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We have a conversation with Claudia Finkelstein, an internal medicine physician, as she reimagines the concept of physician burnout. Join us as Claudia introduces her alternative model for addressing burnout and discusses the multifaceted factors contributing to the well-being of health care professionals.

Claudia Finkelstein is an internal medicine physician.

She discusses the KevinMD article, “Physician burnout reimagined.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Claudia Finkelstein. She’s an internal medicine physician. Today’s KevinMD article is “Physician burnout, reimagined.” Claudia, welcome back to the show.

Claudia Finkelstein: Thank you very much for having me.

Kevin Pho: So we were just talking, you were last on more than a year ago. For those who didn’t listen to that episode, just briefly share your story and journey.

Claudia Finkelstein: Sure. So I’ve been a general internist for over 30 years. I retired actually about a year and a half ago from patient care. Always worked in large academic medical centers, so lots of interaction with medical students and residents as well as fellow attendings. I’ve developed a huge interest in physician wellness, burnout, and well-being, and that’s the direction my career has taken me over the last few years.

Kevin Pho: So we talk a lot about physician wellness and physician burnout on the show and on my site. Just give us your perspective. What’s the current landscape as it pertains to physician burnout today, as we’re talking in mid-December 2023?

Claudia Finkelstein: I think that the current perception is that the field is evolving, right, and that’s part of what this tongue-in-cheek article is trying to get at. So I think that there is no secret, everyone’s burning out. It’s not dependent on what specialty you’re in, what level of training you’re at, what kind of hospital. It’s also not even dependent on being a physician. I think the nurse burnout rate is astounding.

And so the state is, it’s not a secret, it’s out there. The evolution of the field is, as with quality, early on in the field things are very difficult to get rolling, but now I think both at a high level and at a grassroots level, many, many people are trying to get the ball rolling to make some changes.

Kevin Pho: All right, and with that context in mind, your KevinMD article reimagines physician burnout. So tell us about your article.

Claudia Finkelstein: I will. It’s a little bit tongue-in-cheek. So I was asked to give another talk about physician burnout in the context of equity at a hematology oncology conference. And I love the Stanford model of professional fulfillment, which I reference in the article, and I was making a slide with the Stanford model on it, and then I said, but wait, there’s something that is missing here. And so I really just whipped up a very crude Venn diagram of my own.

So as you know, and as probably most of your listeners know, the Stanford model has professional fulfillment as its goal and point in the middle. And what I thought was revolutionary about this model was that it did not focus on only individual resilience being responsible for the state of physicians, right? So it really cracked open the fact that the culture of wellness and efficiency of practice are also pillars of the strength really of an organization, in addition to physicians.

However, in my irreverent state, I’m like, let’s make an alternate model. And there is the inevitable suffering that we all signed up for. I think it’s part of what I think of as the agony and the ecstasy of practicing medicine, because it really is one of the greatest, I’m getting goosebumps even talking about it, to be at the bedside of somebody that you can help in some way, and it’s beautiful. It does take a toll in terms of vicarious traumatization, to be present at sort of everybody’s worst day is your day all day, right? But this is what we signed up for, and this is the area that I think all sorts of wonderful things exist to help us with: coaching, therapy groups, narrative medicine, yoga. You find your path, there are so many ways to help.

But what all those things don’t necessarily help with is the extra junk, that’s the second category of my fabulous model. And for those who can’t see it, it literally is called extra junk on the model. I wanted people to know that this is not a serious, you know what I mean. So the extra junk are the prior authorization, all sorts of EMR hoops, regulations and guidelines that just sort of add junk to your day, as opposed to what we signed up for, right?

And the good news is that in the evolution of the field we’ve gone from just the physician neurotic compulsive personality into realizing that extra junk matters. And so the AMA has all sorts of wonderful resources in terms of practice transformation, the National Academy of Medicine, the IHI, lots of people are working. Even there was a recent great grassroots effort to change the laws on prior authorization. I think it was Dr. Nisha Mehta who got things changed. So there’s the extra junk, and I see a little bit of hope in the extra junk, right, things are moving and people are realizing what burden that is.

