Burnout has become a buzzword in medicine today, but the hype should not overshadow a very real and concerning phenomenon. Burnout was first described in health professionals “on the front line”—emergency medicine physicians or individuals on the battlefield, dealing with chronic, high-risk situations. The psychologists who identified burnout described among these individuals a feeling that they simply no longer cared, they had grown detached from their vocation as a consequence of accumulated trauma. The condition was characterized by intense depersonalization, emotional exhaustion, and a decreased sense of personal accomplishment. That stands today as a definition of burnout.
Some physicians and the lay public may now associate burnout with being overstressed to the point that the physician cannot perform. In reality, physicians can perform very well even though they’re burned out. In fact, only extreme burnout is associated with decreased quality of care, suggesting that physicians tend to push through their feelings of burnout and feelings of exhaustion.
It may be noted that few physicians fully burn out. Although most burnout is associated with factors outside the individual physician’s control (as discussed ahead), affected individuals may make modifications to their practice or personal schedule to offset their perceived burdens and thus relieve some sense of burnout—at least temporarily. Physicians adapt. However, as the rate and volume of change increases, the capacity to adapt is reduced.
Burnout is distinct from stress. Every physician experiences stress, which tends to ebb and flow. Stress also tends to be associated with specific events—a particularly hectic clinic day, preparing a talk. Burnout is more of a cumulative phenomenon and generally is associated with a convergence of stressors.
The current medical environment in the United States appears to be contributing to an increased incidence of burnout and may even be prompting some doctors to choose to leave medicine and to consider alternative career options or retirement. While dermatologists have historically reported high levels of career satisfaction, indicators suggest that dissatisfaction is on the rise. We have a strong workforce of committed physicians who are dedicated to patient care, and as a specialty we want to try to preserve this.
The most recent Medscape survey on physician satisfaction and burnout found that 30 to 65 percent of all doctors experience burnout. Among dermatologists, the reported rate of burnout was 46 percent.
A Mayo Clinic study showed that rates of burnout among dermatologists increased from 31.8 percent in 2011 to 59.6 percent in 2014—coinciding with the time when EMR implementation was at its height (see more below).
Importantly, physician dissatisfaction and burnout are not associated directly with an increase in tasks, duties, and responsibilities. Rather, the degree of dissatisfaction and burnout appear to increase in inverse proportion to the physician’s sense of control or perception of fairness of the responsibilities.
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Among the significant changes to the medical system over the last two decades that seem to be contributing most significantly to increased rates of burnout are the adoption of EMR, an increase in the number of employed dermatologists, and ongoing changes to patient access to medication.
Dissatisfaction related to EMRs is not simply limited to the challenge of choosing and implementing a new electronic health system. While this is, indeed, a potential source of stress and annoyance for many clinicians, most become accustomed to their EMR within a few months, and acute dissatisfaction wanes.
EMRs may contribute to an overall sense of burnout in a few specific ways. For one, many of us continue to find that we spend less “face time” with patients due to the use of EMRs. Consciously or unconsciously, as we spend more time looking at a screen than at our patients, we may begin to feel disconnected and isolated. A recent time-study of family practitioners showed that they spent six hours on EMR in a typical 11.4 hour workday. For dermatologists that see a high volume of patients, the total time spent may be even greater. As our time spent talking to patients is limited, we tend to sacrifice the social dialog that we previously enjoyed, discussing families, hobbies, and the like. Clinical discourse proceeds as friendly banter subsides.
Attempts to decrease screen time and increase face time have led to the creation of a whole new career: The medical scribe. While scribes have proven helpful in certain settings, the physician still bears the responsibility to review and sign off on every chart. Furthermore, adding a scribe increases operational costs, which is irksome to some physicians. For many, the very existence of scribes underscores the inherent problems associated with EMRs, namely that a requirement imposed upon specialists is so unwieldy that it necessitated an entire new workforce.
