From US News and World Report
By Steve Sternberg, Assistant Managing Editor for Health Initiatives
A ringing telephone jarred Dr. Mark Greenawald awake at 2 a.m. The caller was a medical resident at Carilion Roanoke Memorial Hospital.
"One of your patients is going into labor," the resident said. "You might want to come in."
As he turned the key in his ignition, Greenawald remembers thinking the resident probably could handle the delivery on her own. Still, he wasted no time getting to the hospital. Within minutes of his arrival, "all hell broke loose," he says. "The fetal monitor started doing all sorts of things that didn't make sense." The mother-to-be, 20, began struggling to breathe. Greenawald's mind raced as he rushed to deliver her baby.
It soon became clear that the crisis was caused by a freak event called amniotic fluid embolism, in which fetal cells and other debris leak from the womb into the mother's bloodstream, sending her into shock. Once the leak occurs, there's little anyone can do: The maternal death rate for amniotic fluid embolism is uncertain but toward the higher end has been placed at around 60 percent. Those who survive can suffer multiple complications, including brain damage from oxygen starvation.
Greenawald's patient died soon after the delivery. Her newborn suffered massive, irreversible brain damage and died as a teenager.
Despite the odds of a tragic outcome, Greenawald blamed himself. Some of his colleagues cast blame his way as well.
"I had fingers pointed at me, questions raised about my care of this patient," he says.
Consumed by grief and guilt, Greenawald was determined not to let his anguish show. He had administrative duties, teaching obligations and patients who depended on him for care.
"For a year, I kept it inside, until my wife finally said, 'You need to do something. This is not OK.' There wasn't a day that year that I didn't have a lump in my throat from unexpressed grief," he says. "I'm convinced that many physicians are haunted by stories like that, that they've never talked about."
Greenawald's personal and professional crisis, which occurred in 2000, and the soul-searching that followed prompted him to begin thinking more broadly about medicine's cumulative toll on its practitioners.
He began to wonder whether his profession's lofty purpose and privileged status masked a troubling reality: Doctors and other health workers pay dearly for the relentless stress of patient care, a plight compounded by mounting bureaucracy and accelerating change in the health care industry.
The price doctors pay depends on the person and situation. But it can be tallied in many areas, from personal health and wellness to family or professional instability. Soon, Greenawald began sharing his observations with fellow physicians in conferences and other settings.
His revelations and research thrust him to the forefront of a growing movement aimed at tackling one of the most complex and deeply entrenched afflictions in medicine: professional burnout.
A National Epidemic
Burnout is a syndrome caused by workplace stress. It is characterized by emotional exhaustion, bitter cynicism, a plummeting sense of accomplishment and "a tendency to view people as objects rather than as human beings," according to a landmark study led by Dr. Tait Shanafelt of the Mayo Clinic. The study, involving 7,000 doctors along with other workers, was published late last year in the journal Mayo Clinic Proceedings.
Doctors suffer from burnout in especially high numbers, according to the study, which was designed to offer a representative snapshot of doctors and the general U.S. working population. Nearly half of U.S. physicians – 49 percent – meet the definition for overall burnout, compared with 28 percent of other U.S. workers. More than 54 percent of doctors have at least one symptom of burnout, a more detailed analysis found.
Doctors also register more than one and a half times the general working public's rates of emotional exhaustion and depersonalization. Working a median 50 hours per week, their satisfaction with work-life balance is far lower than that of others: 36 percent versus 61 percent.
"We've reached a tipping point," says Dr. Darrell G. Kirch, president and CEO of the Association of American Medical Colleges.
The Mayo study appears to confirm this view. Doctors' dissatisfaction is not only "pervasive," it "appears to be getting worse" – up an estimated 10 percent since a similar survey just three years ago, Shanafelt and his co-authors report. The distress has pushed many doctors to the breaking point: Some are leaving the profession, retiring early or going part-time.
"They're feeling powerless and throwing in the towel," Shanafelt says.
More than 7 percent of employed physicians between the ages of 29 and 65 also reported that they'd considered suicide within the last 12 months, compared with 4 percent of other workers, according to the Mayo study. Around 400 doctors commit suicide each year.
For years, burnout in medicine was widely ignored, regarded as the unavoidable toll of a life devoted to patient care. But that has started to change, as pressures within the health care arena have intensified. Physicians now face greater demands for productivity, an increased reliance on often user-unfriendly electronic medical records, and cascading changes in the way care is delivered.
In one of the biggest shifts, doctors who once ran their own practices often now work for major hospital systems, leading many to feel they've become cogs in a corporate health care world where business demands often overshadow the mission to heal patients.
