Business of Cardiology

The perils of burnout for cardiologists

Cardiologists should consider strategies to avoid excessive stress, unhappiness.

Job-related dysphoria and unresolved occupational stress — “burnout” — are frequent topics of conversation today in many workplaces, including hospitals, clinics and cardiology offices. Burnout was recognized by Hippocrates and Plato thousands of years ago in ancient Greece.

Burnout is now of concern for individuals in many work environments, including modern medicine. We face an epidemic of physician burnout that challenges individual doctors, including cardiologists, and the entire CV enterprise to address changing relationships and detrimental conditions in the physician workplace that have led to this widespread dissatisfaction and disruption. The effect of widespread physician burnout is the subject of many reports in the popular and professional literature; burnout has been targeted for study and intervention by major health care systems, academic institutions, the AMA, the National Academy of Medicine and many others.

Challenges in cardiology

Because of the nature of heart disease, which is often acute and life-threatening, the practice of cardiology is inherently stressful, but more so in the current era of explosive growth in our knowledge base, with the expectation that complex diagnostic and therapeutic procedures and lifesaving interventions will be available everywhere, all the time.

L. Samuel Wann, MD, MACC, FESC
L. Samuel Wann

The hours are long and unpredictable, and the work is physically and mentally challenging. However, other fundamental changes in the structure of medical practice may be even more important in causing burnout, including the loss of physician autonomy related to ongoing consolidation of cardiology practices with elimination of independent practice for many, with no alternative but hospital employment and associated loss of personal control over workplace environment, confounded by the uncertainties of health care reform and the mutability of financial compensation.

More and more time is being diverted away from direct patient contact to meet growing requirements for maintenance of certification and to comply with regulations governing licensure and hospital privileging, preauthorization for coverage from insurance companies and documentation of compliance with appropriate use criteria. Mandatory implementation of the electronic health record, which is optimized in its current iteration to facilitate fee-for-service billing rather than to improve patient care, frustrates clinicians by requiring them to perform repetitive clerical duties not directly related to patient outcomes, judging their adherence to minutely detailed process measures while limiting face time with patients, simultaneously holding individual physicians responsible for patient satisfaction, which is often more related to satisfaction with the whole system of care including insurance coverage, rather than to factors under the control of their physician.

Varying stages of burnout

Burnout has varying manifestations at different stages in a cardiologist’s career.

Physicians in training and early in their careers are challenged with acquiring a working knowledge of a massive amount of information, mastering difficult technical skills, passing comprehensive board examinations, identifying their niche in the profession, finding a job, paying off debts and starting a family. Many early-career cardiologists’ first jobs offer relatively high, guaranteed salaries for a limited time, followed by a transition to production-based “at-risk” compensation. Having paid off debts and passed the board exams, some move on to other hospital salaried positions, following in the steps of many hospitalists, emergency physicians and other hospital-based specialists, who have also been noted to experience very high rates of burnout, frequent job changes and limited institutional loyalty.

Mid-career physicians suffer similar dystopia but have fewer acceptable outlets to escape, as they are more likely to have established family and professional roots and obligations in their community, and are less likely to move, imperfect though their job situation may be. Burnout may manifest more as cynicism and depression, adversely affecting contentment and effectiveness in both the work and home environments.

Senior physicians, with memories of the “good old days,” are especially unhappy with the loss of professional autonomy, the EHR and related bureaucratic burdens, and may have fewer economic incentives to stay in practice, but still have high levels of altruism and loyalty to their patients, their colleagues and their profession. Many delay full retirement, but as the first wave of baby boomers face the realities of aging, a shortage of cardiologists in part caused by burnout of cardiologists in all career stages is a frequent prediction.

Expressions of burnout, and its antidotes, vary greatly by workplace and individual. A negative attitude and unpleasant behavior related to burnout can disturb productive interpersonal relationships essential to team-based care in the hospital, the lab or the clinic, resulting in suboptimal patient care, decreasing patient and professional satisfaction and even in an increase in medical errors. Long hours, fatigue and a narrow focus on work with consequent isolation can lead to withdrawal from normal society, predisposition to major depression, substance abuse and suicide. Physician burnout has serious consequences for individuals, the institutions of medicine and society; solutions for burnout are being pursued in all three arenas.

