As physicians, we learn about the Starling curve in the first year of medical school. It expresses the relationship between left ventricular end-diastolic volume and cardiac output. The same can...
Americans love being number one. We have the #1 most expensive heath care in the world and we are close to the #1 lowest overall quality health care among peer industrialized countries. One of the ways we can ensure that we remain #1 is to ensure that our doctors are burned out. In 1729, Jonathan Swift published his essay: A Modest Proposal as a way of easing the economic troubles of impoverished Irish peoples by having them sell their children as food. So, I have my own “modest proposal” to make sure that hospitals are doing everything possible to be sure that their doctors are burned out.
In 2012, only 46% of U.S. doctors suffer burnout. Clearly, we can do better and should strive for 100% of our doctors to be burned out. Fortunately, there are some specialties that are doing better than others – for example, 52% of family physicians and neurologists report being burned out, 55% of general internists are burned out, and the best performing specialty, emergency medicine, has nearly 70% of its physicians reporting burn out. We are making important headway: in 2011, the prevalence of burnout was only 40.9% of U.S. physicians but by 2014, it had risen to 48.5% of physicians. At this rate, in 2035, 100% of physicians will be burned out.
Here are some specific strategies hospitals can employ:
- Eliminate older physicians. Older physicians are less likely to be burned out than younger physicians. Maybe they just develop adaptive behaviors over the years or maybe they just get used to the stresses of being a physician. By lowering the mandatory retirement age to 45, we can reach our goal of 100% of physicians being burned out more quickly.
- Do not hire married physicians and for those physicians already at your hospital, encourage them to get divorced. Single physicians are significantly more likely to be burned out than married physicians. If you do have to hire married physicians, make sure that their spouse also works in healthcare – it increases the odds ratio of burn out to 1.23.
- Make sure your doctors are working > 60 hours a week. Each additional hour worked per week increases the likelihood of burn out. The good news is that at an average of 51 hours per week, physicians work an average of 10 more hours per week more than the average American. If your hospital can get that up to 20 or 25 hours, the hospital’s burn out rate can increase significantly!
- Do not hire physicians who exercise regularly or have non-medical interests outside of the hospital. These physicians are less likely to develop burn out. You are far better off hiring physicians who do not exercise, have no hobbies, and do not take vacations.
- Make your electronic medical record as inefficient as possible. Some estimates are that 1 hour of patient care = 2 hours of EMR time (Sinsky, Ann Int Med 2016; 165:753). Although I think this may be a little excessive, other studies pretty convincingly have shown that physicians spend 1.5 hours per day doing “the work that no one sees”, such as answering messages, doing prescription refills, and reviewing results. EMR inefficiency is strongly correlated with burnout. So, if your EMR is working well, break it. Electronic medical record use has an odd ratio of 1.29 for physicians to develop burn out. Your mantra should be “Make the physician work for the EMR and do not let the EMR work for the physician”.
- Make sure the physicians have an excessive work load. Pushing your hospitalists to take care of 22 patients rather than 18 patients per day is a great way to do this. In the office, try double booking patients and scheduling patients with multiple active chronic problems for 10 minute return visits.
- Increase administrative tasks. This is one that we as hospital medical directors can really influence. If the doctors have to do their own scheduling, arrange for nursing home transfers, and give their own flu shots, you can be sure that they will be more likely to be burned out. Whatever you do, do NOT allow the nurses, pharmacists, and medical assistants to work at the top of their licenses – try to make the physicians do as much of the tasks that the other staff would otherwise be legally allowed to do. One health system found a great way to do this in the outpatient clinic – their clinic nurses were allowed to chart patient’s medications as part of the “past medical history” on the patient’s initial visits, but they required that only physicians were allowed to remove a medication from the medication list when a patient reports that they have discontinued the medication. This resulted in additional physician time and also has the side benefit that medication reconciliation is usually inaccurate – thus helping to contribute to the #1 most expensive and low quality healthcare in the world. Another great strategy is to not permit physicians to give verbal orders – if the physician is doing some mundane task like attending grand rounds, and gets paged because a patient needs a stool softener, it is far better to make the physician walk to the next building in order to find a computer and put the order in himself than tell the nurse to do it over the phone.
- Don’t hire academic physicians. They are less likely to report burn out than those physicians in private practice. Part of the reason that academic physicians are less likely to be burned out is that their compensation is usually tied to more than just billings. If a physician’s compensation is purely based on billings alone, then the odds ratio for burn out is 1.37. If you do have to hire an academic physician, be sure that they are doing 4-week clinical rotations rather than 2-week clinical rotations since they are more likely to report burn out with 4-week rotations.
- Hire more women. The odds ratio of being burned out is 1.35 for women physicians than for men physicians.
- Make sure that you send signals to the medical staff that you as a leader consider burn out as a sign of weakness and a mental health impairment. This will discourage physicians from self-reporting burn out and seeking help for it.
Increased physician burn out can have a number of side benefits. For example, the odds ratio of a medical malpractice lawsuit is 1.39 for burned out physicians – so, if you want to increase the number of malpractice suits at your hospital, an easy way to do it is to be sure your doctors are burned out. You can increase your medical error rate – medical errors are reported by 15% of burned out physicians but only 5% of non-burned out physicians. Other benefits of having burned out physicians: (1) they are more likely to abuse alcohol, (2) they are more likely to have suicidal thoughts, and (3) they are more likely to plan to leave the medical career – all of these things will help keep the United States #1 in high cost/low quality healthcare. One vexing problem for all U.S. hospitals is that they have way too much cash and have trouble finding things to spend it on – physician burn out is a great solution to this problem because burned out physicians have a higher rate of absenteeism and turnover, so the hospital can spend more on back up coverage and physician recruitment.
Inevitably, there will be some misguided people in your hospital who will attempt to prevent or reduce physician burn out. These people are evil. You must identify them and stop them. However, they look just like everyone else in the hospital so you have to track behavior carefully to locate them and rid your hospital of their plague. Here are some of the specific behaviors to watch for:
- Encouraging physicians to work for the rewards of caring for patients. Physicians who recover from burn out are less likely to report that they are working purely for an income.
- Encouraging physicians to take vacation. 10% of physicians do not take days off of work.
- Encouraging physicians to exercise. Not only does exercise reduce burn out but it also makes your physicians live longer and remember, you want to eliminate older physicians since they are more immune to burn out.
- Encouraging physicians to develop hobbies. Your physicians need to have no other interests in life except for medicine in order to give them the best chance of being burned out.
- Encouraging physicians to work fewer hours and take fewer nights of call. Remember, your physicians are indentured servants, not professionals.
The good news is that there are some very concrete things that we can do as leaders in the healthcare system that can foster an environment of burn out. Here are some of the things that you can do:
- Do not hold career development conversations with your physicians
- Do not inspire the physicians to do their best
- Do not empower physicians to do their job
- Do not express interest in your physicians’ opinion
- Do not encourage physicians to suggest ideas for workplace improvement
- Never treat your physicians with respect and dignity
- Do not keep the physicians informed about workplace changes
- Do not encourage physicians to develop new talents or skills
- Develop a strategy of asymmetric rewards: never tell a physician that he/she did a good job but be sure they catch hell if they make a mistake
- Be sure that your physicians know that you are miserable with your job – misery can be infectious
The United States has worked hard to have the #1 most expensive healthcare in the world while simultaneously having some of the worst quality care in the world. The good news is that we can maintain our #1 status by promoting burn out in our physicians and as hospital leaders, it is actually pretty easy to do.
April 16, 2017