PracticalDermatology

Doctors are among the most resilient people on the planet. We have made decades-long sacrifices to earn the rare privilege of practicing medicine. We can work long days and still feel energized because the thrill of helping patients never gets old. Our profession can instill profound meaning in our lives.

Yet, physician burnout is at epidemic proportions. One-third to one-half of all physicians report symptoms of burnout—emotional exhaustion, depersonalization or cynicism, and lack of efficacy. Burnt-out physicians don’t find joy in their work, they doubt the meaning and purpose of what they do, and they may lose compassion for their patients altogether.

Meanwhile, the rate of physician suicide is about double that of the general population. Roughly one physician dies by suicide every day in the United States. This loss is equivalent to two medical school classes annually, at a time when our country does not have enough doctors. The issue is so drastic that September 17 has been declared National Physician Suicide Awareness Day.

Degradation of Physician Autonomy

Why are suicide and burnout so prevalent among professionals dedicated to health and healing?

We don’t have a simple answer because the problems are complex and multifaceted. In The Truth About Burnout, Christina Maslach and Michael Leiter write that burnout “represents an erosion in values, dignity, spirit, and will—an erosion of the human soul.”

In my opinion, the degradation of physician autonomy erodes the soul more than anything else in our cumbersome health care system.

The power to deliver care has shifted to insurance companies, regulatory agencies, and gigantic health care organizations that are far removed from the patient. They don’t directly care for the patients, but they dictate how medicine is to be delivered.

When physicians lose the autonomy to deliver care, we also lose the power to do what we believe is right. Our conscience, or the essence of who we are, is challenged and sometimes violated.

On a weekly basis, I take care of patients with aggressive skin cancers that could invade, spread, and kill. My staff and I are willing to add them to our packed schedule and stay late to perform life-saving Mohs surgery. However, we were not allowed to.

A patient’s insurance company requires that we obtain prior authorization. This is a 2-week process of red tape that delays good medical care. We make daily phone calls, we plead, we complain, we send faxes, and then we wait. All the while, we feel responsible for the patient’s suffering and delay of care. Our team experiences anxiety and guilt, even for something that we did not cause.

The requirement for prior authorization is unfair and simply wrong. Whether it’s permission to perform surgery, to prescribe a medication, or to order a CT scan, the process is demoralizing. It removes the physician’s autonomy and hurts the patient.

Physicians have fought this process for years to no avail. I have come to accept that the system is designed to avoid or delay the delivery of, and thus payment for, medical care. It is not right, but it is the reality of our health care system.

Fighting Burnout

When doctors burn out, it is because we have been prevented from practicing good medicine.

While we don’t get shot at, the type of injury that physicians suffer from resembles that of combat soldiers. It is called moral injury. Moral injury is a type of invisible shrapnel that injures the physician’s soul.

Here is how the US Department of Veterans Affairs has described moral injury as a factor in PTSD:

“In traumatic or unusually stressful circumstances, people may perpetrate, fail to prevent, or witness events that contradict deeply held moral beliefs and expectations … . Moral injury is the distressing psychological, behavioral, social, and sometimes spiritual aftermath of exposure to such events.”

Physicians have been carefully selected and trained to care for others. We are doctors because we are driven by our compassion. When our patients hurt, we hurt along with them. As such, we cannot tolerate a health care system that seems to be fighting us when we try to do what is right.

When an insurance company or an external agency dictates how medicine is practiced, their misaligned incentive often thwarts good medical care. Their values will contradict and almost always overpower the physicians. That’s moral injury on a daily basis. Over time, it could erode the soul.

If we want to continue attracting the brightest, most idealistic, hardest-working, and most compassionate people to practice medicine, then we must protect the physician’s soul. We must do what it takes to remove misaligned policies or bureaucracy. We must allow physicians to practice good medicine—because that’s when we are most alive.