Aims to improve

Improving the health care workplace has been added to the traditional “triple aim” of medicine: better patient care, better population health and lower costs. The National Academy of Medicine has identified burnout in the health care workplace as a major problem, and has proposed new programs of research and education to address this serious situation. The AMA, state medical societies and other professional organizations including the American College of Cardiology, as well as hospitals and integrated health organizations, have introduced various strategies to enhance and restore professionalism and foster transparent organizational leadership necessary for team building and esprit de corps. Taking note of effective workplace practices employed in other industries from manufacturing to Silicon Valley, many hospitals are paying more attention to programs and physical amenities that foster employee wellness, updating the old “physician” lounge and dining area and ritual of grand rounds lectures to emphasize personal interaction and camaraderie, counteracting the tendency to isolate with a computer or smartphone, which both patients and colleagues find off-putting.

We must insist that future iterations of the EHR focus more on improving workflow and patient care and less on encyclopedic, repetitive, sometimes irrelevant and inaccurate details that interfere with, rather than facilitate, communication with patients and peers, and do not improve health outcomes. The digital revolution offers tremendous advances in information gathering, analysis and clinical decision-making but is very early in fulfilling that potential. Other institutional approaches to burnout include transparency in decision-making, dyad leadership, flexible scheduling and non-threatening discussions of burnout, physician wellness, compensation and medical errors.

Individual cardiologists also have personal responsibility for their own self-care and happiness. There is a life outside medicine. No matter how satisfying and demanding one’s job may be, prioritizing work over family and social life, leisure activities, hobbies and vacations can lead to burnout. In addition to following a healthy diet, many find regular exercise, mindful meditation, spiritual awareness and participation in volunteer activities leads to better interpersonal relationships in the workplace and more effective, empathetic interaction with patients. Individual and institutional awareness of the importance of burnout is the first step in effectively countering its negative effects on the practice of CV medicine.

Disclosure: Wann reports no relevant financial disclosures.

Job-related dysphoria and unresolved occupational stress — “burnout” — are frequent topics of conversation today in many workplaces, including hospitals, clinics and cardiology offices. Burnout was recognized by Hippocrates and Plato thousands of years ago in ancient Greece.

Burnout is now of concern for individuals in many work environments, including modern medicine. We face an epidemic of physician burnout that challenges individual doctors, including cardiologists, and the entire CV enterprise to address changing relationships and detrimental conditions in the physician workplace that have led to this widespread dissatisfaction and disruption. The effect of widespread physician burnout is the subject of many reports in the popular and professional literature; burnout has been targeted for study and intervention by major health care systems, academic institutions, the AMA, the National Academy of Medicine and many others.

Challenges in cardiology

Because of the nature of heart disease, which is often acute and life-threatening, the practice of cardiology is inherently stressful, but more so in the current era of explosive growth in our knowledge base, with the expectation that complex diagnostic and therapeutic procedures and lifesaving interventions will be available everywhere, all the time.

L. Samuel Wann, MD, MACC, FESC
L. Samuel Wann

The hours are long and unpredictable, and the work is physically and mentally challenging. However, other fundamental changes in the structure of medical practice may be even more important in causing burnout, including the loss of physician autonomy related to ongoing consolidation of cardiology practices with elimination of independent practice for many, with no alternative but hospital employment and associated loss of personal control over workplace environment, confounded by the uncertainties of health care reform and the mutability of financial compensation.

More and more time is being diverted away from direct patient contact to meet growing requirements for maintenance of certification and to comply with regulations governing licensure and hospital privileging, preauthorization for coverage from insurance companies and documentation of compliance with appropriate use criteria. Mandatory implementation of the electronic health record, which is optimized in its current iteration to facilitate fee-for-service billing rather than to improve patient care, frustrates clinicians by requiring them to perform repetitive clerical duties not directly related to patient outcomes, judging their adherence to minutely detailed process measures while limiting face time with patients, simultaneously holding individual physicians responsible for patient satisfaction, which is often more related to satisfaction with the whole system of care including insurance coverage, rather than to factors under the control of their physician.

