to varying degrees, in my opinion. The diffusion of responsibility and the resulting dominant power structures of modern leftism just don’t fit with the natural compassion of human nature. In fact, it must suppress human nature. And when our natural human compassion is suppressed, we feel numb. And then we hurt. Booze and pills help. But only for a while. Just ask a doctor. Or ask anyone who’s lived behind the iron curtain.
Modern culture is often described as coarse or vulgar.
I think it’s just demoralized and depersonalized.
The diffusion of responsibilities is a tempting drug, but it has serious side effects.
Trust me. I’m a doctor.
I know.
And I’m really trying to care.
Published in General
A local prolife pregnancy support center has a shiny new ultrasound machine gathering dust because New York State, the abortion capital of the nation, which permits non-doctors now to perform abortions, requires that ultrasounds be read by a doctor. Many local doctors are willing to volunteer their help to the center, but none of their contracts will allow them to. So the machine sits useless.
Tightly managed property.
Gotta be tough.
I’m there.
“Excuse Me, would please donate to [insert recent tornado, hurricane, fire… calamity]?”
“I’m already giving. The government will be sending untold, unaccountable billions Their way soon. Have a nice day.”
Compassion: That comfy feeling you get knowing bureaucrats are helping poor people, so you don’t have to.
So what would happen if Liz Warren gets her way and nationalizes medicine and all medical professionals become employees of the federal government? Where will competent professionals come from when the best aNd brightest choose another field to be excellent in? Will Liz designate those who will “serve?” For the good of all? Will she also designate them as competent and experienced? It is certainly implied that private (for profit) medicine will not be allowed (except for some subset of special people I expect.) Almost makes me want to have something that needs fixing so it can be fixed now by someone who knows something. What an awful state of affairs.
I am so happy that I practiced surgery from 1971 to 1993. I loved that practice, both the technical side and the personal side. In 1993, December, I had a 14 hour surgery to correct a kyphosis from a college injury that was compressing my spinal cord and retired.
The recovery was 6 months and after that I went back to get a Masters in health policy which I intended to use attempting to measure quality in health care. I spent a year in New Hampshire at Dartmouth and returned to California hoping to get a job in research or administration where I could use the methods I had spent a year learning. My project in the degree program was determining the factors that affected dialysis graft success, by the interval between revision surgeries. I put a grant application together along with a Dartmouth statistician and an economist, both experienced in health care. We worked out a project to use incentives to encourage dialysis centers to use native vessel fistulas instead of Gortex or other artificial grafts. Of course, since we were not suggesting a commercial product, like Gortex, there was no chance of corporate support. We needed a federal grant. We estimated that if we could get the 5 million dialysis patents switched from artificial grafts to native vessel fistulas, it could save Medicare, which pays for all End Stage Renal Disease care, $5 billion.
The feds were not interested.
The study I did. http://abriefhistory.org/?page_id=4389
After returning to CA I put together another proposal to improve care of the frail elderly, defined as those in assisted living. The faculty medical group at UC, Irvine where I was on faculty, was enthusiastic. The proposal was to care for the patients in the assisted living facilities, using laptops and an early electronic medical record. The server would be in the medical center. We had done some research suggesting that better care would result in better outcomes and less cost. We had some potential funding lined up but the administrator of UCIMC vetoed the plan. He could not believe that it would not be hugely expensive.
The proposal. http://abriefhistory.org/?page_id=4191
I learned that nobody but doctors was interested in quality. I eventually went to teaching medical students.
I don’t know a young physician who is happy in his/her practice now.
Kinda makes you want to go back to the days where a ham, some eggs and a chicken were sufficient compensation for a minor surgery.
People also fail to understand that cost is an inhibiting factor in the health care demand. People with significant health issues, too often self inflicted because of poor choices and habits, ration their use of the health care system because they have to pay something, even if it is just a $50 copay. Many have no interest in changing their choices or habits, but they still would like relief. If the government provides “free” care, these people will demand it as their right, and the system will be taxed. Doctors will no longer be health care experts, skilled in diagnosis, help and counsel, but simply a required stop on the way to a prescription to alleviate the symptoms of larger health issues. Too often the drugs themselves become the issue. This is true today for many Medicare patients. It will expand to encompass the entire US population.
I don’t know why anyone would enter medicine now. I keep waiting to hear that my general practitioner is retiring, not due to his age, but because he’s fed up with the whole system. I wouldn’t blame him.
A friend of mine did a locum tenens in Ireland about 20 years ago. It was very interesting. About a third of the days patients were coming for a permission slip to be off work. When he asked to examine them to see if the request was valid, they were outraged and complained to the local council.
Two other friends, after the 1975 malpractice crisis in California, decided to drop out of conventional medical practice and bought the ER contract at the hospital in Avalon on Catalina Island. One was a surgeon, the other an anesthesiologist. They ran into a similar situation. After summer, everybody in Avalon goes on welfare. All the patients who showed up were in MediCal, the California Medicaid system. If the two docs questioned them about indications for narcotics, for example, they were met with outraged and finally the local town council suggested they move on since no one wanted to see them. Too many complaints about wanting to examine them before prescribing.