"A lot of them started out being their own boss, and now over half of all physicians are employed. They have patient quotas. Their patient engagement scores are on the internet, and they're being held accountable for how they're being rated. They're told when they can, and cannot, go on vacation," says Lynne Hughes, director of development at the Medical Society of Virginia Foundation. "These guys are grieving. They don't know they're grieving, but they are."
Many patients view doctors as a privileged class, reaping lavish rewards for their skills and expertise. Doctors acknowledge this, but they also know how hard they work and how difficult it is to succeed. Plenty have spent 15 years or longer in a competitive environment mastering the science and technology needed to mend an ailing heart, reconstruct a knee or diagnose Parkinson's disease.
A primary care physician may see 20 to 25 patients a day for five days a week, or more. Many patients need prescriptions or procedures that require scheduling and a health plan's approval – time-consuming, mind-numbing tasks. And while some of these duties can be delegated to others, many administrative chores require a doctor's approval.
"Physicians still spend hours on the phone waiting for an insurance company to pre-authorize something, which is insanity. It's a huge issue," Greenawald says.
Surgeons and emergency room physicians, meanwhile, may spend 10 to 18 hours a day at the hospital, caring for grievously ill or injured patients. New performance improvement mandates from federal and state governments, insurers and professional organizations add another layer of bureaucracy and assure that doctors, who have long coveted their independence and authority, now work under a microscope.
Nonetheless, they're expected to manage their emotions and achieve the best possible outcomes without making mistakes, because there's so little room for error.
"At the end of the day, if you aren't a little burned out, maybe you aren't doing your job," says Nancy Howell Agee, who trained as a nurse and has risen through the ranks to become CEO of the Roanoke-headquartered Carilion Clinic. "It's so hard, it's so personal and it's all-consuming, about real people with real problems."
Burnout also may be triggered by a traumatic incident, such as a patient's death or a mass casualty event in the community.
In a city the size of Roanoke, calamities can hit close to home. In March, for example, an early morning house fire there killed two children and injured two other children and four adults. The survivors were transported to Carilion Roanoke Memorial Hospitalfor emergency care.
The victims "were friends of ours," says Dr. Karen Kuehl, an emergency physician at the hospital who grew up in Roanoke. "They lived on our street. People thought it was our children who had died."
Even seasoned health care workers are still struggling to recover from the loss, Kuehl says. Constrained by patient confidentiality laws, they can't confide in friends or family.
"A trauma physician came to me because he didn't have anybody else to talk to," Kuehl says. "We went to lunch and talked about it and emailed about it for weeks – things you could never discuss in the real world."
Studies show that burnout isn't limited to physicians. Staff members at every level seem to be suffering, from nurses and technicians to residents and even medical students, still on the doorstep of their clinical careers.
Dr. Zubin Damania, founder of Turntable Health, a primary care clinic and health system in Las Vegas, says burnout prompted him to quit his job as a hospitalist at Stanford University Medical Center four years ago.
"It's an absolute national epidemic," he says, "and it's going to harm the kind of care [we] provide."
Proving that burnout harms patients is a challenge, because it is difficult to study its impact on patient care.
But existing research has turned up disturbing clues.
One study of more than 10,000 nurses and 230,000 surgery patients, published in the Journal of the American Medical Association, examined the specific relationship between workload and patient deaths. Researchers found that increasing a nurse's workload by one surgical patient was associated with a 7 percent increase in a patient's odds of dying within 30 days of admission. Boosting the workload from four to six patients would increase the death rate by 14 percent, while going from six to eight patients would be tied to a 31 percent increase.
A separate survey of nearly 8,000 surgeons published in the Annals of Surgery found that 9 percent reported they had made a major medical error in the last three months. Approximately 70 percent attributed those perceived errors to a personal issue such as fatigue, stress or a lapse in judgment. The worse the surgeon's burnout, the more likely he or she was to report making a medical error. Specifically, each 1-point increase in how a surgeon scored on a scale of emotional exhaustion was associated with a 5 percent increase in the odds of reporting an error, while a 1-point rise in to a surgeon's depersonalization score was tied to an 11 percent increase.
The stress of making countless decisions that profoundly affect patients and their families quickly becomes overwhelming, Damania says, adding that young physicians learn to wall off their emotions in self-defense.
"We have to compartmentalize off our humanity," Damania says. "If we were able to let our guards down, we would crumble in the face of it."
Damania and Greenawald are rare among physicians for their willingness to speak openly about their struggles with burnout. Damania took his distress public by inventing a satirical character, ZDoggMD, and making music videos set to hit songs about the tragicomedy of medicine as it's now practiced.
