What Causes Physician Burnout?
In my opinion, there are really four factors affecting burnout, some of which are unique to medicine and some of which are not. Here they are:
- Abusive work environments
- Professional stresses
- Personal factors (aka lack of resiliency)
- Financial factors
Now this pie chart suggests that all four of these factors are equal. That is very unlikely to be true, but since I don't really know what percentages should be assigned to each of these four factors, I just made them equal in the pie chart. A few months ago I asked readers how much they thought personal factors accounted for physician burnout and this was their answer (you can vote too if you like.)
As you can see, only a tiny percentage of docs think personal factors play NO role at all in burnout.
The Four Factors of Physician Burnout
Let's describe the four factors contributing to burnout, one by one.
#1 Abusive Work Environment
A decent amount of physician burnout is simply really crappy jobs. There is a surprisingly high percentage of these in medicine.
Lack of control is frequently cited first as a contributing factor to physician burnout. In emergency medicine, only about 8% of doctors own their jobs any more. The rest are hospital employees or employees of contract management groups. These doctors no longer have the same control over their job and work environment that a democratic group like mine enjoys.
We decide which patients we don't send a bill to. We decide how to split up the evenings, nights, weekends, and holidays. We decide how to staff the ED (i.e. how many patients we'll see per shift on average.) We decide how the compensation will be split up.
Over the last twenty years, more and more physicians have transitioned from jobs they owned to employee jobs. I suspect this is the largest single factor contributing to physician burnout. Yes, you can get burned out at a job you own, but at the end of the day, you have the power to make substantial changes to that job. It is far easier to be content with stresses you chose to take on than those that are thrust upon you.
Add in some abusive hospital and practice administrators, overwhelming volume, lack of support staff, lack of respect, an EMR designed to maximize billing rather than patient care and physician efficiency, inadequate equipment, long hours, ridiculous amounts of call, and you have what amounts to a terrible job. No surprise that it burns people out.
The real tragedy with this cause of burnout is that people often do not realize that this is job-specific. They assume the entire profession is this way and it just isn't. Keep looking. Not every job is abusive.
#2 Professional Stresses
However, there are some very real professional stresses that exist in the vast majority of doctor jobs. There will always be sick and injured patients. We are not surprised to see soldiers return from the Middle East with PTSD after seeing bodies blown to bits day after day but we are when it happens in doctors?
Give me a break. This is a hard thing we're doing here. Death, trauma, child abuse, socioeconomic messes, rare/uncurable illnesses, memory-robbing dementia…the list goes on and on and on. Some people see this sort of thing once or twice in their life and shy away from it. Doctors see it every week and run toward it. That wears on you. You can tell yourself that “The patient is the one with the disease” as much as you want, but it doesn't always work.
How about ridiculous licensing requirements and costs? Board Certification and Maintenance Of Certification that feels like another money grab? $100K malpractice insurance premiums? Frequent lawsuits and threats of lawsuits (even if the risk of personal loss is ridiculously low). Don't forget the paperwork– who decided 10 systems reviewed pays one thing and 9 systems reviewed pays half as much? Insurance pre-authorizations? Disability paperwork? The list goes on and on.
Some of these things can be improved with systemic change, but many of them cannot. They are simply the stresses of the profession. It is a difficult profession and always will be.
#3 Personal Factors
At the risk of getting even more hate mail, I'm going to throw this one in there because I think it is ridiculous to leave it out. A big chunk of physician burnout is just depression in disguise. Depression is the leading cause of disability in people 15-44. Major Depressive Disorder exists in 6.7% of Americans at any given time, and the median age of onset is 32.5, about the time docs come out of training. 2/3rds of people with depression don't seek treatment. I'm sure that number is even higher in doctors. And when things get really bad, the medical knowledge of what can actually kill a person likely contributes to the high suicide success rates among doctors. But far more than 6.7% of doctors report burnout symptoms. Usually, that number is over 50% with at least some symptoms. It clearly isn't all just depression.
