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The Cause of Physician Burnout May Surprise You

By: David P. Lind

Physician ‘Burnout’ is More About the Culture of MedicineSummer is a time for relaxation. It is now becoming safer to go to the beach, attend concerts and sporting events, and gather with family and friends at our favorite venues. Enjoying backyard grilling and other outdoor activities make our summers seem almost ‘normal’ again.

Summer is often associated with reading ‘leisurely’ topics that may not be too taxing on our minds. To that end, my wife always reminds me that I need to adhere to this philosophy and read something that is non-work related and ‘enjoyable.’

That is why I just finished yet another book about…healthcare! This book, “Uncaring: How the Culture of Medicine Kills Doctors and Patients,” written by Dr. Robert Pearl, was a real gem to read.

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The credibility of authors can be unusually powerful, especially if the author has brutally-honest viewpoints that directly correlate with their particular profession. In Uncaring, Pearl is a highly-credible source in spades while writing critically about his own profession. He backs his insights from research and, just as importantly, his own personal experiences. Pearl is the former CEO of The Permanente Medical Group – the nation’s largest medical group – and former president of The Mid-Atlantic Permanente Medical Group. He is one of Modern Healthcare’s 50 most influential physician leaders. That’s right, he is also a physician who is board certified in plastic and reconstructive surgery.

Noted author Malcolm Gladwell wrote about Pearl, “No one is better qualified to write about what ails healthcare than Robert Pearl.”

I have spent almost 10 years writing blogs. Most of my topics relate to employee benefits (through David P. Lind Benchmark) and, more specifically, bloated healthcare costs that emanate from our fragmented system of care (found at this site). It has been my observation that, too often, the healthcare ‘establishment’ is too bent on maintaining the status-quo, even though threats are ramping up to eventually disrupt a system that desperately needs disruption. To this, Pearl bluntly states, “Doctor’s benefit too much, financially, from the way things are and stand to lose too much, culturally (their prestige and privilege), by changing.”

Physician Burnout

Pearl writes that the physician profession is experiencing an unprecedented level of burnout, which impedes the quality of medical care they provide to patients. According to Medscape in 2019, 44 percent of physicians are ‘burned out,’ primarily due to working too many hours at the office, interacting too much with their computers, and not being paid enough to perform the many required bureaucratic tasks. In fact, a 2020 survey (conducted prior to the COVID-19 pandemic) found that all physician specialties reported a burnout rate of at least 29 percent. The physician burnout rates are staggering.

According to Dr. Pearl, however, the variation in burnout rates among different specialties cannot be explained by the amount of money earned, hours worked, or bureaucratic paperwork performed. Pearl’s book comes up with a different reason why physician burnout happens – physician culture.

Why is physician burnout so important? According to a recent report prepared for the Association of American Medical Colleges, by the year 2034, there will be a shortage of physicians ranging from 37,800 to 124,000. This dire projection will affect most Americans when attempting to gain access to quality care.

Physician Culture is influenced by…

Pearl does an extraordinary job of explaining physician culture, which is influenced by two perverse obsessions that doctors historically have within their profession: prestige and status. As described in his book, this physician culture insulates doctors from the financial, ethical, and clinical pressures to change. Strong and harmful culture is embedded in the physician world, and yet physicians are unable to recognize its impact on their lives.

Social and professional status, as determined by British epidemiologist Sir Michael Marmot, have a large influence over a person’s mental and physical well-being. Stress levels and self-esteem are affected by the real or perceived rank one has with friends and society, in general. Psychological studies highly suggest that losing social or professional status will produce the same symptoms associated with burnout – anxiety, fatigue and depression. In today’s world, doctors worry that their profession is losing its power and influence that it once had.

There is an unwritten hierarchy in the medical profession that constantly remind physicians about how they compare with their medical colleagues. In simple terms, the prestige of being a high-volume surgeon at a ‘centers of excellence’ – rather than a general surgeon without having high-volume specialty skills, will determine where physicians fall on the totem pole of hierarchy. Family practice physicians do not fare well in this hierarchy, and therefore, their burnout level is higher than in specialties that require more specific skills. This is unfortunate. Research continues to show that when healthcare organizations place a high value on primary care, evidence-based care and various preventive approaches, the prevalence of chronic disease is reduced among patients by up to half.

This self-imposed hierarchy influences the mental health and overall happiness in physicians. As Pearl indicates, “Their obsession with status will continue to inflict harm on themselves and their patients.” According to Pearl, those physicians who care for patients with urgent, life-threatening problems are more valued than those who attempt to prevent diseases from happening. This culture determines how each physician specialty is placed on the status hierarchy.

Physician preoccupation with status is the culprit of increasing burnout and compromising effective medical care. This long-held culture must require a refreshed approach that will change how physicians see themselves amongst their peers.

