November 6, 2019

Something significant is happening in our clinics, health facilities and hospitals. Doctors and other health workers are increasingly feeling the effects of “burnout”—that mental-emotional state that signals the approach of a serious breaking point. You haven’t quite quit or gone over the edge, but you’re getting there. Meanwhile, you’re still working, working with patients. It makes for a dangerous mix. Hank William III—who looks and sings a lot like his grandpa—has a song entitled “Lowdown,” a sad saga about a man who has reached his lowest point.

Lowdown, once again.  Well, I’m strugglin’ now to get by, my friend.
It’s keeping me up, real late at night.  I just can’t settle down my honkytonk life.

Except for the honkytonk reference, these lines could very well be written about the physical and psychological state of many of our nation’s clinicians.  In many cases, they’re working longer hours and facing more stresses than previous generations of healers; and many of them are descending into despair.

A Somber Report

Last month, a 312-page report was released by the National Academies of Sciences, Engineering and Medicine (NASEM), widely considered one of the country’s most prestigious institutions.  A committee of physicians, nurses, health executives and leaders in bioethics, neurology and pharmacy spent 18 months studying the incidence and effects of burnout in the healthcare field, and the findings were alarming.  According to the report, anywhere from 35 to 54 percent of doctors and nurses experience burnout.

That figure is even worse when it comes to residents, with the report indicating 60 percent of interns and residents are buckling under an overload of stressors.  Not only are they expected to work twice as many hours as their peers (e.g., lawyers, other professionals), but much of their daily grind is relegated to clerical, rather than care-related, tasks.

A Sober Reality

The committee that authored the NASEM report found that an overall dysfunctional healthcare system has caused clinicians to work longer hours, complete more paperwork, and fear more malpractice lawsuits than ever before.  This is what is leading to the burnout.  The resultant symptoms are as follows:

• Emotional exhaustion
• Cynicism
• Loss of enthusiasm and joy in their work
• Increasing detachment from their patients and the patients’ ailments.
• Higher rates of depression
• Substance abuse
• Suicide

Indeed, the suicide rate among physicians in the United States is twice that of the general population and one of the highest among all professions.  These burnout symptoms are staggering in their scope and tragic in their effect.  It reminds one of the ancient proverb, “Physician, heal thyself;” but increasingly, they are incapable of doing so.

According to the co-chair of the NASEM report, Dr. Christine Cassel, “the system is hurting the very people we have put in charge of healing us as a society.”  The results on the healthcare system, at large, are not much better.  The report stated that physician burnout leads to an increased risk to patients, more malpractice claims, worker absenteeism and turnover, as well as billions of dollars in losses to the medical industry each year.

A Suggested Resolution

Dr. Cassel, who is also a professor of medicine at the University of California at San Francisco and the former president of the American Board of Internal Medicine, observed the following:

“What this report is saying is that this is a systemic problem that requires systemic solutions. You can’t just teach doctors meditation, yoga and self-care. We need big, fundamental changes.”

The NASEM committee didn’t just diagnose the problem, they set forth 6 goals for resolving the contributors to, and effects of, clinician burnout.  They are as follows:

1. Create Positive Work Environments. Health care executives should continuously monitor and evaluate the extent of burnout in their organization, using validated tools, and report on this at least annually to leaders, managers, and clinicians within the organization.
2. Address Burnout in Training and Early Career Stage.  The report recommends that schools of health professions alleviate major sources of stress by monitoring workload (including preparation for licensure examinations and required training activities), implementing pass-fail grading, improving access to scholarships and affordable loans, and building new loan repayment systems.
3. Reduce Tasks That Do Not Improve Patient Care. Federal agencies, state legislatures, and other standard-setting entities should identify and address the sources of clinician burnout related to laws, regulations, and policies, eliminating those that contribute little or no value to patient care.
4. Improve Usability and Relevance of Health IT.  Health information technology (IT), including electronic health records, should be as user-friendly and easy to operate as possible to reduce burnout.
5. Reduce Stigma and Improve Burnout Recovery Services. Many clinicians do not report burnout because they fear the potential consequences, including loss of licensure. The report recommends that state legislative bodies facilitate access to employee assistance programs, peer support programs, and mental health providers without the information being admissible in malpractice litigation.
6. Create National Research Agenda on Clinician Well-Being. By the end of 2020, appropriate federal agencies should develop a coordinated research agenda on clinician burnout. Research priorities should include identifying potential systems-level interventions to improve clinician well-being.

Others, who were not part of the NASEM report, would recommend other solutions to this growing problem among American health workers.  For example, residents in the United Kingdom are generally limited to working only 48 hours per week.  Some have pointed out that this has resulted in no net loss of training or clinical competency, so reducing work hours in American residency may have beneficial effects.  Still others, such as Vindell Washington, chief medical officer at Blue Cross and Blue Shield of Louisiana, would urge the federal government to severely constrict the amount of regulatory burdens facing clinicians that force them to spend greater amounts of time in documentation.

That we are in the midst of a serious and growing threat to our health system is beyond question.  Because of burnout, many clinicians are facing real health risks, or are simply quitting.  This, coupled with the growing doctor shortage crisis (discussed in a previous article) will only make things more stressful for our physicians, leading to more resignations.  It will become a vicious cycle.  Hopefully, government and healthcare leaders can come together to formulate creative and sustainable solutions to this impending implosion.  A country cannot allow its caregivers to feel lowdown.