Mama Called the Doctor and the Doctor Wasn’t There

Part 1 in an intermittent series on the Growing Problem with Physician Burnout

All retired and practicing physicians interviewed for this article are practicing or have practiced medicine in San Diego County health care systems.  Each interviewee quoted in this article has asked to remain anonymous out of concern for the health care institutions for which they work or have worked, and because they were not authorized to comment on burnout that exists in their health care systems. 

By Joni Halpern

Drive along any major freeway in San Diego County, and you will come upon towering structures of glass and steel advertised as being among the nation’s best medical facilities, each one part of a different health care system whose doctors, nurses and other health care workers are portrayed as happily delivering optimum medical care to all of us.

But what if the public could peer through the reflective glass of these health care temples and see what has really happened over the past several years to doctors and other health care workers who toil on our behalf?  What if we discovered that our doctors were exhausted by growing workloads, inadequate support, and a losing battle with work-life balance?  What if we knew what medical researchers know – that although COVID-19 has taken an extreme toll on health care workers, physicians were reporting alarming rates of exhaustion and dissatisfaction with their work long before the pandemic?[1 – see footnotes below]

What if our doctors told us that the profession they once loved, the one they imagined as a life’s work, has become something they slog through each day, struggling to make it to a quitting time that gets later and later, as they take their work home?  What if half or more of our doctors admitted they are counting the years, months, and days until they can retire?  What if many of them are planning to give up medicine decades before the normal retirement age, because their mental and physical health is suffering from their work?

What if we knew that at the end of their workday, some of our doctors wished they were dead?

If we knew these negative feelings are held by about half the doctors in our nation, we might fear that when our hour of need arises, our doctors might not be there, or they might not have much to give if they are available.  Listening to the voices of local physicians indicates our fears may foretell the near future.

“If you told me five years before the pandemic that I’d be thinking of retiring, I’d have said absolutely not.  But even back then, I went to the retirement counselor to find out how long I have to stay before I could afford to retire.”

— Local health care system physician

“What is it about this environment that wears us out? You don’t have time to think.  The actual clinical workload is so much heavier.  I finally gave up.  I decided I didn’t want to cut those corners with my patients anymore.”

— Local health care system physician who retired early

“It used to be that you did not have the pressure and stress of having to produce almost beyond your capacity in terms of the workload.  Years ago, you put in a lot of time, but you had time to spend a few minutes in the doctor’s lounge.  You had time to go to the bathroom.  You  had time to think.  You need that time, otherwise you go crazy.  You don’t have it now.”

–Local health care system physician.

Negative feelings about working in health care systems, characterized as “burnout” in innumerable studies over almost two decades, are not limited to doctors.  Countless studies have shown that burnout — described as emotional exhaustion, frustration, cynicism, depersonalization, and a diminished sense of personal accomplishment —  are experienced by many different types of health care professionals, including nurses, nurse practitioners, physician assistants, mental health providers, and others.  Long before the pandemic, surveys showed 40-50 percent (and sometimes more) of health care providers reporting  symptoms of burnout.

However, the flagship occupation of healthcare – the place where the buck stops –traditionally has been that of physician, making physician burnout a cause for concern since at least 2001, in medical research across the country.[2]

While physician burnout may be a paramount concern to health care professionals and health care systems, it does not appear to have earned much notice among the public at large.  The complaints of everyday Americans about their health care seem to be individual rather than systemic:  “I had to wait too long”; “My doctor never looks up from her computer”; “I can’t get in touch with my doctor”; “It will be four months until the next appointment is available,” etc.

Amidst so many other systemic failures and challenges facing Americans, it might not have dawned on us that if doctors are unhappy enough to end their public service early or regret their career choices even while they are still practicing, the outcomes of this negativity might affect our own well-being and longevity.  In fact, many studies have shown physician burnout can result in adverse effects on patients, as well as increased medical costs and harm to physician health.[3]

“Burnout can damage morale and lead once-enthusiastic, dedicated doctors to quit practicing medicine completely,” according to the Agency for Healthcare Research and Quality (AHRQ), a government-funded organization that supports research to improve healthcare.  “[Burnout] can also lead to depression, alcohol abuse, and thoughts of suicide.”[4]

This is not good news for the American population, which already suffers from a shortage of physicians.  The Health Resources and Services Administration (HRSA), part of the U.S. Dept. of Health & Human Services, reported a shortage of 14,900 primary care practitioners in 2018.[5]  That estimate did not even take into account the shortages in so-called “non-primary care physician” specialties, such as cardiology, neurology, and orthopedic surgery.[6]

Physician shortages are expected to get even worse as the American population increases and the supply of doctors decreases.  Our population is projected to grow to about 361 million by 2033, an increase of more than 10 percent since 2018.[7]  During that period, the number of Americans under age 18 is expected to increase by almost four percent, and the population of those 65 and older is expected to grow by 45.1 percent.[8]

The American Association of Medical Colleges (AAMC) projects a total physician shortage between 54,000 and 139,000 by 2033.[9]  Within that total, the shortage of primary care physicians is projected to be between 21,400 and 55,200.  In surgical specialties, the shortage is projected to be 17,100 to 86,700.  In medical specialties, it is expected to range from 9,300 to 17,800, and in other specialty categories, from 17,100 to 41,900.[10]

The AAMC estimates the current shortage would be much greater if we count under-served populations as if they had the same access to health care as Americans with fewer barriers.  If everyone who needs medical care could be served, “the U.S. would need an additional 74,100 to 145,500 physicians,” according to the AAMC’s Health Care Utilization Equity model.[11]

But what is the nature of physician burnout, and how is it robbing us of our physicians?

