According to the American Medical Association, physician burnout “is a long-term stress reaction which can include the following:
- Emotional exhaustion
- Depersonalization (i.e., lack of empathy for or negative attitudes toward patients)
- Feeling of decreased personal achievement”
The article goes on to say:
Physician burnout is an epidemic in the U.S. health care system, with nearly 63% of physicians reporting signs of burnout such as emotional exhaustion and depersonalization at least once per week. While many factors contribute to burnout, the burnout epidemic is often associated with system inefficiencies, administrative burdens and increased regulation and technology requirements.
One expert sums up the primary cause of physician burnout: “It’s been said that people don’t leave their jobs. They leave their bosses. But for physicians, physicians don’t leave their careers. They are leaving their inbox.”
At my own institution, the most common sources of dissatisfaction expressed by physicians are completing the electronic medical records, dealing with insurance companies, and performing other administrative duties that take physicians away from their patients. I will deal with each of these causes and demonstrate why the system—including the burnout created—is working as intended.
Contrary to popular belief, the electronic medical record was not intended to make records easier to read or to improve patient care. It was created so that the Centers for Medicare and Medicaid Services (CMS) could systematically and objectively deny payment for services. “If it wasn’t documented, it didn’t happen” has become the foundation for electronic medical records.
Physicians have been educated through mandatory indoctrination on how to document services to justify billing. Templates have been created to instantiate the mandatory documentation with a few clicks of the mouse. The result is pages of text that nobody ever reads.
However, computers can scan the notes for the documentation, and the failure to detect the documentation provides CMS with an objective basis for denial of payment. Each service has multiple codes, with higher code levels resulting in greater payment. There are requirements to achieve each level of code. What the administrators do not acknowledge, however, is that the value of the time necessary to properly document each level of code (to the physician) far exceeds the increase in payment.
The physician’s time has zero value to the administrator, so the administrators constantly harangue the physicians to spend more time on each record in order to generate higher payments. Some administrators do not understand this phenomenon; some do understand it but do not care. No administrator ever suggests that the solution is for the physician to spend less time on each record in order to see more patients or spend more time interacting with each patient. Physicians are regularly graded by Press Ganey surveys of patient satisfaction. There will NEVER exist a Press Ganey survey for the physician’s satisfaction with CMS.
The insurance companies have merely taken the lead provided by CMS, although the insurance companies have a different twist. They require preauthorization for expensive services, and they deny these authorizations for reasons known only to the insurance company. The stated reason is always that the service is not medically necessary. It does not matter what the physician thinks about the necessity of the service.
An appeal process is available, but the process is made as lengthy and as unpleasant as possible. The goal is obviously to make the process so unpleasant that physicians will not pursue an appeal. The insurance company convinced me a long time ago, so I just document that the insurance company denied the service that I recommended.
Many other physicians have the misconception that the barrier is a lack of education or understanding, so they try to convince the insurance company of the rightness of the request. Their efforts may even work on occasion, but the time and effort required will never be worth the result. If the existing treadmill does not reduce requests for services sufficiently, the insurance treadmill will just spin faster. Many physicians do not understand that the only way to win this game is to refuse to play it. There will NEVER exist a Press Ganey survey for the physician’s satisfaction with insurance companies.
Administrators claim to be very concerned about physician burnout. Their “solution” to physician burnout, ironically, is to increase the administrative burden even further with questionnaires about burnout and mandatory education about burnout. The administrators will never acknowledge that the questionnaires and mandatory training are part of the cause of physician burnout rather than a solution. There will NEVER exist a Press Ganey survey of physician satisfaction regarding the number of mandatory training sessions required.
What are the consequences of physician burnout? Physicians retire earlier, and some have even committed suicide. However, this decrease in the number of physicians solves more problems than it creates for CMS and insurance companies. The United States healthcare system pretends to eliminate the scarcity of medical services, but it is not possible to eliminate this scarcity, so we must pretend that is what’s happening.
Medical services appear to be “free” to the patient, but they are still scarce. Rather than paying for services with money, patients pay for services with inconvenience, time waiting in lines, or time and effort traveling to access services no longer available locally.
Another method of “solving” the imbalance between the actuality and the appearance of the availability of medical services is to decrease the number of physicians who order such services. Fewer physicians translate into fewer services, which translate into lower payments by CMS and insurance companies. Graduates of medical schools are granted the MD degree and are technically physicians. However, a physician has very few opportunities for practice, licensure, and certification by state medical examiner organizations until the physician completes a postgraduate residency training program.
Currently, US medical schools graduate about 10 percent more new physicians than there are residency training slots in the United States. As older physicians who have completed residency programs disappear due to burnout, there is increased demand for new residency training programs or the expansion of existing residency training programs. This could, theoretically, close the gap between the number of medical school graduates and residency training slots. However, more residency training slots means increased administrative requirements, so some experienced physicians supervise residents rather than delivering care to patients.
Furthermore, regulations (and lack of experience) prevent residents from seeing the same number of patients as fully trained post-residency physicians. Thus, replacing older fully trained physicians with residents does not fully replace the capacity for delivering healthcare to patients. In private practice, my workload as a pulmonary specialist was, on average, twenty patients per half-day clinic. A resident at my university sees two to nine patients in a half-day clinic, and regulations require one fully trained physician to supervise three residents (without any other duties), so patient capacity is much lower than the same number of fully trained physicians.
Physician burnout is a problem for physicians, but it is a solution for CMS and other third-party payers of medical care. Given that CMS makes the rules, do not expect physician burnout to go away very soon. Physicians sold CMS the rope by which they are being hanged.