"Making the ZDogg videos was a cry for help," Damania says. "'Please, somebody, see how we're suffering.' Every one of us is in that boat. We feel like a failure, and we can't cut it in a system that says, 'Suck it up.'"
Most physicians hide their distress, fearing that it will diminish confidence in their care. One of these, a colleague of Shanafelt's at the Mayo Clinic, agreed to answer questions via email, but only anonymously.
"Would I tell you who I am?" he writes in a letter that serves also as a manifesto of sorts. "I'd rather tell you that I'm a felon or a wife-beater than tell you how painful burning out is – and that I care less for my patients.
"I lost the definition of who I am, and became spiteful and calloused and exhausted."
Carilion Clinic offers a window into how one system is attempting to bring burnout under control. Its setting, in a scenic valley surrounded by the Blue Ridge and Allegheny mountains, is a big selling point for the physicians who work here. They relish the small-town atmosphere of Roanoke (population 100,000) and its easy access to outdoor activities. The clinic's flagship hospital, Carilion Roanoke Memorial, nestles so close to the Roanoke River that the health system is building a kayak landing for employees and locals eager to glide down the river and get some exercise.
Still, despite the idyllic surroundings, Carilion's nearly 700 doctors have their hands full. They serve more than a million people in 20 counties stretching from West Virginia coal country to Franklin County, Virginia, near the North Carolina border, which has been branded the moonshine capital of the world. Each year, the system logs around 1 million primary care visits, 169,000 visits for emergency care and nearly 50,000 admissions.
Poverty among those Carilion serves is widespread. The population is aging, with nearly 40 percent of patients qualifying for Medicare. One in 6 people qualify for Medicaid, the government health insurance program for the poor, and another 20 percent say they lack health insurance entirely. Many of the most common diagnoses stem from unhealthy lifestyle choices: chronic lung diseases, cirrhosis, diabetes, high blood pressure, heart failure and infections tied to illicit drug abuse.
Caring for patients who don't take care of themselves can be frustrating. There is also a widespread belief that doctors are responsible for making them better.
"They come here and say, 'I was somewhere else last night and the doctor did nothing for me.' They want someone to fix them,'" says Dr. Hemendra Sarda, a hospitalist at Carilion New River Valley Medical Center, a 150-bed hospital and low-level trauma center in Christiansburg, about 40 miles from Roanoke.
The stakes are higher than just the health of the institution and its patients. With its seven hospitals, medical school, brain science research institute, 240 health care facilities and more than 12,000 employees, Carilion has replaced the railroad as Roanoke's economic engine. "We're no longer a blue-collar, Appalachian Mountain, railroad town," says Beth Doughty, executive director of the Roanoke Regional Partnership, an economic development organization.
As at any health system, the workload takes a toll. If Carilion is unusual, it is because the institution is transparent about the problem. The clinic is openly assessing the extent of its burnout issues, attempting to craft professional wellness initiatives and setting up efforts to help the "second victim" – caregivers, like Greenawald, whose patients suffer a tragic medical mishap.
To define the extent of burnout at Carilion, Greenawald and his colleagues carried out an internal survey, the results of which were tabulated in July and provided to U.S. News. Modeled after Mayo's national survey, it yielded similar findings: Overall, 59 percent of Carilion physicians registered burnout. Medical students, physician assistants and nurse practitioners hovered at just under 50 percent. Most affected were residents in specialty training, with 65 percent registering burnout.
Dr. Gary Simonds, Carilion's chief of neurosurgery, says it should come as no surprise that residents are suffering, especially those in his specialty.
"The training is so difficult and the demands are so great," he says. "Nothing ever goes by the book, so you're battering them with the kinds of things that they'll face when they go out in the world and practice. Then there are the technical skills they have to learn, because brain surgery is brain surgery."
Despite their best efforts, Simonds adds, residents often come away feeling their work was futile. "The procedures can go perfectly well and yet the patient can do horribly," he says. "The most common brain tumor we deal with, glioblastoma, is basically a death sentence no matter what we do. The patient will be dead in six months no matter what. Then there are the teenagers that go through the windshield – broken spines, major brain trauma."
There's no perfect prescription for fostering professional wellness in such a high-stress environment, and health systems that acknowledge burnout are testing several remedies, from forming care teams to incorporating scribes to relieve doctors of the heavy burden of record-keeping. The American Medical Association also has championed "joy in practice" initiatives that aim to boost professional satisfaction.
Such solutions get a mixed reception from physicians. "It's like putting a Band-Aid on a gaping wound," the anonymous Mayo Clinic doctor responds via email.
Carilion is attempting more systemwide improvements by working with community nonprofits to address deep-seated social problems that affect patients' health and ratchet up demand for care.