But then the one that I threw in there, borrowed from Dr. Wendy Dean, is moral injury. And I think the fundamental nugget of moral injury comes from the fact that physicians and bureaucrats each have fundamentally different incentives in what they’re doing, right? And so as medicine has become more corporate, the ratio of administrators to providers of care has sort of really increased the number of administrators, because there are so many complexities. And the trouble is, the fundamental goals of each side, when they are not physician administrators, and sometimes when they are, are at odds with each other.

And so I think moral injury is sort of the inability to do the right thing for your patient at any given time. And for me, one of the greatest things, hard to look in the mirror as an American physician and think that we are one of the leading causes of bankruptcy, right? The fact that people we’re trying to take care of wind up going to collections sometimes, and it’s beyond your control. I remember trying to write off a bill of a patient, however with the EMR it’s impossible to write it off, right?

So anyway, the tongue-in-cheek is also serious, and it is an attempt, I guess, the fine focus is the physician personality, the slightly further out focus is including the individual workplace, and this even bigger focus includes sort of how we deliver health care and what’s been going on over the last few many years.

Kevin Pho: How does this reframing or broadening of the perspective, as you put it, when it comes to physician burnout, how would that change some of the solutions to fixing this issue?

Claudia Finkelstein: That’s a really great question, and it’s one that I wrestle with a lot, right? And I think that it would lead to perhaps more advocacy on the part of individual physicians. I would love to see more physicians really taking back some administrative roles, and ones that actually understand what the demands are, because unless you’ve been in it it’s really hard to know just exactly how it goes.

So I guess it would be understanding that just a printer in every room, or I heard of a wonderful solution at a local hospital that they’ve hired an inboxologist, so the person just deals with inboxes. And this level is not enough. The bigger level, the how are there so many patients who are poor enough to not be able to afford care but not poor enough for Medicaid? That’s the population that’s really I think at huge risk.

Kevin Pho: So in your work in the burnout space, I’m sure that you talk and interact with a lot of medical institutions, and they themselves are trying to solve this issue as well. So if we reframe it and broaden that perspective and realize that some contributors to physician burnout is because of workflow issues, institutional issues, the fact that some institutions have to hire an inboxologist, it puts some of the accountability on the institutions themselves as a cause of physician burnout. How do they react to that?

Claudia Finkelstein: Well, they don’t love it, right? I mean, I think everybody wants physician wellness, but none of us want to look at the cause. It’s almost like we all want to have sort of a great psychological space and sleeping enough, avoiding toxins, eating healthy. That’s all hard to do.

So I think what I’m trying to do is sort of rattle the cages and say, hey look, this is really what the problem is. And none of us really love to see where we’re part of the problem, right? And so I think they don’t love it. I try to be funny, I try to be gentle, I try to say, hey look. And I think the trouble is, each of the administrators, they’re not evil people, right, but they are trying to make it in the ecosystem that is bigger than they are. So the same way the physicians are working in a situation they can’t fully control, the administrators are also working in a situation that many times is kind of beyond their control.

Kevin Pho: So I think one solution that you had mentioned earlier was that more physicians need to be in those decision-making administrative roles, and I completely agree with that. Sometimes when physicians talk to administrators, I feel like they’re from two different worlds. What kind of tips do you have for physicians when they want to articulate their perspective when it comes to burnout, and what kind of messages do you think gets through and resonates with administrators?

Claudia Finkelstein: There are a couple of ways to look at this. One way is to sit on the same side of the table as the administrator and say, hey, we both have a common goal, and that is the optimal health of our patients, right? But on some level that’s not necessarily true, based on what I told you a little earlier, that I think the bureaucrats and the physicians don’t necessarily have the same common goal.

