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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
You’re being kind.
I would agree with the assessment of what threatens to afflicts a lot of us. And I’m mostly in agreement with the understanding that it is the violence against physician autonomy that leads to despair. It takes tremendous dedication to our patients and perseverance to get things done the way they have to be done.
Quick example: last week I saw a patient of mine who has severe lung disease and now has a new nodule in the lung that grew in the last 6 months – highly concerning for possible lung cancer. Biopsy is too risky, so I order PET/CT to affirm my suspicion that the nodule is likely malignant (please note, that PET/CT does not “make a diagnosis of cancer” but helps to increase probability of likelihood) before I would commit this patient to a risky limited surgical intervention. His insurance requires authorization for PET/CT – my staff calls the insurance company while patient was still in the office in early afternoon – spends 20 min providing rationale for the test to be done, the request is denied and sent for the review with stipulation that it will be processed within 48 hours. Two days later, after two more phone calls by my staff, I am informed that the claim was not filed until the morning after patient’s visit, meaning that it would take extra 24 hours for their consideration – and that the reviewer is unavailable to speak with me until Monday – which makes is almost a week from my patient’s visit. I know the agony my patient is in.
The good thing is that I’m tenacious and will get it done just because this is the right thing to do – I’m one of the few in private practice, so I – along with my partners – run our practice that way, which keeps our reputation extremely high.
But it is exhausting and extremely frustrating indeed.
We have medical students and residents rotating in our office. The only hope we have that we will serve as role models for them.
All caps is not making this more coherent.
I love how posters assume knowledge of an industry they are not in, but figure they could “do it”, but chose not to.
That’s why I’m not playing in the NBA.
Wow ! I guess I was a robot for 40 years. It was just robotics that led me to learn laparoscopic surgery to reduce pain and recovery time. The thousand laparoscopic cholecystectomies were just robotics. The patients who waited for me to learn the methods, because the medical schools completely missed this development as they had no interest in patient comfort and convenience. I had explained I was just learning this as it was brand new. They said they would wait. Doctors’ relatives from around the country were coming to Orange County to have a robot do something that they could not find where they lived.
OK. If you have any doubts (doesn’t sound like it) you could read my book.
https://www.amazon.com/War-Stories-50-Years-Medicine-ebook/dp/B00ZQLNHXU/
I’m not sure how much you are removed from actual practice of medicine. With all the hype of AI, it offers results based on the fundamental principle: “garbage in – garbage out”. Vast majority of the algorithms are mostly good for standard preventive low complexity cases – and utterly fail the sick. And it is care of the sick that doctors are here for.
I detect a bit of anger in the one commenter who seems to dislike doctors, especially surgeons. Sometimes this comes from a bad experience. If so, I am sympathetic. I spent years doing peer review, was on the board of CMRI, which was the Medicare peer review organization for California. I was an expert witness for plaintiffs and defense in med-mal cases. I’ve seen plenty of bad care and the efforts to do something about it.
I’ll tell you something. There are weak and incompetent doctors and surgeons. Some of them do little harm, often because others know about it and shield the patients. When I was first in practice, there was one internist at the hospital (St Josephs in Burbank CA), I was told to never call him after 6 PM. He was assumed by everyone, including the nurses, that he was probably drunk. Another, a GP, was very busy because his patients loved him. My senior partner in practice had 10 kids so he tended to have someone drive him to the hospital and home afterward. One day this GP was giving him a ride and pointed to a house they were passing. He said, “That guy called me yesterday with chest pain.” Mike, my partner, said, “What happened ?” The GP said, “I dunno. He never called me back.”
I have lots of stories but they were not the majority of doctors, or surgeons, I knew or encountered. The weak doctors would shape up when their weaknesses were pointed out, including substance abuse. I also encountered some crooks. They had high priced lawyers and were immune to efforts to discipline them.
Fascinating how this post coincided with our experience yesterday. I took Little Miss Anthrope to see her hematologist for a ferritin check (she’s been known to have extremely low iron stores). He examined her and surveyed her on her levels of energy and concentration, which were poor and why we suspected possible low ferritin.
While we waited for the blood results, he asked me if I’d be open to giving her another infusion if her levels were low (the last infusion was in June). I was puzzled by the question. LMA has a low grade glioma of the brain stem and is currently on Mekinist to try to shrink it. She’s constantly receiving medical care of some sort. Of course we would want an iron infusion if she needed it.
