Ricochet is the best place on the internet to discuss the issues of the day, either through commenting on posts or writing your own for our active and dynamic community in a fully moderated environment. In addition, the Ricochet Audio Network offers over 50 original podcasts with new episodes released every day.
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
This post must be read by every Republican legislator and executive at every level. This should be Senate testimony this calendar year. This should have been House testimony the month after Paul Freakin’ Ryan was given the Speakership. It was not because he and his cabal/conference never actually intended to really reform the “reforms” of Obamacare. They, and Mitch McConnell, always only intended to tweak the settings on the levers of power in favor of themselves and their Big Medicine patrons.
Except that doctors are not actually the most respected members of our society. And those doctors who get involved in politics at the professional organization or other level are self-selected leftists. So, you get LabCoatLeftism: leftism wrapped up in the cover of lab coats, of supposed experts and supposed caring doctors.
One of life’s great mysteries.
Sure dude. Roll into the ED after your car wreck and let the “algorithm” manage you. In the delivery room when the baby has a cord compression and “decels” let the algorithm do the emergency C section. Have the algorithm put in that central line in the ICU.
Let that “well trained LPN” manage your hypertensive emergency with fulminant pulmonary edema and respiratory failure.
I’m guessing you have zero experience in medicine.
This is one of the vibes I get from a few of my friends. They’re doing well, and the taxes the pay go to fix those things so they don’t have to consider them directly, face to face. They’re “OK” with paying taxes. Me too. I just don’t think an organization sporting billions of dollars, paying what are essentially tenured bureaucrats to dole out those dollars in one form or another (including health care), is quite the same as heading down to the local shelter or soup kitchen and ladling food onto trays.
It’s also not the same as taking those dollars you might pay in taxes and donating them directly to a local shelter or soup kitchen. Because at least then, you can see the effects of your charitable gift, right in front of you. Helping to fund the build of a new shelter, maybe. Now that’s you in there. You cared. You made a direct and appreciable difference.
Instead, taxes get taken out before you receive your earnings, so you don’t even get to make a choice on where to spend that money. Someone else does, someone whose direct accountability to you is less than zero.
A flawed system, maybe. But it sure does buy a lot of peace of mind.
Doctors are already employees of the federal government through their employers – hospitals and clinics that accept Medicare and Medicaid. Many younger doctors are all about the “work-life”balance and essentially punch a clock. They are not vested in their patients, they are just clocking time until the end of their shift. This does not apply to all docs of course, but I am seeing it more and more in the younger docs. ANd they have never worked in an environment any different so they aren’t as onery as the older doctors who remember that they were once independent professionals and still push back on the system.
The medical school where I taught students for 15 years, before I finally quit for good, charges $57,000 a year tuition. That was five years ago so it is probably more now. Every year, I used to ask my students if any were interested in military grants for tuition. The military will pay tuition in return for a year for year service. None were.
When I was examining military recruits, I used to encounter a few kids choosing this option to avoid student loans. They were invariably applying to medical schools I had never heard of. There are lots of smaller medical schools now. I know nothing about their quality but it is my impression that they do not have big teaching hospitals. Young physicians now typically have more than $250,000 in student loans. Physician compensation, aside from a few specialties, has declined. Young physicians are loan repayment slaves. They could opt for the military for a few years and emerge debt free but the ones going to better schools seem not to be interested.
I suspect there are few young physicians willing to get involved in politics. Hospitals have been buying up medical practices and most physicians, at least in California, are employees. The old model of the physician as an independent voice is pretty much obsolete. The medical associations are pretty much dead, as far as I can see.
News to me. Most people who think the AMA has any power, aside from being a part of government now, is dreaming. The AHA was all onboard with Obamacare because they assumed it would shift power away from the hated doctors who were always interrupting plans by advocating for patients (the medical equivalent to deplorables). The doctors are now employees and can be controlled or fired, as my former surgical group was a few years ago, after running a trauma center successfully for 35 years.
I’m so discouraged. I hate the loss of the good medical care I have been able to obtain for my family. I don’t see that outstanding care on the horizon for my grown children and grandchildren.
I am deeply angry about it.
In the midnineties, Peter Drucker wrote an article called “The Age of Social Transformation” for the Atlantic Monthly on what he called “the knowledge-based society.” This passage has stayed with me ever since I read it so many years ago:
Surgeons don’t just fall off trees in the backyard. They have talent, genius, creativity, memory, and intelligence that are unique to each one of them.
Hence the popularity of “life style” specialties. Emergency Medicine is one. All shift work. “Trauma Surgeon” is another. Shift work and no overhead. I saw this in my students. Some, of course, is related to compensation. “We pretend to work and they pretend to pay us.” Medicine is not the “cottage industry:” that Ted Kennedy complained about. Between waitress sandwiches, of course. Doctors are now mostly salaried and will vote accordingly.
As for substituting LPNs; much routine, like well baby, care, could be shifted to them, as WalMart is doing. The trouble with such “algorithm drive care” is that the “representativeness heuristic” is a trap. People come in with the flu all day and you miss the one with something else, like AIDS. Doctors are trained (I did some of it) to be aware of such patterns, LPNs are not. My wife was a nurse practitioner after were divorced (we were apart for 25 years, then got back together) and would call me when she had a puzzling case. The GP she worked for was supposed to “supervise” her but he was too busy. She would call me and we would talk about it. I did some workers comp peer review for ten years. I would often talk to Physician Assistants who were running WC clinics for orthopedic surgeons, who were only interested in the surgical cases. They would appreciate advice.