So there’s really compelling evidence, there’s a calculator of what physician turnover costs an institution. So sometimes the thing to do is to speak in the administrator’s language, and to show them how, if you assume X percent of burnout, and assume that out of X percent, Y percent will retire early or change professions, there’s a whole website of side gigs for physicians and non-clinical careers, et cetera. So if you show them that X percent are burned out and of those Y percent are likely to leave clinical practice, and that it costs, I don’t know, I think it’s something like three times the yearly salary to recruit a new person, even just in terms of ROI, it is worth their while to spend some time and energy looking at how to reduce burnout.

Kevin Pho: Yeah, I think that number, in terms of how much it costs to recruit a new physician to replace one who’s burnt out, it’s into hundreds of thousands of dollars, right? Just to give that context, I’ve heard numbers even up to into millions of dollars as well, but just to give a range of the scope, it’s at least into hundreds of thousands of dollars.

Claudia Finkelstein: Absolutely, it’s several years worth of the salary of the person you’re recruiting. So it’s different if you lose a neurosurgeon or a radiologist versus a primary care, but it’s still costly. And I think the primary cares are exiting more quickly and are possibly a more vital part of the health care system, so you’re right.

So one way that I talk to them is not only appeal to their higher nature, that we all want the best for our patients, appeal to their fiscal nature, that it costs a heck of a lot of money to replace everyone who goes, and there’s abundant literature showing that many are likely to go.

Kevin Pho: So yeah, tell us a success story where you’ve intervened on behalf of a burned out physician or physician group, you perhaps brought into perspective using this framework that you mentioned, and really moved the needle in favor of those previously burned out physicians. Tell us a success story that you’ve had experience with.

Claudia Finkelstein: I sure would love to tell you that I moved any administrative needles. I think my greatest area of success has been in the individual resilience category. So I’ve developed a couple of peer support systems, based on the model by Jo Shapiro at Brigham and Women’s, and I have done individual coaching with physicians, given tons of presentations.

And so I think on a one-on-one or a one-on-small-group of my own colleagues, I feel that I have been quite successful in normalizing things, in sort of helping to steer them into ways of better perspective to what’s going on. I have to say, some of the people that I have coached have changed jobs, still clinical but in different ways. I wish I could say that I changed visit length, control over your own schedule, any of that stuff.

Kevin Pho: We’re talking to Claudia Finkelstein. She’s an internal medicine physician. Today’s KevinMD article is “Physician burnout, reimagined.” Claudia, you’ve been obviously in this physician burnout space for a while now, you’ve gotten to see where the trends are leading to. What do you anticipate the next short-term future to bring when it comes to physician burnout? Where do you see the trends leading us to?

Claudia Finkelstein: So I think one of the trends is that the younger generation of physicians is much less willing to tolerate. There are all sorts of resident groups that are trying to unionize, and so I think the physicians themselves are taking back some degree of power.

I think, as I mentioned before, there was a recent grassroots effort, I don’t remember what state it was in, to change the laws regarding prior authorization. There’s a great movement afoot through the Lorna Breen Foundation to remove questions that can be stigmatizing regarding physicians’ mental health. So I think from the bottom up there are important changes happening. At the level of the AMA, IHI, and NAM, there are also things changing.

I think the next thing is to get more into the political sphere, where actual policy decisions are made. And what I would anticipate is that, in the same way, speaking with administrators you speak the fiscal language. I think there’s tons of data, and COVID certainly uncovered the terrible price that is paid for a lack of population health infrastructure.

Kevin Pho: And my final question, Claudia, let’s leave off with some take-home messages that you want my KevinMD audience to remember.

Claudia Finkelstein: Sure. The take-home messages are that you signed up for a very noble profession. There is some suffering associated with it, but it is a very noble kind of suffering. The extra stuff is not because you are not strong enough to take it, it is because the system in which we are trying to do good work is kind of rigged against the ability to do easily each new thing in medicine. It takes time. And I think that this field is evolving and will continue to evolve. So I guess it would be, don’t give up hope, and thank you for doing what you do.

Kevin Pho: Claudia, thanks again for coming back on the show and sharing your perspective and insight.

Claudia Finkelstein: Thank you very much.