As director of Physician Health Services, Inc., a subsidiary of the Massachusetts Medical Society, I am a psychiatrist who has dedicated the latter part of my career to preserving the well-being of physicians. Lately, I've had a lot of work, because physicians are, in general, not well.
In fact, I would go so far as to say that we have an occupational health crisis in health care. In the same way mining is unsafe for workers, health care is becoming an unsafe work environment.
Burnout among U.S. doctors, particularly primary care physicians, is bad and getting worse. A 2015 study by Mayo Clinic researchers, working with the American Medical Association, found that more than half of physicians felt emotionally exhausted and ineffective, and more than half described their work as less meaningful. A recent study in the Journal of the American Medical Association found that doctors in training were at a much higher risk of depression than the general population.
Just about every state has a program to help physicians. These were set up in the 1980s and '90s as safe, confidential destinations for physicians with serious health challenges. At first, they were used mostly by doctors with drug or alcohol problems. Some programs segued into treating psychiatric problems, and then into treating behavioral or anger-management issues. In those cases, doctors were typically sent to us by authority figures: department chairs or CMOs who told them, “You are crashing and burning, and you better get help — or else."
But the new topic around programs like ours is stress and burnout. These challenges, which once were aberrant, now afflict 55 percent of the physician population. And most of these doctors are self-referring. Four years ago, 85 percent of our physicians required referrals; last year 40 percent were self-referred.
What has made health care unsafe — or rather, unhealthy? A confluence of things.
- Physicians now have more to do than ever before. They see a growing number of sicker patients and receive diminished reimbursements, so they need to work longer hours.
- Doctors today are distracted by the tasks that go beyond talking to patients and making medical decisions — from meaningful use requirements to the metastatic growth of ICD codes to the bane of prior authorization, which requires doctors to battle a gatekeeper to prescribe a medicine or get a test performed.
- All this is happening amid an explosion of medical knowledge, so we are in some ways victims of our own success.
Helping individual doctors
Technology is presented as one answer to these problems. But for older doctors, technology doesn't necessarily help. We didn't grow up with computers and smart phones and notebooks, and therefore are particularly challenged converting from paper to electronic records.
And in general, technology is a double-edged sword. Yes, it allows for greater communication and standardization, but the interface has not been seamlessly woven into the clinical encounter. Doctors are faced with, “Am I looking at my patient or working on completing my records?"
That affects patient satisfaction. Doctors know that they're being judged, on patient surveys, for their listening and communication skills. So they have to walk the tightrope of banging out four to five visits an hour — and providing good medical care — while avoiding the risk of being dinged by sub-par patient satisfaction scores.
Here in Massachusetts, we are fans of one-on-one professional coaching to help physicians cope with these stressors. A new cottage industry of performance coaching for practicing physicians has evolved. These coaches work with physicians around issues such as self-care and work-life balance. They provide concrete strategies for improving office skills — and refusal skills, so doctors can learn how to say “no" to colleagues, staff or patients.
This is not therapy. Therapy assumes some pathology, while coaching encourages the doctor and coach to set goals and use a hands-on, goal-oriented, problem-solving approach. Coaching helps physicians manage the demands of our current, hectic work environment, and does not assume that the individual physician is flawed or defective.
Changing the system
Beyond helping physicians individually, we must approach this growing problem systemically. As I talk to medical leaders about what physicians need, I am trying to create a culture of coaching within the profession, so medical leaders in different practice environments can develop coaching skills and work with frontline clinicians.
And in the larger health care arena, we could use two broad-brush changes: escalating the move to value-based care to get there sooner, and, rewarding adult primary care to a greater extent. We need to figure out a way to create better support for this almost impossible job of delivering primary care to sick adults. This is the most central specialty in the health care system, and it's in the red zone for increased burnout and diminished workplace satisfaction.
As I see it, primary care is the heart of the system, and this critical organ is diseased. When the Institute for Healthcare Improvement came out with its Triple Aim — improving outcomes, improving the patient experience, and reducing costs — it was a missing fourth aim: the professional and personal satisfaction of health care professionals. The system needs to invest in that fourth aim, because it's central to other three.
I did the math once, and found that our $1.5 million physician well-being program, when compared to Massachusetts' overall health care spending of $60 billion, is just .0025% of the total state health care budget. The industry is spending pennies to support that fourth aim — and ultimately we get what we pay for.
We have a big challenge on our hands. The volume and pace of physician work has exploded over the last few decades. Everyone is feeling it. Patients are feeling it, as well. More and more patients are asking their doctors, “Are you OK?"
Medicine needs energetic professionals who have a sense of personal well-being. We all must get rid of the notion that doctors are superheroes who can suck it up and do anything. There is a lot of Kryptonite in the workplace now.
Steven Adelman, M.D., is a psychiatrist and the director of Physician Health Services, Inc.
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