Algorithms are widely used but are focused on limiting care, not optimizing it, and billing issues.
They have education and training.
Talent or genius or creativity has little to do with surgery.
Surgeons are robots.
Doctors are not trained to think.
Sorry I’ve been out of touch on this thread. I got behind on my COS (Clicking on Stuff), and spent the last 2 days with my laptop, performing vitally important functions of no importance whatsoever. I spend a lot of time on COS, but I still get behind.
Anyway, thanks for everyone’s kind words. They mean a lot to me.
As many on this thread have figured out, my post was not really about physician burnout. It’s about the social disease of socialism. The bigger government gets (even if it’s largely benevolent), the more people tend to lose their humanity – that personal compassion which makes us human. When we feel that we are losing our humanity, it hurts.
Someone asked me in a PM or an email sometime ago about my self-description on my Ricochet wall. I describe myself as a “bleeding-heart conservative.” He asked what that meant.
This post is an effort to explain it. Big governments, even with the best of intentions, are necessarily cold and impersonal. Those crazy, impulsive emotions that make humans so unpredictable are what make us human. That’s why you feel so great when you’re in love. You’re running on pure emotion, nothing makes sense, and you don’t care. You’re never more human than you are when you’re in love.
Government is cold and impersonal. As it should be. But when it’s allowed to grow, then we forfeit some of our humanity. Just a little bit, at first. Then, a bit more. And after a while, you don’t even notice it.
Until you do.
NP are not perfect.
Neither are doctors.
Doctors are now mostly salaried? But aren’t most or all doctors independent contractors?
most doctors are lazy: young and old, male/female, black/white/asian, everyone, etc.
Try it sometime.
The sanctity of the individual above all else is the bedrock of western values.
individual justice > social justice
individual responsibility > social responsibility
moral values are individual not collective.
the expansion of government has reduced private charity activities.
welfare leads to moral decay.
i agree
No, he’s right. Every doctor I know is on salary, with maybe 2-3 exceptions.
I’m a solo doc in concierge medicine. I earn what I earn.
When I go to a medical conference, I’m generally the only doc in the conference hall who works for himself.
Everybody else works for a hospital, or a muti-specialty group, or an insurance company, or whatever.
try to think or try to perform surgery?
I can’t be a surgeon because i don’t have the motor skills.
it’s not because i’m not smart enough.
doctors think they are smarter than non doctors.
i disagree vehemently.
BURN
MODESTY? pretend to try it sometime
i love how doctors exaggerate all their positive traits.
what percent of doctors are w2 vs 1099?
I think you may have it backwards. I don’t think you need extraordinary motor skills to be a surgeon. It helps, but most of this can be learned and improved upon.
And you’re right, doctors tend to be arrogant (I prefer the term confident). Partially because without a certain degree of arrogance, you can’t make life and death decisions for someone without being paralyzed by uncertainty. I believe that a certain degree of arrogance is required in my field.
I used to be fairly active in MENSA, and I never encountered another doctor there. I’m sure they’re in there somewhere, but it’s not common. The stereotypical doctor is a child of teachers, who’s always worked hard and been a good student, has a high tolerance for delayed gratification, and prefers playing it safe over risk taking. There are some docs who have extremely high IQ’s (just like in every other job), but they are few, in my experience. Like manual dexterity in a surgeon, high IQ helps in medicine, but not as much as other factors, like work habits, judgement, creative problem solving skills, and so on.
I’m not the one describing the job requirements of a field I don’t know anything about.
Look, you and I agree on most of this, I suspect. Let’s call a truce on this.
I plead guilty to a lack of modesty. I’m really good at what I do. As you are as well, I suspect.
But I have no desire to argue about the skills of surgeons. I’m not a surgeon (I do minor surgery in my office – not the same as treating pancreatic cancer or whatever). I have enormous respect for them, but I really don’t know what it’s like to be a surgeon. So I’ll just leave this.
I’m sorry if I came across too strong. I was trying to be cute. It sounded scornful. Sorry about that.
A doctor is a complete package of talents and abilities that combine to become a unique human being.
My daughter is a gifted flutist who no longer plays her flute, I say with some sadness. When she was born, the nurses commented on how long her fingers were. When she ten years old, her flute teacher asked us to get her a solid silver open-hole flute. We said, “Really? She’s ten years old.” He said that the number of kids with fingers long and strong enough to reach and cover the holes completely is one in several million. She also had the right mouth shape. For flutists, the embouchure is part of the instrument. Again, few people have the right mouth to play that instrument. Kate also is a perfect soprano with perfect pitch. (I always get a kick out of the great composers like Mozart who wrote for a soprano voice that is so rare. The great composers were true dreamers! “Someone will come along who can hit that note! I’m sure of it.”) It takes an ear unusually well tuned into very high notes and very sensitive hearing, which was something we noticed in Kate when she was a newborn. My point is that a human being is a work of design. Everything the person needs to achieve his or her purpose is there–all to be discovered as he or she explores his or her unique set of curiosities.
People are not interchangeable parts.
I think the reason we take doctors for granted is that we have trouble recognizing the wonders of how our fellow human beings are hardwired for particular purposes.
I actually find this subject fascinating. Why does one person become a neurosurgeon while another with such a close set of talents become the developer of an artificial leg?
No, doctors are not ordinary in their knowledge, intelligence, creativity, and decisiveness. Neither are Navy SEALs. Nor are great composers. Nor are great flutists. :-)
Um, maybe you need to get out more?
How about….Jedi?
This is fantastic.
I’ve done a lot of ER work. That is completely true.