Physician (Un)wellness

Alice Ma, MD
Professor of Medicine in the Division of Hematology and Oncology at the University of North Carolina School of Medicine in Chapel Hill

I’ve been mulling over the concept of wellness, or really on unwellness, for the past several months. You can’t read a publication without someone going on about “cultivating a culture of wellness” or “avoiding physician burnout.” My own institution recently installed a “chief wellness officer” to add focus to the issue. I was planning to roll my eyes and make snarky comments, but then I heard her speak and I unrolled my eyes and bit back the snark. She gets it. Moreover, it appears that my institution, or rather the folks at the top of my institution, seem to get it too.

Burnout, defined as emotional exhaustion, interpersonal disengagement, and a low sense of personal accomplishment, appears to be growing by leaps and bounds amongst physicians. It occurs across all career stages – in the young idealists and those on the verge of retirement and, most ominously, in folks in the middle of their careers. Up to 50% of us are so roasty toasty that you could make s’mores over the flames of our bad attitudes.

As our wellness officer, the amazing Samantha Meltzer-Brody, MD, MPH, explained to us, physician wellness is where the discussion of quality was 10 years ago. The Institute of Medicine (now the National Academy of Medicine) had announced that medical errors were a significant cause of patient morbidity and mortality, and health care institutions across the country decided that the blame should be placed on the backs of the physicians. If those doctors could just “be more careful” and “quit making mistakes,” the problem would be solved. Joe and Terry Graedon, hosts of the popular NPR show “The People’s Pharmacy,” wrote a book with a title that still makes my teeth clench: Top Screwups Doctors Make and How to Avoid Them.

What’s driving the effort to prevent burnout? You guessed it: cash (in addition to compassion and altruism).

Obviously, putting the onus solely on providers didn’t work. Health care systems now have entire departments dedicated to quality improvement because it takes more than individual effort to ensure that medical errors don’t occur.

So, where are we today? Well, physician burnout is a major problem, and it seems that the solution is back on the plate of the individual provider. If we all just attend to our wellness and improve our resiliency by taking a yoga class, journaling, listening to mindfulness seminars, or meditating on gratefulness, the problem will go away. Before that, though, let’s all make sure we fill out the many, many, many mandatory surveys to document how burnt out we are.

What’s driving the effort to prevent burnout? You guessed it: cash (in addition to compassion and altruism). The American Medical Association estimates that replacing one physician can range from $500,000 to more than $1 million.1 This estimate includes recruitment, sign-on bonuses, lost billings, and onboarding costs for replacement physicians. That’s not including indirect costs of burnout such as medical errors, higher malpractice risk, reduced patient satisfaction, and damage to the organization’s reputation and patients’ loyalty. The departure of a physician also results in increased stress on the remaining providers – we’ve all been through it.

The savvy institution will read the writing on the wall – carved by the jagged bitten fingernails of frustrated providers – and start to tackle wellness beyond the individual level. True change will require institutional efforts to improve the culture of wellness and efficiency of practice, in addition to support for the encouragement of individual resilience.

I see some rays of hope. I had been complaining bitterly that ordering a red cell transfusion for an outpatient in my center’s electronic health record (EHR) system took twice the number of keystrokes that it should, since the order set was for both red cells and platelets. In order to get red cells for the patient, I had to de-select all of the orders for a platelet transfusion.

When I asked why in the blue blazes we couldn’t have separate orders for red cells and for platelets, I was told, “It’s easier for the IT people if the transfusion orders are bundled.” Yup, the IT people clearly need to have their lives made easier at the expense of patients and frontline physicians. The flames on the burnout meter rose by about 300 degrees.

But to my great surprise, the most recent EHR update included a change: We can now select the order sets we want from the transfusion menu. It’s almost like someone was listening to the ranting (OK, I was pretty loud) and decided to do something. It’s not quite as easy as ordering red cells, since I have to click 12 separate orders to opt in to the orders I want, but it eliminates another 18 clicks to opt out of the platelet order set. Small progress is still progress, I guess.

While I’m on the topic, I’d like to acknowledge standout physician/comedian/performer/ sarcasm genius Zubin Damania, MD, (aka ZDoggMD) for his awesome video, “It’s Not Burnout, It’s Moral Injury.” This one isn’t a parody of a music video, like my other favorites. It’s a cry from the heart that burnout is “moral injury,” or the end result of forcing medical providers to sublimate the conflict between serving the best interests of the patient and the best interests of a profit-oriented health industry. If you haven’t watched it, I highly recommend you do. It doesn’t offer solutions, but it’s great at articulating the problem. It doesn’t absolve the individual of the need to cultivate resilience, but boy, it had a room full of clinic providers on their feet with upraised fists.

After which we all focused on deep breathing and gratefulness meditation.

Reference

  1. American Medical Association. How much physician burnout is costing your organization. Accessed May 6, 2019, from https://www.ama-assn.org/practice-management/economics/how-much-physician-burnout-costing-your-organization.

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