Doctor burnout is a rising problem in Minnesota

By Jeremy Olson
Minneapolis Star Tribune, May 24, 2015

Physician burnout is on the rise in Minnesota and across the country, as the traditional strains of a medical practice — long hours and draining cases — are compounded by new challenges, such as computerized records and payment reforms that judge doctors by their patients’ health. A series of influential studies by Minnesota researchers suggest that burnout could aggravate the state’s shortage of primary care doctors by driving some into early retirement and undermine the quality of patient care by eroding doctors’ compassion and attention to detail.

“There is an epidemic going on with respect to stressed and burned-out physicians,” said Mitchell Best, executive director of Vital WorkLife, a St. Louis Park-based employee assistance program. In a national survey released this month, it found the share of physicians reporting severe stress increased from 38 percent in 2011 to 46 percent last year.

Paperwork was the most common work-related stressor for the 2,005 doctors who completed the Vital WorkLife survey, while the share complaining about electronic medical records increased from 15 percent in 2011 to 25 percent last year.

“Medicine has become factory work,” one doctor wrote.

Physician burnout is finally drawing the attention of the mainstream media. But the media is failing to connect the problem to the takeover of medicine by large corporations and the usurpation of physician and patient decision-making authority by the managers of those corporations. The media is connecting the burnout problem to “paperwork” and the growing pressure on doctors to spend time entering data into computers. That’s a true and useful connection to make. But that analysis is incomplete. A thorough diagnosis of the rapidly rising rate of physician burnout must begin with the most fundamental cause: The deliberate transfer of authority from individual doctors and patients to the managers of large corporations.

A front-page article published in the Minneapolis Star Tribune over the Memorial Day weekend illustrates the problem. The headline was, “Doctor burnout is rising in Minnesota.” Above the headline in even larger font was the pull quote, “Medicine has become factory work.”

To its great credit, the article did not mince words about the severity of the problem. It cited research indicating that the physician burnout rate had grown substantially since 2011 and quoted an expert saying the problem had reached “epidemic” proportions. It stated that the most significant cause of the crisis was the increasing amount of time doctors must devote to typing data into electronic medical records (EMRs), and that the doctors most vulnerable to burnout are in primary care.

But the article did not ask why doctors are being forced to spend so much time entering data. It did not  examine the larger issue: Physician-patient authority is being transferred to large corporations.

The media’s treatment of the burnout crisis reflects its treatment by the peer-reviewed literature.  Medical journals only began to pay attention to this issue in the 1990s (two decades after the managed care revolution began), and health policy journals pay the issue almost no attention at all. Moreover, the papers that do appear in medical journals have yet to get beyond documenting the fact that EMRs are playing a significant role in physician burnout.

The most influential paper published to date is probably a paper published in 2012 in the Annals of Internal Medicine.  That paper was the first to attempt to determine a national rate of burnout  among doctors. It reported that 46 percent of American doctors suffered from at least one symptom of burnout and that this ”alarming” rate was above the rate for the general population. But the paper was not designed to determine the cause of the problem, and the authors did not attempt to link the burnout crisis to the spread of assembly-line medicine.

You can do some quick and dirty research on your own to confirm what I just said. When I plugged “physician burnout” into the PubMed search box on May 26, I found 148 papers published in 2014 versus just 11 in 1990. I also found that nearly all of the research appears in medical or occupational health journals. Of the first 200 articles PubMed’s search engine returned to me (ranked in reverse order of publication), 195 appeared in medical or occupational health journals.

Only five of the 200 were published in health policy journals (all of these were among the lesser known health policy journals), and of the five, two dealt with physicians in other countries, one addressed patient satisfaction with physician interview skills rather than burnout, and one reported on a fluffy survey that confirmed this platitude: “feeling engaged was very important to physicians’ job satisfaction.” Only one of the five articles addressed burnout in American physicians in a rigorous fashion, and that one found that the VA’s medical home project is causing “participant burnout,”  in part because it is not adequately staffed. This article appeared in Health Care Management Review.

When I plugged in “physician burnout electronic medical records,” I got a grand total of six papers, all published in 2013 or 2014, which is to say long after EMR advocates had persuaded Congress to punish clinics and hospitals that did not fork over thousands of dollars to buy an EMR. One of these six papers (published in 2014) summed up the health policy community’s paltry research on the connection between EMRs and burnout as follows:  “Little has been written about physician stress that may be associated with electronic medical records.”