Varying stages of burnout

Burnout has varying manifestations at different stages in a cardiologist’s career.

Physicians in training and early in their careers are challenged with acquiring a working knowledge of a massive amount of information, mastering difficult technical skills, passing comprehensive board examinations, identifying their niche in the profession, finding a job, paying off debts and starting a family. Many early-career cardiologists’ first jobs offer relatively high, guaranteed salaries for a limited time, followed by a transition to production-based “at-risk” compensation. Having paid off debts and passed the board exams, some move on to other hospital salaried positions, following in the steps of many hospitalists, emergency physicians and other hospital-based specialists, who have also been noted to experience very high rates of burnout, frequent job changes and limited institutional loyalty.

Mid-career physicians suffer similar dystopia but have fewer acceptable outlets to escape, as they are more likely to have established family and professional roots and obligations in their community, and are less likely to move, imperfect though their job situation may be. Burnout may manifest more as cynicism and depression, adversely affecting contentment and effectiveness in both the work and home environments.

Senior physicians, with memories of the “good old days,” are especially unhappy with the loss of professional autonomy, the EHR and related bureaucratic burdens, and may have fewer economic incentives to stay in practice, but still have high levels of altruism and loyalty to their patients, their colleagues and their profession. Many delay full retirement, but as the first wave of baby boomers face the realities of aging, a shortage of cardiologists in part caused by burnout of cardiologists in all career stages is a frequent prediction.

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Expressions of burnout, and its antidotes, vary greatly by workplace and individual. A negative attitude and unpleasant behavior related to burnout can disturb productive interpersonal relationships essential to team-based care in the hospital, the lab or the clinic, resulting in suboptimal patient care, decreasing patient and professional satisfaction and even in an increase in medical errors. Long hours, fatigue and a narrow focus on work with consequent isolation can lead to withdrawal from normal society, predisposition to major depression, substance abuse and suicide. Physician burnout has serious consequences for individuals, the institutions of medicine and society; solutions for burnout are being pursued in all three arenas.

Aims to improve

Improving the health care workplace has been added to the traditional “triple aim” of medicine: better patient care, better population health and lower costs. The National Academy of Medicine has identified burnout in the health care workplace as a major problem, and has proposed new programs of research and education to address this serious situation. The AMA, state medical societies and other professional organizations including the American College of Cardiology, as well as hospitals and integrated health organizations, have introduced various strategies to enhance and restore professionalism and foster transparent organizational leadership necessary for team building and esprit de corps. Taking note of effective workplace practices employed in other industries from manufacturing to Silicon Valley, many hospitals are paying more attention to programs and physical amenities that foster employee wellness, updating the old “physician” lounge and dining area and ritual of grand rounds lectures to emphasize personal interaction and camaraderie, counteracting the tendency to isolate with a computer or smartphone, which both patients and colleagues find off-putting.

We must insist that future iterations of the EHR focus more on improving workflow and patient care and less on encyclopedic, repetitive, sometimes irrelevant and inaccurate details that interfere with, rather than facilitate, communication with patients and peers, and do not improve health outcomes. The digital revolution offers tremendous advances in information gathering, analysis and clinical decision-making but is very early in fulfilling that potential. Other institutional approaches to burnout include transparency in decision-making, dyad leadership, flexible scheduling and non-threatening discussions of burnout, physician wellness, compensation and medical errors.

Individual cardiologists also have personal responsibility for their own self-care and happiness. There is a life outside medicine. No matter how satisfying and demanding one’s job may be, prioritizing work over family and social life, leisure activities, hobbies and vacations can lead to burnout. In addition to following a healthy diet, many find regular exercise, mindful meditation, spiritual awareness and participation in volunteer activities leads to better interpersonal relationships in the workplace and more effective, empathetic interaction with patients. Individual and institutional awareness of the importance of burnout is the first step in effectively countering its negative effects on the practice of CV medicine.

Disclosure: Wann reports no relevant financial disclosures.