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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
I’m so sorry you had to deal with this.
truly awful
they compete on service but not on price?
the 4 insurance cooperatives charge the same price but for slightly different services?
I’m in sales.
I make zero life/death decisions in an average day.
i apologize if my remarks were directed at surgeons. i don’t have much experience with surgeons, especially ER surgeons.
My biggest gripe is with hospital administrative staff and doctors who are scared to treat patients with advanced or complex diseases.
My dad didn’t dislike surgeons, either.
You’d have liked him.
He wasn’t board certified in gerontology, nor in cardiology, nor in internal medicine (even though he did all of them and I suspect he was pretty good.)
He hated boards of certification.
You’d have hated him.
He didn’t work for an HMO, and he hated slowly being enslaved by the progenitor of the HMO: Medicare, and its DRGs or whatever the acronym was.
You’d have loved him.
He did house calls in brick rowhouses in places like Upper Darby and Chester, PA. He went to the office after dinner for office hours. He took care of old people, if they paid money now, or if they paid money later, or if they paid homemade wine or crocheted hotpads, or if they didn’t pay at all. Every Thursday at Clinic down at Penn, in the city, they never paid at all but he went anyway. He took me with him.
I loved him. If you’d sat at his court, the Camp kitchen table, pleading your cause while he puffed on his Marlboros and sipped his Scotch, you’d have liked him. If you argued with him, he’d have liked you.
i can compromise on board certification.
It’s ok. That was then, this is now! Give me board-certified.
Heck, our own littlest girl will be board-certified soon in some unpronounceable specialty, and her new hubby already is, but even so they are both swell folks!
My dad didn’t hate surgeons, but he knew what they’re like, especially, I suspect, brain and heart surgeons. Our daughter taught us that the higher up on the body they are, the worse human beings they are. Neurologists aren’t exactly worse, just stranger.
But she’d almost kill to have the very best surgeon in charge when one of her beloved patients was wheeled in, and she got done knocking them out and turned their fragile futures over to his brilliant craftsmanship while she made sure they kept breathing in their fragile presents. Just as all the surgeons, I’m told, want our little girl there, when a tube needs to be stuffed down a stubborn throat and especially when it’s time to take it out. I’m reporting objectively, of course, not as a Dad.
Likewise, if someone were going to do surgery on my eyeballs, I would want the best eye surgeon in the world doing the job. And I can prove it: four times someone did slice into my eyeballs (yech), and all four times, I hired a Cincinnati guy who I’m told might be the best eye surgeon in the world. We all have to brag about our flimsy celebrity connections. (That’s one of mine, but full disclosure, I have a Robert Redford/Donald Sutherland/Judd Hirsch one in my pocket if we are going to start to play “I Can Beat That”.)
I think my dad’s philosophy was that you can’t have surgery without surgeons, but don’t ever trust them to diagnose patients’ medical conditions objectively.
You said specialties were right behind.
I really don’t care. I’m pretty much done. Won’t affect me personally except as God help me, a patient.
That’s really funny. :-)
It is an example of the erosion of traditional skills that appendicitis is diagnosed with CAT scans. When I trained the Bible for such conditions was a book called “Cope’s Early Diagnosis of the Acute Abdomen.” It was in the library of every surgical resident. It is till in print but I doubt many read it today. I suspect the driving force is cost. The traditional diagnosis emphasized “early” to avoid perforation. It also involved a negative appendix rate as high as 25% in girls since perforated appendices may result in infertility.
In these days of cost obsession, it is preferable to the money changers to allow someone to go home with a perforating appendix than pay the cost of a few negative explorations. Toward the end of my career, I was doing appendectomies laparoscopically. One funny story. A physician colleague sent his daughter over one Friday afternoon with early appendicitis. I took her appendix out that night through the scope. She went to the same private school that my kids attended. Half the kids in the school were doctor’s kids and the school nurse was a doctor’s wife. She heard that this kid had had an appendectomy Friday night and called then hospital to see how she was. What she didn’t know was that the kid was in class.
