Physician Workforce and Burnout
by Dr. Jon Hart
We hear a lot about burnout in healthcare these days. To start a conversation about physician and clinician burnout, I like to think back to what the term means from a mechanical perspective: the reduction of a fuel or substance to zero and/or the failure of an electrical device or component due to overheating. You’re either out of gas or you’ve worked so hard as to blow a circuit and shut down – or both.
When we speak of burnout in the workplace, the APA Dictionary of Psychology defines it as physical, emotional or mental exhaustion, accompanied by decreased motivation, lowered performance and negative attitudes towards oneself and others. I think it’s telling of our profession that the ICD-11 medical diagnosis coding system classifies burnout to an occupational experience and not a medical condition.
The ICD code QD85 says, "Burn-out is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:
feelings of energy depletion or exhaustion;
increased mental distance from one's job, or feelings of negativism or cynicism related to one's job; and
reduced professional efficacy.
Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life." (Our diagnosis code almost puts the blame on the one burned out in its description that the stress has “not been successfully managed.”)
Physician and clinician burnout is real, it’s growing in its prevalence, and its impact is palpable on healthcare in the US. At the recent Reimagining Primary Care Forum in March 2024, Gary Price, MD, President of The Physician’s Foundation and Lisa Rotenstein, MD MBA MSc, Director of the Physicians Foundation Center for Physician Experience and Practice Excellence at Brigham and Women’s Hospital, shared some wisdom on the topic.
Symptoms of burnout in physicians went up considerably during the COVID-19 pandemic. According to Dr. Price, though, the prevalence of burnout symptoms remains at its pandemic high, experienced by 60% of physicians. Physician turnover and physicians leaving practice are two consequences of burnout. Dr. Rotenstein defined turnover as a person leaving practice completely or going to different practice, and PCP turnover is second only to Hospitalist Medicine as the specialty with the highest turnover rate. Dr. Price’s organization has estimated the cost to society for the increased turnover rate and decrease in PCPs is around $4.6 billion annually.
Not an insignificant problem.
Also consider the clinical impact and effect on health outcomes along with that financial impact. Dr. Rotenstein has data to show that physician turnover is associated with worse patient outcomes in the Medicare population, so this issue impacts people’s health outside the realm of physicians and clinicians.
It adds to the PCP shortage, too, even when docs don’t completely leave practice. The influence of burnout and its symptoms has led many PCPs to decrease the numbers of patients they’re seeing in a day. This effectively decreases access to primary care.
What’s causing this? Like most things, it’s multifactorial.
The Physician’s Foundation has found that, surprisingly, it doesn’t seem to be related directly to compensation. Dr. Price said there is a higher proportion of burnout in employed physicians despite increased pay compared to their independent colleagues. They found that administrative tasks are the major drivers of frustration and dissatisfaction, i.e., tasks performed below the level of licensure like documentation, prior authorization paperwork, and all-around box-checking.
Conversely, Dr. Price’s team discovered that time spent with patients is the #1 driver of professional satisfaction among physicians. One can surmise, then, that efforts to speed throughput and increase volume of patients seen in a workday can contribute significantly to burnout.
Given that information, the accelerating frequency of burnout makes sense in the context of the continuing trend of physicians as employees rather than owners or leaders of their own practices. The stats show that 77% physicians are now employed by hospitals or corporate entities. Over the past 4 years, per Dr. Price, health systems acquired 7,600 practices and corporate entities consolidated 36,600 physician practices.
Physicians and clinicians have handed over control of their days, workflows, processes, and priorities to entities primarily focused on profits – quick profits, preferably – where docs and clinicians are cogs and patients are widgets. Throughput and billed visits have taken precedence over helping people be healthy and taking time to build much-needed relationships. Seen as mere commodities, physicians and other are now asked to do more and take on more (especially menial tasks) to see how much stress the machine can handle in its production.
I think we’re seeing the limits.
What can be done? Doctors Price and Rotenstein had a few suggestions to address the proclivity toward burnout, beyond simply revamping our entire healthcare system.
The first response from Dr. Price when asked by the audience how he thought we could improve was an endorsement of Direct Primary Care (DPC). “The best model in primary care that I’m familiar with that’s working is DPC.” The other suggestions that work within the more conventional model of primary care included:
Team-based Care – Find the best ways for physicians, NPs, and all the members of the modern primary care team to work together, based on both outcomes and experience. Leverage the skills and expertise of each team member to appropriately offload work that currently keeps physicians and clinicians from maximizing their time and energy in the care of the patient.
Technology – In addition to getting the right people doing the right tasks, find ways to work technology solutions into your processes and workflows, especially in potentially automated tasks like phone and Inbox messaging, Rx refills, prior authorizations, and documentation. In many instances, a tech solution is cheaper than adding more humans and its impact on the best use of the physician’s time can be remarkable.
In addition to the tech suggestion, I would simply suggest looking at office workflows and processes, verifying that the tasks in each process are both adding to the effectiveness of the work and are being performed by the right person – the team member whose skills and expertise best for with the job to be done.
The experts also mentioned culture as a possible solution, where docs are given control of their schedules and leadership works to foster a culture of wellness. These are a bit nebulous for me (squishy is what really comes to mind), and frankly, I think they miss a big root cause of the culture disconnect in healthcare.
What would that be, you ask? Misaligned incentives. To better ensure a positive experience for healthcare workers, an organization needs to have the goal of improved patient outcomes through optimized health and well-being, financially incent that goal, and build processes and workflows to support that goal. Doing so focuses on the things that bring physicians joy – time spent with patients and improved outcomes – while minimizing the detractors – administrative burden, menial tasks, and the dehumanization of the modern healthcare machine.
Burnout of physicians and healthcare providers is an ever-increasing problem and one that negatively impacts all of us, patients and physicians alike. As our PCPs are leaving healthcare or becoming less effective due to burnout, the shortfall of primary care providers grows, access is limited, and our outcomes continue to worsen.
There is no one solution, as there is not just one cause. However, large steps could be made toward improving the circumstances of physicians and thereby decreasing burnout by addressing the frameworks within our healthcare system that add meaningless and tedious works onto physicians and clinicians, that leave PCPs feeling as if they are stranded on their own without support, and that dehumanize physicians and patients. The appropriate use of technology, an emphasis on team-based primary care, and the proper alignment of incentives to the goals of better outcomes can all move us closer to a more sustainable environment.
Lisa Rotenstein, MD MBA MSc. Director of the Physicians Foundation Center for Physician Experience and Practice Excellence, Brigham and Women’s Hospital
Gary Price, MD. President, The Physician’s Foundation