He noticed my puzzlement and explained that the infusions are expensive and are typically denied by insurance. I replied I didn’t remember having to pay a lot for the last one (we typically meet our high deductible in January or February at the latest and our out-of-pocket not long after). He said all the claims are denied. And then told us about his wife who had some kind of orthopedic surgery and her claim was denied. I could sense how demoralized and frustrated he was.
I asked Mr. C to look into what our insurance paid for the last infusion. And, it turns out the doc was right. The first claim for $6,300 was denied and our insurer asked for more information. The second claim for $6,700 was paid (minus our $50 contribution). But, there ya’ go. The doc’s day is probably at least half filled with submitting forms and documenting claims to fulfill the interests of the regulators and insurers — time taken away from caring for patients.
We get great care in this country, comparatively. But it comes at the steep price of dehumanizing the practice of medicine.
This is so right. We in the profession could solve this in a weekend, by acting like Teamsters, by refusing to care for patients until the problem is solved, by offering ER care only. But Docs are pussies. Putting patients first makes it difficult to take that first step of refusing to offer our services until the problem is solved. Now that most of us, m’self included, are employees of big companies which would fire us if we stepped out of line, this isn’t gonna happen.
Right, very very wrong, very very wrong, very very very very wrong.
Ten minutes in the OR with a gifted surgeon would disabuse you of these ignorant claims. Health care administrators should do this too.
From the beginning of civilization, medical technology has never decreased society’s demand for the intellectual specialties of medical and surgical practice.
That it is suddenly doing so now is a classic example of primitive or “concretist” thinking. A primitive thinker always thinks that his immediate environment–the things that are happening right now, right here, which he is conscious of–represents all of reality, and that they are not connected to the remote past, or to remote places, or to events involving other people, by laws of cause and effect, nor by abstract relationships: things that are of the same category even though they are concretely different, or things that are of different categories even though they are superficially similar.
He is unable to detect the abstract similarity of things that are concretely different in some way, like computer-assisted diagnosis vs. pre-computer diagnosis. He is unable to think relatively about reality; everything is absolute to him.
He is unable to understand marginal thinking, like the fact that the smartest diagnosticians and surgeons of society in the age of primitive medicine simply worked at the margins of primitive medicine; and in exactly the same way, today the smartest diagnosticians and surgeons work at the margins of today’s medicine: the most difficult tasks of today’s medicine, which didn’t even exist in prior eras.
The division of labor and the development of a capital structure simply change what it is that marginally profitable human labor does, and increases its degree of specialization and its economic productivity. Not whether humans labor at marginally productive tasks or not. To the primitive thinker, the word “doctor” is a concrete object, whose concrete meaning is defined by whatever his personal experience of “doctoring” tells him it was. So to him it is obvious that once a computer starts doing that fixed, concrete thing, the doctor goes the “way of the dodo bird”. What actual doctors start doing at Johns Hopkins, far from the primitivist’s range of vision, simply isn’t reality.
In fact, technology, for example in medicine, always simply replaces the demand for the now-old skilled, specialized forms of labor, and the freed-up labor hours and human potential are exploited by people learning and deploying higher skills, which now appear at the new boundaries of human ability.
The article states “if you are a sick person” the process of a doctor ordering tests and waiting for either the results or the usual fight with insurance bureaucracy is a terrifying one.
It is more than that. It is also damn expensive.
For 2 and 1/2 years I struggled with intense pain in my left lower quadrant of my torso. I had cat scans, ultra sounds, and eventually a MRI of my brain. The MRI came about due to how everyone at the clinic understood I was in horrific pain, but tests showed nothing was there. Was a brain tumor hiding inside my head & getting my nervous system to think I had pain in my left side?
The MRI was negative on anything other than I was in the pink of health. Luckily I had insurance that paid almost everything related to this – otherwise I would have been inundated with costs of over $ 15,000.
I’d still be in this fix except right before Thanksgiving, 2010, my household ran out of crackers, cookies, biscuits, pasta and other items containing wheat. Both of us were under deadlines to get massive amounts of writing done. Despite having adequate amounts of money to buy groceries, neither of us left the house til I had an appointment the Tuesday before the Turkey Day.
