I am naturally a problem solver, and I share this characteristic with most of my fellow physicians. When I felt burned out at one point in my career, I was certain that a literature search would help me solve the problem by giving me answers I could use to make my burnout a thing of the past.
My research, within the academic literature and information on the web, led to some disheartening conclusions. While we have good definitions for burnout, we also have a very poor understanding of what exactly causes it. We do know some risk factors for burnout and that it is at an all-time high. The results of my search, however, were nebulous at best. Even worse, much of the conversation is framed around making physicians, already incredibly resilient people, even more resilient. The burden of solving burnout has been laid on problem-solving doctors.
I found that an entire industry has been built up around burnout, and there are plenty of ways to make money by telling us how to solve our problems. There are coaches, courses, and books all offering solutions to improve burnout (as a disclaimer, I have used a coach for burnout and found it to be helpful). The burnout infrastructure tells us that we will be less burned out if we add more of X (mindfulness, meditation, therapy, etc.). We are all are smart enough to realize, however, that our colleagues who do yoga, exercise, and eat right can still be burned out. This advice ADDS to the problem by shifting the solution to burnout to the physician.
After this research and my own challenges with burnout, I have instead come to believe that resolving burnout is about subtraction, not addition. Instead of adding more beneficial chores for ourselves, we need to subtract the things which distract from our mission of helping our vulnerable patients as they seek health and combat illness.
I work as a urologist, and in recent years my specialty has ranked at the highest end of burned-out physicians. We see lots of patients in the clinic, take some of them to the operating room, juggle inpatient and outpatient care, and take calls for emergencies, all while dealing with a significant shortage of other urologists. Our work is going to be challenging no matter what, and we chose that work because it is interesting and valuable. Yet we spend a lot of time worrying about things that aren’t directly tied to the care of patients. These include, at a minimum: coding challenges, prior authorizations for procedures and tests, “peer to peer” phone calls to ensure proper patient care, endless box clicking, billing queries, and detailed responses to patient messages that should require a clinic appointment but can’t because your next available visit is too far away. These issues compound our burnout, and we must subtract some of them. As long as all these burdens are present, no additional self-driven “wellness” will remedy our burnout.
The biggest improvements in “subtraction” must come from payors and the regulatory apparatus. The 2021 E/M coding changes for outpatient care were a recent victory in this arena. The maze of ever-shifting requirements in the HPI, ROS, and physical exam were finally gone, and we could focus on the medical decision making. Another useful form of subtraction is a good scribe, in that certain documentation elements can be delegated (although this may be a double-edged sword as the physician is ultimately responsible for the entire work product). Burnout coaches are also useful, specifically when they help you subtract. They do this by assisting with setting boundaries (i.e., doing less work) and improving our mindset and framing of problems. These are helpful steps, but we must find more ways to subtract from the burden on physicians.
Health care administrators, like most physicians I think, sincerely want to improve burnout. They hear daily about staffing and provider shortages and know firsthand that there are no easy solutions. The amount of help they can provide, unfortunately, is limited. Administrators can develop good culture, open communication, and hire adequate support staff, but they cannot fix the larger regulatory and clinical staffing environment. They cannot change the fact that our health care system errs more on satisfying payors than treating patients.
We must have realistic expectations. Being a physician is hard work, and not every aspect of work as a doctor will have a positive emotional impact. Yet we can all agree that the balance of what fills the bucket and what depletes it is off. There are some signs that those in power are starting to get it. Surgeon General Vivek Murthy has spoken about making physician burnout a priority. But when we finally get the stakeholders interested in burnout, the solutions must be about subtracting burdens and not giving us more “wellness” to engage in.
If and when action is taken by regulators, it must shift power away from payors to those who provide care. If and when we get a meaningful seat at the table in this conversation we must focus on reducing burdens on those who provide care. As a culture, we see a problem and want to ADD a program, a course, or a solution. If we allow this path to be the focus of burnout solutions, we may unwittingly add burdens while failing to subtract distractors from the provision of care.
Kent DeLay is a urologist.