A lot of that going around. I think that most American professionals grew up in a culture unlike the one they found when they began to practice. Marcus Welby and Perry Mason had a respected role that had nothing to do with being a cog in service to bureaucratic dictates.
In the previous century I was stationed at an Army base hospital staffed with 35 doctors. I was a fairly senior medical lab tech at the ripe old age of 20 so I often covered the whole clinical lab and blood bank overnight. My roommate, a recent combat corpsman was pretty much the whole ER support staff (except for me as a backup stitcher and IV starter). There was a third guy who did XRays and whatever else needed doing.
The Medical Officer of the Day rotated and that was a learning experience. Surgeons like to confront and intervene with problems presented. Internal medicine guys (and our quietly brilliant one pathologist) loved ordering tests and doing research. Both of our OB/GYN docs had a weird kind of serenity in the face of any crisis. The psychiatrist seemed vaguely terrified of most medical issues. Late-night bull sessions in the ER indicated to me that either certain personalities gravitate to certain specialties or the specialties inculcate ways of thinking in practitioners. But all the docs clearly loved it when a patient presented in their particular wheelhouse and they could do what only someone with their art could do. There is even a kind of shared magic there for support staff, like being on a team when the quarterback is playing out of his mind and everything works to perfection.
Trying to package, instrumentalize, commodify skills and arts is what bureaucratic systems do. Teachers, diagnosticians, surgeons, and lawyers are being commodified. The satisfaction of excellence in delivering a very personal service requiring study and skill which service has a true value greatly exceeding whatever fees or prices are assigned does not fit in a commodified regime. All of us are feeling the stress of that loss, whether as providers or recipients of service.
I’m struggling with how to say this without sounding too snarky, but…
A suggestion – remove all computer monitors from doctor’s offices. Or at least spend the first 15 minutes of every appointment in a room without a monitor.
I’ll be honest – I don’t trust doctors. But when I go in for a (mandatory) checkup, we frequently spend a lot of time with them asking me questions. And all too often the doc can’t break away from the screen long enough to even look at me. I checked it at an appointment last year. The doc spent 25 minutes in the room with me. She looked me in the eye 3 times in that 25 minute period. This same doc said she was going to refer me to a class offered by their organization, that they’d call me. I received the call 8 months later.
So the docs may be experiencing “moral injury”. I get it, that’s tough. As a patient I’m experiencing a drain on my finances and irritation at being treated like another spreadsheet. Guess which side I have more concern for.
Every doctor in the country would do that tomorrow. With glee.
But then the patient couldn’t get meds, x-rays, labs, or anything else. Everything has to go through that stupid computer. Everything.
I’m with you. The system sucks. That’s my point.
I think it is a type of immaturity that seems a hallmark of the liberal rational; I care, but I don’t have time, etc. so will delegate the responsibility, authority, and accountability to someone else . When that doesn’t work, I’m blameless, I can blame the government, the right etc., but not myself because I voted for the guys that care.
Caring is a personal thing that cannot be called in, it requires taking action and being accountable, skin in the game; and if liberals believe they can manage the way someone cares about someone else, they are mistaken, and the evidence is in, I think that drs (and I would guess all caring professions) are becoming in need of caring as much as those they care about.
Since Obama care, there would be no medical care without the EHR. The doctors have no choice and are the most regulated profession on earth,. Maybe nuclear power folks.
I have a suggestion for you. Find a cash medical practice and go there. There are more and more of them, usually with older docs whose debts are paid and kids educated. Do a computer search for “Concierge Practice” or Cash practice.
Funny how the most heavily-regulated sectors of our economy are also the most fouled up.
Please put me in touch with them.
I’m for it.
Maybe it’s time for some industry-wide, medical-rebranding. I mean, it worked for McDonalds and Pabst Blue Ribbon, why not health-care? Just as yesterday’s “Garbage Man” is today’s “Waste Management Specialist,” we could start by calling doctors something else. Something super-empowering, super-inclusive, sure to boost the spirits of any overwhelmed-practitioner. And since the only people who insist on being called “Doctor” have no medical training, the transition to the new terminology should be a breeze.
We used to joke in the ED that we could cut visits 75% by having 2 bowls in the waiting room.
One full of work notes, the other full of narcotics, with a sign above them
Help Yourself
I’d sure hate to fill you in on what’s happened to SEC and IRS regulation since lawyers and not business owners or people experienced in running businesses started writing regulations. Nothing in public financial reporting has much to do with running businesses and reporting their actual results. Investors are not getting more nor more useful information to guide investing in public companies. The Big CPA firms are more afraid of the regulators (and not doing anything to threaten their pensions) than they are interested in actually getting the right result for clients. It’s kind of – no, really – embarrassing to see them working.
It’s uncanny how similar this post is to one I put up on Ricochet onedays ago. I can’t say my prose is as mellifluous and vivid and Dr. Bastiat’s but I explored a similar idea of how failed institutions negatively affect the individual. It’s very rough when the place you work at inhibits your potential to help people. If nothing else, I’d say it’s worth reading just because of the coincidence.