I was there to get a hydrocodone refill. When asked my pain level, I reported a big fat & happy zero.
The nurse went into diagnosis mode. This was a big deal. I wasn’t in pain. Could I come up with anything different in my life to account for a lack of pain? I felt foolish mentioning I had not had a thing with wheat for at 4 days. She realized I was gluten intolerant, & gave me pamphlets on how to live my life gluten free. (More complicated than it seems. For instance barley also has gluten and it is often in things that claim to be “wheat free.” Soy sauce also contains gluten.)
Our physicians have scant education related to benefits & risks to health relating to vitamins & nutrition. I was so lucky that the nurse who saw me that day had been trained to push people for information. It is also interesting that none of the 3 doctors I had seen asked me about diet.
Doctors lack awareness of the juggernaut between the medical industry including Big Pharma and various agencies such as the FDA and CDC which supposedly would protect us. However the average person on the street is now becoming aware that in so many cases, the FDA, CDC and EPA are far more likely to collude with Big Industry than to actually require decent standards in terms of approval protocols for drugs and common everyday items people use. A recent example in the late 1990’s government approval for a vaccine, RotaShield, for infants that went on to make 106 infants critically ill, while one infant died. If research is rushed through, people die.
Hopefully you will never get into a situation wherein the tests show everything is great, you should shut up as you are not in pain. Besides, the cat scan showed that the 3rd world person who read it for Hospital Franchice Incorporated says it is all in your mind.
But should reality ever pull you out of your ivory tower, I do hope you have a family member available to fight for you. If I had not accompanied my spouse to his May ’19 ER visit, where his pleas for admission due to his belief his appendix was ruptured were scoffed at (after all, these days a person in pain is an opioid seeker!) he’d have been sent home with the ruptured appendix. Luckily I stuck to my guns & made them realize that people reading tests read far too many each day, and the cat scan needed a 2nd appraisal.
The end result of this will be socialized medicine. It will be pointed out to the masses of voters that with Insurance Claims Depts being bean counters, the entire system is so screwed up that only socialism will solve it.
If the public is told that taxes will go up, but that they won’t have to deal with Big Insurers, or worry any longer if the Big Insurer processes their totally overpriced insurance premium on time, and that now they no longer owe that insurance premium, plus deductible, plus co-pays, the public will probably want socialized medicine. Doctors hate Big Insurers, nurses hate ’em, and people hate ’em.
Obama had a chance to do real reform, but his solution was to keep the very industry that created the need for reform in the loop. Without any panel of people seeing to it that the insurance industry does not get to make life and death decisions.
In Israel, health insurance costs around $50 per month but it is obligatory and subsidized by the government. There are 4 competing insurance c0-operatives but they compete on service, not on price. In Israel, life expectancy is 82. In the US, it’s 78. Incidentally, this may not be widely known, but many of the doctors in Israel are Arabs, especially in hospitals.
You nailed it the problem is exactly as you’ve described. Further this is the absolutely inevitable if using a third party payer system including both employers and Uncle Sam. It’s a by product of rising cost due to patients not needing to care what the cost is and desperate attempts to control the uncontrollable. And any schemes to have the taxpayer further carry the load will just make it worse. We seem to be determined to go there soon so l can’t offer any hope this will get better.
Only part of the cost increase is due to the third party payer problem and probably the biggest other factor driving increase costs are expensive advances in treatment options. Everyone thinks these are beyond there own ability to pay and so seeks to find a way to have someone else pick up the bill but that means everyone winds up paying further increased costs due to the inefficiencies produced. The unspeakable truth is there is no way to provide every medical treatment to every patient, there are limits. Schemes that promise to do that will result in some form of bureaucratic rationing, the least efficient way to allocated limited resources. But no one wants to hear that, they want to be told fairy tales about providing everything to everyone while generating huge savings. This will further take from Doctors the ability to control the diagnosis and treatment decisions resulting in even greater frustration.
The formula for ultimate frustration is responsibility without authority so it is not surprising that Doctors are responding as they are, especially in light of the level of preparation they must accomplish and the degree of liability they bear for patient outcomes.
The Doctors aren’t really in a position to fix this because the decision to seek, medical help is dependent on some form of third party payment putting that third party in control. It really is true that “He who pays the Piper calls the tune.”