Dissatisfaction with EMR is compounded by ongoing adjustments to their use. From a practical standpoint, systems are generally designed to be adaptive, with the goal that over time their use becomes more streamlined and intuitive. This is not always the case. Recently, in our hospital system, an EMR update introduced five additional clicks to perform a biopsy. To an outside observer five clicks may not seem onerous, but considering the frequency with which dermatologists biopsy and the fact that this was a system “update,” it’s puzzling and frustrating to find more work added. Instead, the process should have been streamlined.
For many physicians, actual or anticipated system updates create a degree of chronic stress on the operational level. This is compounded on an organizational level when government mandates changes to EMR-based incentives and payment programs.
Consider the MIPS and MACRA updates currently rolling out. As with its predecessor “Meaningful Use,” these new initiatives require dermatologists to collect and report data that in many cases are not germane to the care provided. Once again, it’s not simply the added work that irks dermatologists, but rather the added work, mandated by a third party, without notable benefit to the physician or patient.
Changing Employment Patterns
Whereas two decades ago the vast majority of dermatologists were self-employed, today an increasing number of us are employees. As employees, some of use are giving up a level of autonomy previously experienced or starting off in a practice setting with a long-term career trajectory different from what we might have first imagined.
This trend presents two important considerations. For one, the trend itself may reflect overarching changes in healthcare that make it more difficult for individuals or small groups of individuals to practice efficiently. Conversely, the current system seems to emphasize profits over patient care, thus encouraging the proliferation of large corporate healthcare networks. For physicians who went into practice with the goal of serving patients, this emerging reality leads to disillusionment and dissatisfaction.
Second, those dermatologists who are employed may feel that certain corporate regulations or requirements interfere with their ability to provide optimal care. Whether it relates to an inability to select an EMR system (which may be selected by a corporate headquarters miles away) or the lack of schedule flexibility, a disconnect between one’s intended practice and one’s actual practice can lead to distress.
To be clear, not all employed dermatologists are unhappy, and there is no reason to believe that the vast majority of employers are disinterested in their employees’ sense of satisfaction or patients’ well-being. Nonetheless, the perceptions of a changing and still unsettled employment climate can undermine physician satisfaction.
Burnout or Depression?
Burnout is a depressive condition, and it is important that the burnout/depression overlap be explored, argue some leading researchers. In commentary in The Lancet (8;389(10077):1397-1398) last spring, Renzo Bianchi , PhD of the University of Neuchâtel Institute of Work and Organizational Psychology and colleagues argued that, “By cultivating the idea that burnout is not a depressive condition, despite evidence to the contrary, investigators inhibit themselves from exploiting the accumulated knowledge on treating and preventing (job-induced) depression when helping sufferers of burnout.”
“It is important to consider burnout a form a depression because there is mounting evidence that burnout actually is a depressive condition. Individuals with burnout symptoms typically exhibit the full array of ‘classical’ depressive symptoms, including the most severe, e.g., anhedonia and depressed mood,” Dr. Bianchi explains. “A practical problem related to the use of the burnout construct is that the burnout construct only captures a limited number of the symptoms exhibited by individuals experiencing unresolvable (job) stress.”
Dr. Bianchi points to the key symptom of suicidal ideation that may be ignored in burnout measures. “By using well-validated measures of depression, we have the possibility of comprehensively assessing key manifestations of workers’ suffering, in order to help workers more effectively. Another problem is that burnout is not diagnosable,” he says. “This literally means that, to date, no one can identify an individual suffering from burnout, or distinguish someone with burnout from someone without burnout. Needless to say that this surrealistic situation is highly problematic. By contrast with burnout, depression can be diagnosed.”
The term “Burnout” may be more appealing to some because it lacks attachments to psychiatry and may be less tigmatizing, Dr. Bianchi says. “However, this state of affairs should not lead us to overlook the depressive nature of burnout. A correct diagnosis is a prerequisite to an effective treatment. If burnout is a depressive condition, then this should be recognized.