Some of it is lack of perspective. This is the target Side Hustle Scrubs focused much of his post about. We sometimes forget that most people don't like their jobs. It's called work because someone has to pay you to do it and I'm sure we've been complaining about work for millennia. I doubt most of the Roman Legionaries felt super fulfilled marching across Germania for months to go fight some Gauls. There's a support group for people who hate their jobs, it meets on Friday nights down at the bar. Yes, medicine takes a ton of work to get into, requires difficult hours, can be physically and emotionally demanding, and carries high liability. That's why it carries a fair amount of prestige and relatively secure, high pay compared to most jobs.
Some of it is a lack of resilience, although I actually think medical school admission committees do a pretty good job of selecting for highly resilient people. It takes a certain amount of resilience to get good grades in difficult classes, score well on a tough test, do research, gain leadership experience, develop health care experience, and learn to love serving others. The application process itself selects for persistence. That's probably not a bad thing as the most important trait in doctoring is attention to detail and hard work rather than sheer intelligence.
Most of the people who go into medicine are very idealistic folks, and when the student hits the third year (or perhaps intern year) and that idealism is smashed into a brick wall of reality, it can be pretty traumatic for these idealistic people. I remember when I got a Notice of Claim from my first month of internship and then another from my second month. Some small portion of the person who applied to medical school died, and I think I'm still more idealistic than most docs! I like being one of The White Knights of Medicine who always get to take care of people whether they can afford to pay me or not–Anyone, Anything, Anytime.
Some of it is work-life imbalance. There's definitely a culture of suffering and workaholism in medicine.
“You know what's wrong with Q2 call? You miss half the good cases!”
And, of course, there are too few doctors to go around in many locations.
But lots of this lack of resiliency results from bad choices we make. We choose to eat like crap. We choose not to exercise. We choose not to spend time with family and friends. We choose not to pursue outside hobbies and interests. We choose not to care for ourselves but to martyr ourselves on the altar of medicine. Then we're surprised when medicine carries through and finishes us off.
It's easy to blame the systemic issues above under # 1 and #2 because then we carry no blame, no guilt, and no responsibility. But it is an intellectually imbecilic argument. All doctors are functioning under the same flawed system. Many doctors have crummy jobs. But all doctors aren't burned out. Some are clearly more resilient than others when facing the same stresses. So why not work on the doctors at the same time you are working on the systemic issues? It seems silly not to.
#4 Financial Factors
Here is where I have chosen to focus a large part of my energy in decreasing the burnout problem. Doctors generally do not start earning real money until they are the age when many FIRE advocates are already financially independent. Doctors usually finish training with a dramatically negative net worth. Perhaps -$200K, perhaps -$500K. Sometimes worse. And some people don't even get to the end of their training and that high salary that represents the light at the end of the tunnel.
Many doctors fail to match, and that number is rising. The problem of doctor level loans without a doctor level job is particularly acute for Caribbean medical graduates, where the match rate is in the 55% range.
Add a lack of financial literacy and business sense taught in medical school, dental school, and residency to a societal expectation that doctors are rich and you have a recipe for a lot of financial disasters despite a high income. These stresses cause sleepless nights full of worry, an inappropriate focus on what pays best, and most importantly, working too much.
Despite my own successful side gig, I am amazed at how many doctors feel like they need one because medicine just doesn't pay enough. The average physician wage is approaching $300K/year, which places doctors solidly in the top 2-3% of Americans. As I tell the medical students who come over to the house once a year — if you can't live on $300K you have a spending problem, not an earning problem.
How to Help Combat Physician Burnout
So what can be done? Well, let's take these factors one by one.
The best way to eliminate toxic jobs is to stop taking them and if you mistakenly find yourself in one, leave. You may have missed the memo about the doctor shortage, but you have a very particular set of skills and they are highly portable.