Pearl argues that for culture to eventually change, the U.S. must change to an integrated, prepaid, technologically advanced physician-led healthcare delivery system. Under this, no longer are physicians competing with one another, but rather, they collaborate and communicate with one another to serve the patients.

This book serves as a good reminder to all policymakers and the physician community that culture matters a great deal. Cultural change is seldom by choice, but rather, by survival.

Now, it’s on to the next book…and the hammock!

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Making Sense of the ‘Iowa Patient Safety Study©’

By: David P. Lind

Making Sense of the ‘Iowa Patient Safety Study©’Confronting problems we have in healthcare today and fulfilling our vision for the future begins with having the courage and willingness to do the ‘right thing.’ Too often, however, doing the ‘right thing’ runs contrary to how we are incentivized to perform. As we know, incentives drive behaviors – both good and bad.

In his book, “Mistreated: Why We Think We’re Getting Good Healthcare and Why We’re Usually Wrong,” Dr. Robert Pearl appropriately wrote: “The design of our healthcare system – how it’s structured, reimbursed, technologically supported, and led – determines how the people in it will behave.” This sentence clearly articulates the inherent problems found in a haphazardly-designed system that now comprises almost one-fifth of the U.S. economy.

I have learned a great deal from our recent “Iowans’ Views on Medical Errors – Iowa Patient Safety Study©.” Five large takeaways from this study include:

  1. Nearly one-in-five Iowa adult patients experienced medical errors in the past five years, either for themselves or for someone close to them.
  2. When a medical error occurs, six-in-10 Iowa patients are not notified of the error by the responsible healthcare provider.
  3. Most Iowans who experienced medical errors desire to report the error because they want to prevent the same error from happening to someone else. This runs contrary to conventional belief that patients desire to report medical errors primarily to receive compensation for the harm they received.
  4. Iowans strongly feel that medical errors must not be hidden from the public and should be reported, both to the patient and to an appropriate regulatory agency.
  5. Iowans believe medical errors are mostly caused by overworked staff, lack-of-care coordination and poor communication.
Reading between the lines on many of the survey findings, here are some of my general thoughts on what we can learn from this report:

  • Medical errors are a national public health crisis, and Iowa is certainly not immune from this persistent epidemic.
  • Making healthcare safer is difficult largely because healthcare organizations operate in a very complex healthcare system. They use a myriad of inoperable electronic health-record systems that are not fundamentally equipped to allow for effective communication between providers. Most importantly, strong incentives to push appropriate patient care in the right direction is sorely lacking. Because of this, delivering efficient and safe healthcare appears to be more problematic than putting a man or woman on the moon.
  • Surveyed Iowans are not necessarily blaming individual workers who devote their worklife to the medical profession, but rather, they tend to believe that well-meaning medical professionals are trapped in a subpar delivery system.
  • The patient ‘perspective’ must be actively pursued to measure the outcomes of the care they receive, and this experience can help reveal the prevalence of medical errors. The future of healthcare will be determined as much or more by patients as by physicians.
  • Zero-tolerance of preventable medical errors should be the norm, rather than exception – Most everyone knows that this problem is happening, but little has been done to determine the extent of this problem and how to make it unacceptable in the future. When errors occur, provider care systems are largely silent on this topic, often failing to share prompt, open disclosure and a full apology to harmed patients. This primarily happens because providers wish to avoid the possibility of malpractice lawsuits and maintain a pristine public reputation. Patients, on the other hand, have reasonable expectations that are woefully unmet after an error occurs. They likely feel thrust into a confrontational situation while still being in a fragile state of health. In short, if we don’t demand safe care, they don’t supply it. In 2017, commercial passenger airlines had zero deaths due to accidents…because that industry has a zero-tolerance approach to preventable errors. The medical industry can learn greatly from other industries.
  • Organizational culture is critical to the success of delivering safe care. The environment in which medical staff work – such as hospitals and clinics – can provide the necessary organizational culture to ensure the healthcare delivered is as error-free as humanly possible. Medical staff should not be afraid to report medical errors when they do occur. Safety improvement initiatives will only succeed when leadership, safety culture programs, fundamental communication practices, commitment to transparency and patient engagement are fully-aligned with the objective of greater patient safety.
Thought leader and author Frank Sonnenberg describes trust quite succinctly, “Trust is like blood pressure. It’s silent, vital to good health, and if abused it can be deadly.” To have an efficient and effective healthcare delivery system, trust will be required at all levels and by all participants. This means that, at their most vulnerable time, patients should not be taken advantage of by those who are given this trust – especially when medical errors occur.

If we can put a man on the moon in 1969 using technology dated 50 years ago, why can’t preventable medical errors be tracked and mostly eliminated today? We must first have the moral will to succeed, and then design and install correct incentives to ensure the desired behaviors and outcomes.

The re-design of our healthcare system requires the grit we used when launching a rocket to the moon. In healthcare, however, its more about human (and organizational) behavior than rocket science.

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