The healthcare system always conducts a “root cause” analysis when a medical error occurs. It looks for a systemic problem to address in order to prevent a recurrence. Although multidimensional, we have failed to address one of the root causes of physician burnout: an inability to act consistent with our own personal or professional ethical values, which is fertile ground for moral distress.
I have written here about the moral distress that comes with caring for patients with COVID-19, and how it leads to burnout. However, moral distress pre-existed the virus. I believe that in this era of change in institutional employment of physicians, the heavy emphasis on productivity incentives to increase mutual reimbursement is a factor in causing moral distress and increasing burnout in physicians.
Financial incentives have always been a source of conflict of interest in medicine. Even among staff model institutions or other employers offering a fixed salary, productivity is monitored. Physician employment by hospitals continues to increase each year. Hospitals provide physician wellness programs, wellness officers, resilience training, ethical counseling, team-based care, and other useful techniques to blunt the significant emotional and physical consequences of burnout. We await empirical outcomes of these interventions. Simon G. Talbot, MD, and Wendy Dean, MD, accurately state in a STAT article: “Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already.” For my younger colleagues, MacGyver was a fictional TV character in the 1980s who was a genius at “fixing” things using engineering and technical genius in a non-violent manner.
I wrote several years ago about misaligned incentives between hospitals and physicians. Hospitals are increasingly being remunerated by fixed payment models with an incentive to limit services and procedures. Yet, physicians are incentivized by employers to increase productivity by generating more work relative value units (wRVUs). So, not only are incentives in opposite directions, but they create moral conflicts for physicians who are torn between providing appropriate care or focusing on increasing productivity to the benefit of themselves and employers.
A recent study published in Health Affairs surmises that “wasted spending now comfortably exceeds $1 trillion annually” in the United States. While it is unclear is what “wasteful” represents; even half of that number is clearly iniquitous. The pressure to produce for the private practice or hospital employer may create perverse incentives and may also provide justification for the few with a flawed moral compass to perform “non-beneficial” work. A recent survey published in the Annals of Surgery by Christopher J. Zimmermann, MD, et al targeted 5,200 surgeons using the revised Moral Distress Scale, a validated instrument for measuring moral distress in clinicians. More than half (58%) noted they are sometimes or often asked to perform non-beneficial surgery, while 77% said they performed at least one non-beneficial operation per year.
Academic surgeons are now suffering from the same disease of “productivitis.” In interviews with 30 surgical chairs, consensus indicated that academic health systems were supporting business goals instead of academic goals.
In many institutions, the power of governance has shifted away from demoralized academic leaders to corporate figures. Shrinking reimbursements are a part of but not the only reason for the demands for more productivity. Business leaders wish to expand programs and build new brick-and-mortar edifices. The encumbrance ultimately falls on physicians by opening pathways that allow them to increase their compensation through incentivized clinical productivity. This, of course, brings in more revenue for health systems to fund programs. The resulting time and effort devoted to more wRVUs then deemphasizes the other two missions of teaching and research—particularly clinical research.
I have been consistent in my view that excessive reliance on wRVU generation tied to compensation is a slippery slope. One of the chief causes of physician attrition is a conflict of values with employers due to our inability to act in harmony with our own ethical values. Beneficence may become secondary to personal or institutional interests.
Multiply potentially millions of such behaviors and we can surmise how this can lead to deep cynicism and loss of faith in the profession itself. We must always ask ourselves: How does this benefit the patient? Anything that does not benefit the patient may lead to something far deadlier than a slippery slope.
Bhagwan Satiani, MD, is professor emeritus in the division of vascular diseases and surgery in the College of Medicine at The Ohio State University. He is an associate medical editor of Vascular Specialist.