Look, I am not a burnout expert. And neither are you (presumably). None of us know much, but that won’t stop the regulations from coming. Program directors are already being asked to provide “wellness plans.” Through the SVS, experts have been enlisted to help, but it is now clear that what works for others won’t necessarily work for vascular surgeons. The next step is up to us. We are the only ones with detailed knowledge of our lives. I believe we are moving closer to answers but still face a few significant hurdles. Don’t worry, there are solutions. Hear me out …
Dr. Malachi Sheahan III
Previously, I shared three studies with you, which found that vascular surgeons had the highest rates of suicidal ideation and career dissatisfaction among surgeons while spending more hours in the hospital than any other specialty. So what has been done to address these horrific numbers? Very little. We need answers now, but most of the data are over 10 years old. Much has changed in our specialty. The endovascular revolution created an entirely new working paradigm. A busy vascular surgeon used to perform 300 cases annually; now this number approaches 1,000. More procedures means more clerical work. Lead aprons and radiation exposure have added new ergonomic and medical concerns. Reimbursement dynamics now favor shorter, more frequent patient interactions over longer, more complex cases. We are benchmarked against old work standards while CPT bundling continuously lowers current RVU designations. EMR was supposed to make our lives better; it has done the opposite. Patient-centered health care has become a mantra, but the measures taken often backfire. Practicing medicine where the desired outcome is a high score on patient satisfaction surveys will likely lead to unnecessary tests, poor cost allocation, and low physician fulfillment. Quality of care is now measured scrupulously while the quality of our lives remains undocumented.
In the absence of organized reform, burnout appears to be increasing. A recent Mayo Clinic–AMA study found the current prevalence to be 54% among physicians. All of this has not happened overnight. I believe practicing vascular surgeons are resilient by default. The majority of us trained prior to the enforcement of duty hour restrictions. Out of high school, I enrolled in a 6-year BA/MD program (skipping 2 years of college seemed like a great idea in high school, less so when I got there). Half of my class never finished. In my intern year, six of the eight categorical residents dropped out. My odds of reaching PGY 2 were 12.5%. Fuzzy math aside, all of your stories are similar. We have proved our resilience over and over again. What is happening here is different.
Burnout is described as emotional exhaustion, low self-esteem, and depersonalization/cynicism. It develops slowly, progressively as stressors increase. A common thread seems to be the feeling that you alone are not enough. Examine your daily life. What are your most common stressors? For me, they relate to time management, clinical documentation, and whatever fresh hell my kids’ teachers have cooked up for “school projects.”
*****Scene*****
Wife: Can you help Luke (kindergarten) finish his diorama? It needs to be a scale depiction of his 3 favorite scenes from Wagner’s Ring cycle.
Me: Sure, I just need to complete the wind tunnel testing on Jack’s (3rd grade) carbon-neutral peanut-free alternative fuel source rocket booster.
Off stage – 7th Grade Son: The genetically modified spiders got loose again!
*****End Scene*****
We want to do a good job, but more hurdles are placed in our way. A recent AMA/Dartmouth Hitchcock study found that 50% of physicians’ time is spent performing data entry and other administrative work. Only 27% of time was spent on patient care. Every hour of face-to-face patient time requires 2 hours of EMR/clerical work. We are trapped in a bureaucratic prison. For years, every quality initiative was solved with a new form. To enter a simple note today, we must first “establish our relationship” with the patient, then ably click through a minefield of “warning boxes” signifying impending DVT prophylaxis catastrophes and antibiotic crimes and misdemeanors, next we scroll through a pre-populated postapocalyptic hellscape of minute- by-minute vital sign entries and lab values dating back to inception. Then, and only then, finally, ON PAGE 11, we can meagerly type: Patient at wound care, will come back on evening rounds.
Another important component of the burnout syndrome is dehumanization. Recently I spoke with Donald Zimmerman, PhD, author of the textbook “Person-Focused Health Care Management.” His thoughts on health care were dramatically altered after spending 43 days in an ICU following abdominal aortic aneurysm repair. He describes the experience as “my worst nightmare that then got worse and then never ended.” While we can learn from his experience, how many of us were trained to face this horror? Dehumanization is a natural protective response, especially when we have so little time for patient interactions. Compassion fatigue sets in when we don’t have the time and resources to care for our patients.While poor outcomes have been cited as a result of burnout, this appears to be an end-stage result. The Minimizing Error, Maximizing Outcome (MEMO) study funded by the AHRQ found that physicians often served as a buffer between their patients and poor medical environments. The organizational flaws that led to burnout also independently resulted in substandard patient care. The burnout physicians experienced was a symptom of the defective health care system and not causative of the poor care. Doctors were literally sacrificing their well-being to care for their patients.