And the 25 million bucks a day that the US taxpayer shells out for Israel’s expenses pays for it.
Funny how we can so easily subsidize other nations’ health solutions but can’t figure out how to follow the example of the nations we are subsidizing.
And to talk about any subsidizing of our country’s health expenses labels one a Commie. Logic then dictates a person asking, “Is our 25 mil a day allowing the Israelis to become Commies?” Few would answer that question in the affirmative.
LOL. Just for grins what do you do?
How many life or death decisions do you make in an average day?
I was an ER physician for 30 years. Almost every day I had to make life or death decisions with incomplete knowledge, and they had to be made right now. Get it wrong and I’ve killed someone. Right now.
Surgeons are in a similar situation.
Most of the physicians I’ve known in my career were smarter than 95% of the population. Even the bad ones.
Uh huh.
And how many people are there in Israel? Comparing a country with the size and population of Cook County is not likely to lead to answer to our problem here in America.
FYI, the assistance Israel receives from the US is a voucher that must be spent on US military equipment.
It wouldn’t be that big if we were looking at individual states or metropolitan areas instead the entire country. Which is exactly what we should be doing.
Silly comments, Kozak. I very specifically and explicitly defined primary care as it is defined in the industry. There are areas involving skill and rapid response where immediate characteristics are indeed essential- those include emergency response care and most surgeries. But, if you are at all familiar with the developments in Army medicine R&D, and academic medicine research, even many surgeries actually will be better performed robotically because they are able to dampen over-responses. Clinical stuff, and a lot of specialty stuff, will be yanked right away from the AMA cartel. Get ready.
I am not a doctor (I did have a nursing license for over 20 years), and my area of specialty in my legal job was medical research at a large (top 20) academic medical center, working IP and research scope issues for world-class researchers. I can clearly understand how a current doc could feel threatened by the tsunami of changes that are inevitably occurring. One doc that I worked for in his smart device start-up company was (before I did some medical VC and then moved on to the medical school job) an outstanding spinal surgeon. He would go in and do fussy delicate stuff, and then have his nurse finish off closing up (actually doing and tying off the stitches), etc.
In 1988, computers were such that you basically needed an electrical engineer or other specialist to keep your machine running. Medicine is like that today- about 90% of what a doctor charges for (he does even less in an organized practice) is done or could be quite effectively done by others of significantly lower skill, or by machine- including visual signs/scans, palpation, auscultation (I have a very good friend, a pioneering research professor of medical devices- not to mention my daughter, who is professor of biomedical engineering for a large medical school- and he did the initial work stethescope vests with added functions at least 15 years ago). This is currently a billing scam which will- Herb Stein again- end sooner rather than later.
This is a good example of concretist thinking.
Imagine we were living in the day when antiseptic surgery were new. “Surgeon”, to a concretist thinker is word that means concretely what it means in his own immediate, local world: “someone who cuts off limbs that get infected after doctors poke their fingers, covered with soil brought in from the street after they parked the carriage and scraped the mud off the hooves of their horses”.
Our concrete, absolutist, static thinker tells us that “surgery will be yanked right away from the surgeon cartel! Surgeons will go the way of the dodo bird!”
In fact, “surgeon” is just a descriptive, abstract category applied to whoever, in a given technological era, has the specialized marginal skills to do surgery treatment in that period. Once the profession has absorbed the new antiseptic surgery technology, there are still just as many surgeons, because their marginal value is just as great.
The antiseptic techniques have created a new baseline: you don’t need to be as good at using a saw, because the new technology has shifted the definition of what differentiates a great surgeon from a great carpenter.
yes, you’re right. but i don’t think one question is related to the other.
this is insane.
was your patient on medicare or hmo?
you’re the outlier in a good way
robot is not an insult.
robotics is a division of artificial intelligence.
actually, i don’t dislike surgeons.
i dislike doctors who work for hmo’s and are not board certified
“I don’t always like Kozak Comments. But when I do, I prefer ones like this.”
–The Most Interesting Man in the World, at least to the Brown-Eyed Beauty.
we have laws that protect insurance cartels.
we have a system that restricts supply and subsidizes demand (like housing).
it’s insanity.
imagine having auto insurance and the body shop calls to tell you that your plan doesn’t cover paint or bumpers.