Through a pilot project, funded by the Virginia Health Care Foundation, the clinic is building a network of local nonprofit agencies to match patients with services such as basic health care, jobs, educational opportunities and safe housing. Today, many of those patients turn up in the emergency room seeking help because they're malnourished or need shelter, or they want something as simple as as a pregnancy test, which they could easily get in other settings.
"It's the first time our community has partnered to address these needs and take the pressure off physicians," says Aaron Boush, Carilion's community outreach manager.
Another initiative aims to provide primary care physicians with more comprehensive administrative support so they can focus their attention on their patients. Health workers such as clerks and nurses update documentation, negotiate with health plans and make sure doctors have all the information they need when patients show up for appointments. Patients are encouraged to come in for their blood tests a couple of days in advance, so the doctor will have the results in hand when the patient arrives in the exam room.
An online portal called MyChart also makes it easier for doctors to communicate with patients and for patients to make appointments online, sparing callers and clerks alike the annoyance of call waiting and multiple messages.
For trauma surgeons, whose patients often arrive on gurneys with life-threatening injuries, burnout prevention may require a more personal approach, says Dr. Bryan Collier, Carilion's chief of trauma surgery. He asked that the hospital make a psychologist available to his team, and required that his doctors and nurses make time to speak with him.
"Not everyone on staff is excited about talking with someone," Collier admits. "But 5 percent of our patients die, we spend more time in-house than any other physician, and we have young families. We face the quintessential risk of burnout. I went to the administration and said, 'I want to be able to talk to someone, and I want my staff to talk to someone, too.'"
Just as important as preventing burnout is caring for colleagues who suffer from it. For Greenawald, this is a personal crusade – a way to help others who are experiencing what he went through after his ordeal in the delivery room.
Working closely with others in Carilion's administration, he is developing an initiative that aims to recruit first responders to assess colleagues showing signs of burnout, and then link those colleagues with resources so they can get the care they need, such as personal counseling or substance abuse services.
Another key element is the second-victim program for doctors, nurses and others who find themselves reeling from a bad clinical outcome. Soon after the event, a trained volunteer reaches out to the health worker and offers to serve as a sympathetic listener. The objective is not to relive the trauma, which may be the target of litigation and thus off-limits for discussion, but to provide peer support for an aggrieved colleague. So far, about a dozen Carilion health workers have taken advantage of the program.
Addressing burnout requires a comprehensive strategy that targets a wide range of issues, Greenawald says.
"If you believe the problem is the culture of medicine, then you have to address the nuances of that culture," he says. "You can teach physicians mindfulness and meditation techniques, but if you throw them back into the war zone, it's not going to work."
Time to Act
Changing the practice of medicine is a gargantuan task, given the entrenched nature of how doctors are trained and their own firm commitments to the way they practice. But a first step is to shine a spotlight on physician burnout by elevating it into the public consciousness with hard data and recommendations for change.
Nearly two decades ago, the Institute of Medicine (now called the the National Academy of Medicine) issued a report called "To Err is Human" that rocked a smugly confident U.S. medical system by stating that as many as 98,000 Americans each year may die from preventable medical errors – a number many experts now view as low. A British Medical Journal study released in May supports that view, ranking medical errors as the third-leading cause of death in the U.S. after heart disease and cancer, killing 250,000 people a year. Burnout undoubtedly is a critical factor, experts say, making doctors more prone to making mistakes.
Dr. Victor Dzau, the academy's president, believes the time has come to take stock of the impact of physician burnout in a fashion similar to the landmark 1999 report: by taking a comprehensive look at every aspect of health care with a bearing on burnout and examining approaches to tackling the problem.
In early July, at the urging of several prominent medical leaders – including Kirch of the Association of American Medical Colleges, Dr. Thomas Nasca of the Accreditation Council for Graduate Medical Education and Dr. James Madara of the American Medical Association – Dzau convened a small, closed-door session of interested parties to consider issues related to burnout. The purpose of the meeting was to determine whether the academy could bring medical experts together to assess the scope of the problem and recommend solutions. Dzau came away convinced, he tells U.S. News, that "we should take this on."
Such efforts can't come too soon.
One recent Tuesday at Carilion New River Valley Medical Center, Dr. Susan Lee strode up and down the hospital lobby gesturing while having a strident discussion on her cellphone. Lee, Carilion Clinic's chief hospitalist, was refereeing a dispute between a surgeon and a younger staff member over who was responsible for a patient's care.
Before long, Lee says, both were dropping "f-bombs," and the surgeon had called Lee to complain. She was doing her best to calm him down, knowing all too well what was really wrong.
"He's volatile," she says, "and he's burned out."