The failure of the lay and professional media to connect the burnout problem to the conversion of medicine to “factory work” is astonishing because that outcome has been predictable since the dawn of the managed care movement in the early 1970s. From the earliest days of the managed care revolution to the present, managed care advocates have promoted horizontal and vertical consolidation of the entire health care industry into giant systems that would use their power to exert greater control over doctors.

Beginning in 1970, when Dr. Paul Ellwood invented the misnomer “health maintenance organization,” up to the present time when people like Atul Gawande celebrate the Cheesecake Factory as the model for our health care system, managed care advocates have promoted the usurpation of physician authority by the managers of gigantic corporations. They promoted this vision without expressing any concern about the effect their vision of “reform” would have on physician morale.

Here are four examples of the behavior I’m talking about, two from the dawn of the managed care era and two from more recent times:

•    In its January 1970 edition, Fortune magazine published two articles and an editorial lamenting the health care crisis and celebrating corporate supervision of doctors.  The editorial ended with this chilling comment: “[T]he management of medicine has become too important to leave to doctors.” (“It’s time to operate,” Fortune, January 1970, 79). One of the articles quoted Ellwood recommending the consolidation of clinics and hospitals into “health systems” controlled by large corporations such as Kaiser Permanente, Metropolitan Life, and  “industrial and merchandising corporations … such as IBM or Sears, Roebuck.” (“Better care at less cost without miracles,” 80, 127.) The editorial and the articles offered no information on how doctors might feel about being “managed” by insurance companies and “industrial and merchandising corporations.”

•    One year later, Ellwood and several colleagues published their influential paper in Medical Care recommending competition between HMOs as the solution to the health care crisis. They closed with the observation that their proposal “would have some of the classical aspects of the industrial revolution – conversion to larger units of production, … division of labor, … and profitability as a mandatory condition of survival.” (“Health maintenance strategy,” 1971;9:291-298, 298.) Ellwood et al. said not a word about the possibility that such radical “reform” – shifting control of medicine from doctors to corporations driven by a quest for profits – could harm physician morale.

•    In a 2003 paper published in Health Affairs, Donald Berwick and fourteen other bona fide members of the health policy elite (including Ellwood) opined that “payment for performance should become a top national priority” and urged Medicare to lead the way.  This paper, utterly devoid of footnotes, said nothing about whether subjecting doctors to Skinnerian behavior-control tactics would damage physician morale.

•    In 2012, Atul Gawande, who first came to our attention advising Hillary Clinton on her husband’s managed competition plan for the nation, published an article in The New Yorker entitled “Big med”  in which he lavished praise on the Cheesecake Factory, a national restaurant chain, and urged readers to join him in celebrating “large-scale, production-line medicine.” Gawande did not bother to report any information on physician and nurse burnout caused by the assembly-line medicine he is so enthusiastic about. His only suggestion for health care professionals is to get used to it. As he put it, “Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients’ experience counts for more.”

The incuriosity about the connection between managed care fads and physician morale revealed by Ellwood and his intellectual heirs is consistent with the physician stereotyping they routinely engage in. The health policy literature brims over with undocumented claims that state or imply that doctors are greedy, authoritarian, ignorant, incurious about their patients, defensive, and irrationally hostile to information technology (see, for example, Gawande’s statement above to the effect that nurses and doctors care more about their “own convenience” than their patients). When we view any segment of society this negatively, we tend not to care what “those people” think.

However, not every institution and health policy analyst has caved in to the pressure to stereotype doctors and ignore the effect of assembly-line medicine on physician job satisfaction. The VA, for example, is studying the effect of its “medical home” project on physician morale. Within the medical community influential organizations, including the Mayo Clinic and the AMA, are supporting research on physician burnout. And some of the nation’s largest news organizations, including the New York Times and the Wall Street Journal, have begun to report on this issue. We have reason to hope, therefore, that even if managed care proponents continue to ignore the burnout problem their theology is causing, the rest of society will eventually make the connection between the burnout crisis and managed care.

Kip Sullivan, J.D., is a member of the board of Minnesota Physicians for a National Health Program. His articles have appeared in The New York Times, The Nation, The New England Journal of Medicine, Health Affairs, the Journal of Health Politics, Policy and Law, and the Los Angeles Times.