Lay distinctions made between burnout and depression often rely on false ideas about depression, Dr. Bianchi notes. “For instance, many people (including some health professionals) tend to forget that most forms of depression result from unresolvable stress. As emphasized in a paper that we recently published in The Lancet, unresolvable stress has been found to play a key role in the etiology of depression in people with no noticeable susceptibility to depression. Of course, some forms of depression primarily result from genetic anomalies and metabolic dysfunctions. But in most cases, depression results from unresolvable stress. An implication of this finding is that anyone, including the most resilient individuals, can experience depression if the adversity that they encounter exceeds their coping and defense resources,” he says. “Put differently, depression is essentially a pathology of unsuccessful adaptation to adversity.”
Viewing burnout through the lens of depression clears the way for applying different management strategies. While pharmacology can be helpful in some specific cases, a psycho- and socio-therapeutic approach to depression is probably more promising, Dr. Bianchi maintains. Behavioral Activation Therapy and Cognitive Behavioral Therapy show benefit on an invidiual level. “Recent methods, such as Transcranial Magnetic Stimulation, are also promising. This being underlined, in many cases, depressed people need a profound change in their social environment and living conditions in order to feel better in the longrun,” Dr, Bianchi emphasizes. “With respect to job-related depressive conditions, leaving one’s job is sometimes the only effective solution. Organizational and social changes are generally difficult to produce because of the complex power relationships and conflicting systems of interests at stake. We should not forget, for example, that some occupational management strategies are based on stress.”
Access to Medications
Challenges associated with restricted medication access affect dermatologists in multiple, significant ways. Primarily, as payors increasingly attempt to restrict access to certain medications with the intention of containing or reducing costs, dermatologists find themselves justifying and defending their treatment decisions. Whereas medical decision making was once the sacrosanct purview of physicians, we find that our opinions may only be as good as benefits managers and pharmacists believe they are. The constant challenges feel like an assault on our expertise and cause dermatologists to question the value and benefit of what they do—a clear contributor to burnout.
Beyond the philosophical or personal implications of access restrictions, the paperwork and administrative burdens continue to pile on physicians. Relatively simple topical formulations that have been on the market for years suddenly require prior authorizations. This means more time writing letters, clicking buttons, or otherwise working—without actually seeing patients.
Compounding this already complex issue is the fact that patients often direct their dissatisfaction with access to the physician. They may ask, “Why did you prescribe a medication I can’t get?” or “If I need the medicine, why can’t you get it approved?” Worse, if their concern is associated with cost, they may even accuse us of benefiting financially by prescribing certain drugs over others. Patients have been known to question their doctors about “kick-backs” for prescribing certain drugs.
On the macro level, we see our judgement challenged. On the micro level, we feel patient trust in our care is eroding.
There are five key ways that dermatologists can help confront burnout.
1. Workload. As noted above, the problem of burnout is far more complex than simply feeling overwhelmed or over-stressed. However, by reducing daily stress and making one’s workload more bearable, a dermatologist may be better able to manage other factors that contribute to burnout.
Ensure that your job does not exceed your resources to accomplish it. Especially if you are employed, ensure you are provided with resources in order to get the job done.
Many physicians must make a conscious effort to delegate. Unfortunately, in our current system, everything requires the physician’s signature. Literally every medication that needs a prior authorization needs a signature. Delegating the task of preparing the prior authorization may prove helpful, even if the physician still needs to sign off.
As a group, physicians must advocate for change so that pharmacies and insurers agree that the physician’s direct signature is not necessary for every single thing. Ordering a simple flu shot—which a patient can get at a grocery store today with no prescription—has been shown to require up to 36 clicks in some EMR systems. This is ridiculous in itself and compounded by the fact that the physician can’t even delegate the task to a staff member, since he or she must sign off. As a group, we must consider creative, systematic solutions to such issues.
Physicians tend to be high-achievers with a limited capacity to say “no.” However, it is important that physicians make a conscious effort to not over-extend themselves, especially to the point of neglecting one’s own health. Being healthy—eating well, sleeping well, and exercising—is associated with reduced stress or an enhanced ability to manage stress.
To be clear, the solution to Burnout is not more yoga. However, any strategies to reduce stress can improve the individual’s capacity to deal with the factors that cause burnout.