Thanks for the link! I read all your stuff, but somehow missed that one.
You’re right that our topics are similar, but we took very different approaches.
Great post, Henry. Thanks again for pointing it out.
If anyone asks me if they should go into medicine, I tell them no. You would be entering a price controlled industry. You could set a price for you services, but nobody would honor it except for the rare person paying cash, for whom you have to offer a discount. You will accept whatever pay the insurance company or government will give you and you will like it, thankyouverymuch. And you will jump through ridiculous hoops to get it.
As a radiologist reading remotely from home, I am utterly replaceable by another radiologist. My job is to read many cases quickly and efficiently. Nobody wants my personal touch. My goal is to generate the same accurate reading as any of my colleagues. Preferably in an easy to read format like a lab report, not flowery lengthy prose full of odd passive voice construction like in the olden days. There is a push towards canned preformulated reports for consistency, which reduces my product to a fill in the blank report meant to be quickly digested like a plain unsatisfying saltine cracker.
I never thought I’d experience what will (or may be) written about in history books as (perhaps) the beginning of a dark age, or just a pause in human growth potential, or an “era remarkable for its inconsistencies.” This period of intellectual and social/cultural dishabille is sad. I grew up reading science fiction and being endlessly optimistic about possibilities and creativity and just flat out intellectual exuberance, as well as marveling about the wonder and cleverness of God’s creation. (Who could doubt God when humans have a such robust sense of humor?) If asked if I wanted to live in interesting times I would have said NO!
In my view this is a superb, profoundly insightful and important article. Once again I find myself hoping that a piece by this author receives a wider audience.
Even if it isn’t a podcast! I suspect that the remnant of American voters who can read still numbers in the tens of thousands.
In a spate of housecleaning in case we ever have to move, I’ve been throwing out several decades worth of American Heritage and Michigan History magazines. It’s amazing how the publications from the 80s had words in them, something you don’t see much anymore. Well, there are still some words, but now most of that space is now taken up by whitespace and photos. Even in the early 2000s there were a lot of words compared to now.
So you might want to be careful with your guesstimates of how many Americans can still read. There isn’t so much to read anymore, so how would we know?
I’ve mentioned this book on Ricochet, but I will again: Professor Regina Herzlinger, Who Killed Health Care? It’s a great book, and her main point is that we are not putting doctors at the center of the system, and they are the heart and soul of patient care. Herzlinger’s book came out just ahead of the ObamaCare reforms, which she predicted accurately.
What I don’t understand is that the doctors seem unanimous in their anger about the constant and growing interference between the doctors and their patients. Doctors are the most respected members of our society. And they are the only ones with the technical knowledge to make their case. There simply isn’t anyone else. Together they would wield enormous political clout.
The doctors are the only ones who can fix this. Politics cannot be avoided. It’s the only way we accomplish anything in this country. The good news is that when doctors speak, people sit up straight and listen.
To me, the obvious doctors to get this activism started would be those like my kids’ second pediatrician, Dr. Ellie Dankner, who have retired prematurely because of the managed-care changes that drove them out.
Warren is a nut, of course. But what we are actually seeing is the ultimate evolution of medicine into what it should be, as a market-based competitive industry- for the reason that the classic “doctor” is now utterly obsolete. As Herb Stein said, when something can’t go on as is, it won’t. Medicare projects to run up massive deficits in the trustees’ 75 year projection, but in 75 years no one would recognize medicine as it is practiced today; the projection is nonsense.
The essential changes occur when incumbents are unable to peddle influence and repress competition sufficiently to preserve their incumbency advantages, thus more advanced political societies tend to change very late only after it is impossible to avoid or stave off any longer via political influence peddling. The problem with China is not its state-sponsored industries, it is more that they lack a Medical-Industrial Complex, so while the US Congress is busy taking bribes from the AMA, AHA, and PhaRMA and borrowing heavily to send the cash back to those cartels, China will adopt modern technology methods of cheap health care provision because the powers that be will owe no favors to incumbents. That whole segment of US spending will instead be available to China to buy off former US allies.
Doctors were essential one hundred years ago: you needed very smart people to take and absorb the available information, elicit more information from questions and observation, and then provide the best guess of what to do, and in some cases (surgery, etc.) actually handle the intervention. Today, we have ever-growing amounts of information, tremendous sensors to collect more, and basic data processing to collate and evaluate the information. Doctors actually take instructions from the algorithms and follow designated protocols; you don’t need doctors to do that- you don’t need nurse practitioners either. A moderately trained LPN with a good computer system could do virtually everything a doctor does today. And we are not talking artificial intelligence- this is basic information-processing, relational databases, etc, less tricky than what Amazon does to you every time you visit that site.
Should we keep training doctors? Yes- for research, policy formulation, oversight, exceptions management, etc. But there is no shortage of primary care physicians, and the same fate awaits most specialties before long.
As patient caregivers, doctors are going the way of the dodo bird.
Keep in mind that those algorithms that are replacing doctors are algorithms for herd management.
What a powerful piece.
We live in interesting times. In so many ways.
Everything is called PTSD nowadays. It’s getting boring.