Don't be afraid to pack them up and walk away to somewhere that will appreciate them a little more. Yes, it's a pain to change jobs. It might take six months to get licensed and credentialed. But you've proven to yourself already that you can suck it up and do anything for six months. Maybe there are family or location issues that make it a little harder for you to leave. Or maybe you feel called to serve these particular patients more than any others.
Sometimes toxic jobs can be changed, but you need to recognize what the problem really is and start working on it. Saying “No, that's ridiculous” can go a long way.
No, that's ridiculous for me to be on call every night for six months.
No, that's ridiculous for you to pay me at the tenth percentile for my specialty.
No, that's ridiculous for you to expect me to see four patients per hour.
No, that's ridiculous for you to expect me to do that paperwork at home for free.
No, that's ridiculous for me to operate with poorly trained staff.
No, that's ridiculous that your nursing turnover rate is 150% per year.
Systemic Professional Issues
Some of these can be changed. The revolt against MOC in Internal Medicine has put the other specialty boards on notice. Lobbying your legislature for legal changes that reduce malpractice premiums can actually make a difference. We can stop taking insurance with ridiculous pre-approval processes.
But some of the professional challenges we face are never going away. Supporting each other through these difficult times can help a lot. Lots of hospitals and clinics have implemented strategies that make a difference here. Mostly, they are about giving people a chance to step back for a bit and reflect and especially to feel appreciated. I am amazed at what doctors are willing to do for a simple thank you. A dedicated parking spot and a few free meals don't cost much, but they go a long way.
Why not work on this at the same time as everything else? As St. Augustine said, “Pray as though everything depended on God. Work as though everything depended on you.” Change what you can and try not to focus on what you cannot change.
- Take some time off. If you're offered vacation, paternity leave, or maternity leave–actually take it.
- Try to eat a little better.
- Implement an exercise program. It is clinically proven to improve pretty much everything.
- If you have depression, get on some medication and go talk to someone. If you see someone struggling, reach out to them.
- Build and maintain important relationships with your immediate family, your extended family, and your friends. Get out of the medicine bubble. Even better if you can get out of the upper-middle-class bubble. That sure helps with perspective sometimes. If all of your friends can afford to go heli-skiing with you, you need some more friends.
- Do the yoga, meditation, breathing, prayer thing. It has clearly helped lots of people.
- Find a balance between work and other interests. Work is a healthy thing that adds value to your life. But it's hardly the only thing and it can only do so much. Don't expect too much from it.
The interesting thing about financial factors is that taking care of business financially can help ALL of the above issues. While financial planning is not the only solution to burnout, it is really hard to get burned out at a job you no longer need.
Toxic job? That's what that six-month emergency fund is for. A good financial position puts you in a good negotiating position. A doc with $500K in student loans and a $1 Million mortgage is not negotiating from a position of strength.
Professional stresses? Want to do some admin work to improve your work environment? Serve on your specialty's committees? Lobby the legislature? Having your financial ducks in a row allows you to cut back and do that.
Want to work on your own resiliency? Money gives you the ability to cut back and create the time to exercise, spend time with those you care about, pursue hobbies, or see a therapist.
Financial problems? Yup, making better financial decisions fixes those right up. Not always instantaneously, but the hope that comes from knowing you have a plan and are heading in the right direction starts immediately.
Exhausted? Cynical? Unproductive? You might be surprised to see how much of that goes away when you cut back to full-time. Not enough? Try 3/4 time or even half time. Most doctors can pay for a reasonably nice life working 20-30 hours a week, especially if they already took care of business by paying off student loans, paying off mortgages, and saving up a decent nest egg. What does it take to cut back or even retire completely? Nothing but the ability to manage money well combined with a physician income.
There you have it. This post won't be read nearly as much as the previous one because I didn't put “Stop Whining” in the title, but it reflects my current thoughts on physician burnout, its causes, and its cures.
What do you think? What are the major contributing factors to physician burnout? What can doctors as a whole do about it? What can an individual doctor do about it? Have you been burned out? How did you come back? Will you be coming to the 2020 Physician Wellness and Financial Literacy Conference? Comment below!