Laguna Beach had lots of hippie kids living on the beach or in shacks or garages in those days. Sometimes one would come to the ER with suspected appendicitis. None, of course, had insurance and it would take months to get them signed up with MediCal, We finally settled on a solution. If the kid had significant findings in the ER, we would take them to surgery and scope them. Then, unless they had perforation, we would send them home from the recovery room. Never admitted and never charged. Now they do CAT scans and send home people with appendicitis because it is cheaper.
The insurance company lobbyists wrote Obamacare. The Democrats assumed the mistake Hillary made was to exclude insurance companies. This time they let them write the bill with a bunch of 25 year old Democrat lawyers.
I assume you know that life expectancy is very much affected by inner city blacks and Hispanics. Infant mortality is another statistic very much affected.
I used to know a gastroenterologist who said this. He wasn’t very good at Medicine but a good businessman. We were amused at his projections.
And also by early death from opioid abuse and meth.
From the CDC:
I am sure a certain amount of those are accidental–being on drugs means a person’s cognitive abilities are diminished, and he or she is likely to be unable to keep track of how much he or she has had.
But I consider all such self-destructive behavior to be suicidal. And that number 70,000 in a single year is wild. I can’t even begin to process it.
The big question we as a society have to ask ourselves is why and how we are killing optimism and hope.
Honestly, I don’t see a way out of this. If we went with a system where patients pay for everything, MD’s would have to withhold care to those who couldn’t pay.
If we go with the socialization model, MD’s would have to withhold care because someone looking over their shoulder says they had to.
Under America’s traditional system of free medicine, MDs never withheld care from anyone. You are confusing the problems created by the socialists with the reality that existed before the socialists began to gain power to solve what they claimed were unacceptable imperfections in free society.
You are believing the socialist propaganda, in which every problem they create by destroying another successful institution of free society is blamed on that institution. By re-writing history, they gain approval for their next tear-down.
Yeah, there used to be these things called “charity hospitals” and a lot of docs volunteered their time at “free clinics.”
Again- the real time and physically-skilled specialties will remain as-is for the longest time, and some elements will never be replaced. I repeat- this is not even about AI- it is basic information-processing when there is no real-time driver. Go into denial all you want, but routine practice is collection of information and information processing. Our information-gathering capabilities increase constantly- at lower cost all the time- and our information processing capability conforms too Moore’s Law.
There was a time when chess players were convinced that their unique cognitive capabilities were unmatched- till Gary Kasparov could no longer beat Big Blue.
I have nothing against doctors- I worked with many, very closely, in my working life. Some are great people, some are arrogant SOBs, all were pretty smart. But the information-collection and processing functions are replaceable, period. Dr. Watson does not market itself as such because of political opposition from the AMA- but the capability is there and constantly growing. Only political influence and regulatory capture by provider cartels slows it down. Right now the traditional medical practices are busy trying to deny hospital privileges to docs who dare to break the current treatment mold, and to get video consults paid for the same way as in-person visits are; obviously, if you don’t need to be physically present, the game changes, period. Trying to pretend otherwise is a fool’s dream.
At some point pretty soon rural medicine will go “distance-remote treat” because the docs don’t want to live out in some burg 200 miles away from the big city lights, and the principle will be proven. There will be a small office with a computer and a bunch of different types of sensor systems, including full body visual scans, etc. linked to a central database, run by Amazon or Johns Hopkins.
Try to deny reality, but it bites regardless.
You note that Kozak immediately went to the most complex cases, those that are exceptions in any new regimen. Those will always be with us to some extent, although diminishing as the systems get smarter. MASH is necessary out on the battlefield, George Savage is essential in his ER.
But there is no shortage of primary care physicians, as I said in my first post.
