Some 15 years ago, when Daniel Roberts, MD, FHM, decided at the end of his medical residency that his career path was going to be that of a hospitalist, he heard the same thing. A lot.
“Geesh, don’t you think you’re going to burn out?”
The reasons for such a response are well known in HM circles: the 7-on, 7-off shift structure; the constant rounding; the push-pull between clinical, administrative, and – what many would term – clerical work.
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Now, the practicing hospitalist at Mayo Clinic in Phoenix sees trainees coming out of residency thinking that the shift work aspect of HM will protect them from burnout. Forget worrying about it, some of them say. As with most things related to the scourge of physician burnout, the reality is more nuanced. Burnout is neither inevitable nor preventable nor untreatable.
“The truth is somewhere between,” Dr. Roberts said.
Burnout is a hot topic among hospitalists and all of health care these days, as the increasing burdens of a system in seemingly constant change have fostered pressures inside and out of hospitals. Increasingly, researchers are studying and publishing about how to recognize burnout, ways to deal with, or even proactively address the issues. Some MDs – experts in physician burnout – make a living by touring the country and talking about the issue.
But what causes burnout, specifically and exactly?
“The simplistic answer is that burnout is what happens when resources do not meet demand,” said Colin West, MD, PhD, FACP, of the departments of internal medicine and health sciences research at the Mayo Clinic in Rochester, Minn., and a leading researcher on the topic of burnout. “The more complicated answer, which, at this point, is fairly solidly evidence based actually, is that there are five broad categories of drivers of physician distress and burnout.”
Dr. West’s hierarchy of stressors encompasses:
• Work effort.
• Work efficiency.
• Work-home interference.
• A sense of meaning.
• “Flexibility, control, and autonomy.”
Basically, the five drivers lead to this: Physicians who work too much and too inefficiently, with too little control and sense of purpose, end up flaming out more so than do doctors who work fewer hours, with fewer obstacles – all the while feeling satisfied with their autonomy and value.
Academic hospitalist John Yoon, MD, assistant professor of medicine at the University of Chicago, says that health care has to work harder to promote its benefits as being more important than a highly paid profession. Instead, health care should focus on giving meaning to its practitioners.
“I think it is time for leaders of HM groups to honestly discuss the intrinsic meaning and essential ‘calling’ of what it means to be a good hospitalist,” Dr. Yoon wrote in an email interview with The Hospitalist. “What can we do to make the hospitalist vocation a meaningful, long-term career, so that they do not feel like simply revenue-generating ‘pawns’ in a medical-bureaucratic system?”
A ‘meaningful’ career
The modern discussion of burnout as a phenomenon traces back to the Maslach Burnout Inventory, a three-pronged test that measures emotional exhaustion, depersonalization, and personal accomplishment.1 But why does burnout hit physicians – hospitalists, in particular – so intensely? In part, it’s because – like their predecessors in emergency medicine – hospitalists are responsible for managing the care of patients other specialties consult with, operate on, or for whom they run tests.
“Once the patients come up from the emergency room or get admitted to the hospital from the outside, the hospitalist is the one who is largely running that show,” said Dr. West, whose researchshows that HM doctors suffer burnout more than the average across medical specialties.2 “So they’re the front line of inpatient medicine.”
Another factor contributing to burnout’s impact on hospitalists is that the specialty’s rank and file (by definition) work within the walls of institutions that have a lot of contentious and complicated issues that – while outside the purview of HM – can directly or indirectly affect the field. Dr. West calls it the hassle factor.
“You want to get a test in the hospital and, even though you’re the attending on the service, you end up going through three layers of bureaucracy with an insurance company to be able to finally get what you know that patient needs,” he said. “Anything like that contributes to the burnout problem because it pulls the physician away from what they want to be doing, what is purposeful, what is meaningful for them.”
For Dr. Yoon, the exhaustion and cynicism borne out by the work of Maslach and Dr. West’s team are measures indicative of a field where physicians struggle more and more to “make sense of why their practice is worthwhile.
“In the contemporary medical literature, we have been encouraged to adopt the concepts and practices of industrial engineering and quality improvement,” Dr. Yoon added. “In other words, it seems that to the extent physicians’ aspirations to practice good medicine are confined to the narrow and unimaginative constraints of mere scientific technique (more data, higher ‘quality,’ better outcomes) physicians will struggle to recognize and respond to their practice as meaningful. There is no intrinsic meaning to simply being a ‘cog’ in a medical-industrial process or an ‘independent variable’ in an economic equation.”
Finding meaning in one’s job, of course, is less empirical an endpoint than using a reversal agent for a GI bleed. Therein lies the challenge of battling burnout, whose causes and interventions can be as varied as the people who suffer the syndrome.
Dr. Jerome C. Siy
“You have to first make sure you understand the relevance of burnout in your group and in your practice,” said Jerome Siy, MD, SFHM, CHIE, head of the department of hospital medicine at HealthPartners in Minneapolis–St. Paul, Minn. “Because just like every group has a different culture and every group has a different work model, you need to identify what is it in your group that is going on … when you do that, you can then really distill out, what are the issues going on for your group?”