2. Control. Underlying the problem of physician burnout is an actual or perceived lack of control—of one’s practice or of patient care. Physicians increasingly feel that their voice and perspective are being discounted. Our voice in the healthcare system is disproportionately low, compared to our contributions as stakeholders in patient care. Overwhelmingly, dermatologists believe that if they had a greater voice in the healthcare marketplace that they might have better shaped the integration of EMRs, for example. If the specialty is going to be tasked with compiling data, why not let us influence the decision so that we capture meaningful data?
Physicians cannot and do not want to control drug pricing, but we do want to minimize the use of prior authorizations and the hurdles to acquiring the drug we believe each patient should have.
3. Rewards/Perceptions. Most dermatologists went into medicine with a goal to serve patients, and we thrive on seeing our work benefiting patients. When we feel patients are dissatisfied with us over drug pricing and access, for example, that hinders our relationships with them.
As we become more screen focused and less patient focused, we may not be perceiving the benefit we provide to patients. A computer does not deliver positive feedback. Evidence shows that seeing a happy patient and feeling like you provide quality care actually decreases burnout.
Dermatologists note a mixed perception of our specialty in the house of medicine, where our contributions may be considered less important or superficial. The reality is that we treat very serious diseases that impact lives. Lack of professional recognition also affects burnout. Like it or not, we do need to bring attention to our worth. Dermatologists provide diagnostic skills and services during consults that other physicians cannot. Making sure that we are recognized for our contributions, even in a hospital system, is very important.
The American Academy of Dermatology has initiated the SkinSerious campaign to educate the public as well as the healthcare systems that skin disease is not only about cosmetics. Such recognition gives us a sense of personal accomplishment in our internal reward system.
4. Community. As we endure the demands of daily practice and spend less time interacting with patients, we may also spend less time interacting with peers. However, those who interact with their peers feel more grounded and thus experience less burnout. Peer-to-peer exchanges help dermatologists learn new things. We are trained to appreciate insights gained through interaction with different specialists, medical students, and residents.
Without further worsening a tense work/life balance, dermatologists may seek ways to interact with and collaborate with peers. Consider a journal clubs or new CME activities. Volunteer.
Speaking with peers is beneficial, even if the purpose is commiserating, as such conversations may yield new ideas for coping with stress and fatigue and even lead to practical solutions to managing some of the burdensome tasks physicians bear.
5. Fairness. If you don’t feel like the medical environment is fair to you as a physician, then you always need to work towards fairness as much as possible. Dermatologists have a different practice style than most other physicians, and some decision-makers may legitimately be unaware of or unconscious of those differences.
Rather than expect other individuals or even organizations to find solutions, dermatologists must take an active role. Do something, because if you do nothing, there will be no change.
The roots of burnout stretch well beyond our own field, but we can have a greater influence if we ensure that all parties—the pharmaceutical companies, insurers, hospital systems—understand that burnout of physicians will not yield a good outcome. Ultimately, we are responsible for the delivery of care. If you burnout the people that deliver the care, you will no longer have care.
Healing the System
Burnout is a symptom of an unhealthy healthcare system. If physicians are unhappy, then the whole system needs to change, because patients will no longer get the care they need. For their part, dermatologists can play a role in bringing attention to the issue, with the goal to raise awareness in our clinics, hospitals, and within the industry. The entire healthcare system needs to change now, rather than continue its current trajectory. If 60 percent of patients consistently voiced dissatisfaction with the system, then the market would respond. Why are physicians different?
The only way to initiate meaningful change is to ensure all stakeholders have a voice. At an individual level, dermatologists can make changes to improve their environment and practice experience. However, to truly address burnout requires system-wide change.
To get the attention of financial decision-makers, consider this: research shows it costs an organization between $500,000 and $1 million to replace a lost physician. Weigh that against the cost of a single patient and the resources that go into ensuring patient satisfaction. Assigning a dollar value to a doctor that leaves because they’re burned out in a hospital or a clinic, means something.