I didn’t say “right behind”, I said “a lot of specialty stuff”- for example, chronic treatment of chronic diseases by gastroenterologists, and other non-time-sensitive specialties. You can tell by the time immediacy of the need for care. If the key is information collection and processing, as long as there is any time forgiveness (as in minutes, not weeks), the care does not need a real-time doc except where there is a specific skill level needed for a procedure. But that is exception, not mainstream.
That is my feeling as well: that once upon a time, doctors had been trained to do diagnosis of conditions like a ruptured appendix.
I still meet from time to time, a few doctors who are fresh out of residency and still know their way around the human body. I often wonder if they are from a line of doctors & admired the way their fathers or grandfathers (or mothers & grandmothers) practiced medicine. So they have determined that they will be “old school” in terms of thinking of a diagnosis.
I’m not sure what you meant at the end by “being sent home with appendicitis as it is cheaper…” Wouldn’t some of those sent home die?
Yep. In a sense, every hospital was a charity hospital, I think. As far as I know, they all were as late in the 1960s.
Just as they are today, only cheaper in costs to society.
There was a time when theoretical physicists were convinced that their unique cognitive capabilities were unmatched–till a physicist could no longer produce Newton’s Third Law. Because a printing machine manufactured a physics textbook. From then on, someone who wanted to do what the theoretical physicist, Isaac Newton, did could just read Newton’s Third law out of a machine-made book.
This shows that physicists were no longer needed once a machine produced the first text book containing Newton’s Third Law.
To a static thinker, if what a physician does today, in the little region of person-space-time that he happens to occupy, is replaced by a machine, then “physician” (a static idea, like all ideas to the concretist) becomes superfluous.
But society is a dynamic, self-modifying, problem-solving system. The marginal value of a physician today is built on the capital created in the past by physicians and machine-makers and others. He uses those machines to do today what a machine can’t do today.
He will be doing something different tomorrow. He will be using the machines made between now and then to do what machines in his present moment in the future cannot do.
Once technical discoveries had made tic-tac-toe a trivial game, the best game players no longer played tic-tac-toe. They made up other games.
Me too, but I have read the AMA, etc. lean left and don’t really represent doctors. I think that is the Robert Conquest rule of organizations going left. Same with psychologists who see a lot of political agenda inserted in their organizations declarations.
We encountered this when developing a trauma center in the late 70s. The hospital staff was far more invested in the trauma center than most of the doctors. The story is here.
https://chicagoboyz.net/archives/13160.html
The nurses and techs and even the pharmacists were enthusiastic and made it work.
Very interesting.
A good family friend was an orthopedic surgeon in Chicago, who was team physician to the White Sox for years. This was in the “bad old days” of mostly cash for routine care. After he died, his wife, who had been an OR nurse when they met, went back to work and was bitter about all the patients he had cared for who still owed them money that was never repaid even though they were in the same economic and social circles.
I don’t think my mom was ever bitter about my dad not collecting more of what was “owed” him. She was a devout Christian. I don’t know that Dad ever thought of anything being owed him by his patients. In important ways, he lived as if he were a devout Christian. If either were still alive I’d ask about all this.
It reminds me I wish I’d kept a diary. My life wasn’t important in the ways people think of as important, nor in the way I thought it surely would be important when I was young, but I still wish I’d kept a diary. We oldsters lived through uneventful non-celebrity-related events that future oldsters would find interesting. I know this partly because I would love to know what all those oldsters in my life lived through. Especially Aunt Trix. I mention her not because you recognize this particular name, but because if you are old you especially wish that you knew what ____ lived through, your own version of Aunt Trix or Uncle or Grandpa someone else.
I guess my followup comment got lost. She was bitter BECAUSE she had to go back to work. Their only son went to medical school and became a psychiatrist working on Alzheimer’s and is still going.
https://www.mcleanhospital.org/profile/joseph-coyle
He looks like his dad. I haven’t seen him in many years.
the key word is ‘gifted’
what percent of surgeons are ‘gifted’?