“I spent more than 40 years in medicine.  I went into it because it was a good way to do something good for people.  It’s a noble profession, it always has been, and it should stay noble.  But burnout happens when doctors lose the joy in practicing medicine.  Nowadays, the overload of administrative work, the stress of not spending enough time with any one thing you are doing before having to move on to the next thing without feeling you have done the best you could – these are things that have happened to medicine over the last few decades.  They take away the joy of practicing.

“Over the past few years, the number of patients has increased, the procedures have increased, but not the number of doctors needed to match those increases.  The complexity of what doctors have to do has increased.  We have more knowledge and more options in therapy that were not available before.  All of that has affected the amount of work a doctor has to do.  It leads to burnout.”

— Retired former physician and department head in local health care system

“Non-medical administrators have taken over everything.  Now, the only things that matter in medicine are the bottom line and control over everything we do.  Doctors are like widgets.  We feel we’ve lost our moral integrity.  We came into the profession to take care of people.  Now it’s metrics over everything else.  Six minutes or 15 minutes with a patient?  You can’t do anything in that amount of time.  You can refill a prescription.

“You don’t have time to find out what is really going on with your patient.  You are busy entering so much information into the computer.  You have to check off that you have asked a patient about all kinds of information not pertinent to what they came in for, but the computer system wants it updated:  their cholesterol, their mammogram, their colonoscopy, etc.  You don’t have time for anything else.  There’s no connection with your patients.  We’re little gerbils inside a spinning wheel.”

— Local health care system physician

“Doctors are no strangers to hard work.  When I was coming up in the profession, we worked until we got it done.  But there was a big difference between then and now.  There was no time limit on how many minutes you could spend with your patient.  I really cared for my patients, but chasing down what was bothering them really excited me.  You need time to listen to your patients.  You need time to think.  Nowadays, there’s no time with your patient.  You don’t have time to think.”

–Retired local physician; community medical volunteer

In studies and individual interviews with physicians, some causes of burnout are repeatedly listed:

• The overwhelming volume of patients doctors are required to see, along with the huge number of emails, phone calls, texts, and computerized notifications that demand responses requiring hours more after regular work shifts
• The effect of electronic health records in governing physicians’ time, pressing them to finish punishing workloads, timing their every move, and interfering with their independent judgment in choices that affect patient care
• The conditions for payment imposed by government-funded and private insurers
• The paramount health care system goals of raising revenue, cutting costs, and reducing liability

Each of these topics requires a separate discussion for which justice cannot be done in this brief article.  Later articles in this series will attempt to highlight the issues associated with these topics.

However, many physicians summarize the overarching cause of burnout as the unrelenting fixation on the bottom line.  Insurers want to pay less for patient care.  Hospital administrators want to generate more revenue to cover the enormous cost of operating health care systems (one component of which is the notable sums paid to their non-physician corporate leaders).  Government funders impose difficult and accelerating reporting and billing requirements, but often pay much less than care actually costs.  Private equity wants to swallow up independent practitioners and then sell off their stripped-down, stressed-out service networks for a tidy profit.  Doctors want to earn enough to repay their costly educations and achieve a level of compensation commensurate with the incredible level of responsibility involved in caring for the most precious asset any of us possesses – our bodies.

Across the nation, doctors are complaining that American health care has been reconfigured to serve neither patients nor doctors, but to maximize revenue.  This rearrangement of priorities, doctors contend, has led to financial strategies that have deeply interfered with their independent judgment, the allocation of their time, the doctor-patient relationship, and the joy they once found in the practice of a demanding profession.  In one study, almost half the physicians surveyed reported they would accept less compensation in exchange for more freedom in the use of their work time.

“Medicine is more than just zeroes and ones on a computer.  It is something sacred, something that makes a doctor feel good when it is practiced right — when you establish a relationship with your patient, when you chase down the cause of their pain, when you feel like you have the chance to be there for your patient. It’s things like that that make a doctor feel good.  Otherwise, why take on such a huge responsibility?  Money alone isn’t enough.”

— Retired local physician formerly with health care system

“It’s not about money, because even if we were getting much more money, this workload is not sustainable.  It’s too much.  It’s horrible.”

–Local health care system physician

“We’re not asking for ‘Golf Wednesdays.’   Just don’t drag us into the mud where we lose our integrity and the satisfaction of helping people.”

–Local health care system physician

————————————————————————————————————

[1] Stajduhar, Tony, “On the Verge of a Physician Turnover Epidemic,” 2021 Jackson Physician Retention Survey Results, Jackson Research 2021, Intro.
[2] Gopal Khanna, M.B.A., Arlene S. Bierman, M.D., M.S., “Combatting the Burnout Epidemic,” Blogposts from AHRQ Leaders, July 24, 2017, https://archive.ahrq.gov/news/blog/ahrqviews/physician-burnout.html
[3] C.P. West, L.N. Dyrbye, T.D. Shanafelt, “Physician burnout: contributors, consequences and solutions,” Journal of Internal Medicine; March 5, 2018.
[4] Id.
[5] Skorton, David J., M.D., President and CEO of American Association of Medical Colleges, “A Dire Shortage and Getting Worse:  Solving the Crisis in the Health Care Workforce,” Statement in Hearing Before The Senate Committee on Health, Education, Labor and Pensions Subcommittee on Primary Health and Retirement Security, May 20, 2021, p. 2. (citing U.S. Dept. of Health & Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis.  2016.  “Supply and Demand Projections for Internal Medicine Subspecialties: 2013-2025)
[6] Id.
[7] Id.
[8] Id.
[9] Id.
[10] Id..
[11] Id. at p. 3.