Not surprisingly, attitudes regarding burnout vary significantly between health care executives and physicians. A New England Journal of Medicine survey of their Insights Council found that 96% of respondents agreed that burnout is a moderate or serious problem, although physicians were significantly more likely than executives to rate the problem as “serious.” Opinions on solutions varied as well, with executives more likely to support redesign of EMR, while physicians favored reduction of documentation and clerical work. Obviously the physicians’ solution would be more costly to the corporation as the executives deflected the problem back to the EMR designers. Neither group favored the use of resilience/wellness programs as a primary solution.
Of all the remedies proposed, I find resilience training to be especially egregious. Studies consistently show a 40%-50% prevalence of burnout among physicians. How can this be an individual problem? Why train doctors to endure a broken system? This type of problem solving is why burnout continues to flourish. Doctors are not suffering from a disease but rather exhibiting a symptom.
To arrive at possible solutions, let’s look at the elite athlete analogy. What are you trained to do? What are your exceptional skills? For me it is clearly EMR documentation (just checking to see if any of my residents have read this far). How many of us would describe ourselves as expert at billing? Paperwork? Medication reconciliation? Discharge summaries? Should LeBron James hawk 16-ounce Miller Lites in the nosebleeds during halftime? This may sound like I am expressing a cocky attitude that these tasks are beneath us, but we now have concrete evidence that forcing physicians to perform these duties hurts patient care and literally kills us. Full stop. Physician burnout can lead to suicide in the absence of clinical depression.
While hopelessness is part and parcel of the burnout syndrome, there are now potential solutions within our grasp. Clearly a reduction in clerical duties will be a key component of any realistic plan. Our time must be proportioned. Few of us are asking to work less. Reducing patient interactions while increasing the average time of these encounters has been shown to reduce burnout without decreasing work hours. We want to do a good job. It is time to remove these barriers.
Our next steps have already been taken, and for me it represents the best example of the potential of Vascular Specialist and the SVS. Under the leadership of SVS President Clem Darling, MD, and Executive Director Ken Slaw, PhD, a task force was created to address this issue. Ably chaired by Dawn Coleman, MD, and including Sam Money, MD, from the SVS Executive Council and Past SVS President Julie Freischlag, MD, the task force has collaborated with actual burnout experts Tait Shanafelt, MD, and Susan Hallbeck, PhD, to create a survey designed to identify the causes, prevalence, and potential solutions to the burnout problem in vascular surgery.
The first survey has been completed and will be issued to all SVS members this month to coincide with the SCVS annual symposium. The second, which will focus more on physical issues, will be released during the VAM in June.
Look, no one hates surveys more than I do. We simply have to get this information. Each survey is designed to only take 10 minutes. Things are going to change one way or another. Let’s lead, not wait to follow. With your help this will be the last time I write this ignorantly on this crisis. Vascular surgeons are few in number but this gives us the potential to deliver the most comprehensive self-assessment any specialty has ever performed. Lend your voice to the coming change.
Finally, there are now innovations in use which have proved beneficial in mitigating burnout. A Stanford University School of Medicine program allows physicians to “bank” time spent on committees, teaching, or other administrative duties and exchange these credits for home delivery meals, cleaning services, or even work tasks such as grant applications and paper writing. While the physicians could certainly afford to pay for these assistances, the success of the program demonstrates it is the time saved in arranging the services that the doctors truly valued. Our happiness seems to excel when we spend our time performing the tasks for which we are best suited.
It is time to change. When a system reaches this point, something breaks. Let’s stop being the thing that breaks. Fill out the survey. Get involved. There is time to act before we all burn out on burnout.
Dr. Sheahan is the Claude C. Craighead Jr. Professor and Chair, Division of Vascular and Endovascular Surgery, Louisiana State University Health Sciences Center, New Orleans.
