Burnout, Not Otherwise Specified: Defining, Addressing Rheumatologist Burnout
Across the country, practicing physicians are experiencing increasing levels of burnout, and rheumatologists are no different, according to national data and experts in the field.
Burnout — which occurs when work or personal pressures exceed an individual’s ability to cope with them — can manifest as physical and mental responses. Long-term, unaddressed burnout among clinicians can have devastating consequences, including chronic health conditions, emotional exhaustion, cynicism, a low sense of professional accomplishment, diminished quality of care and increased likelihood of early retirement.
Reasons for burnout are as myriad as there are physicians describing the problem. However, some of the most common culprits include the rise of electronic health records and a perceived distancing away from what many physicians see as their primary role — patient care.
“Rheumatologists treat patients with chronic and complex diseases,” Colin C. Edgerton, MD, FACP, chairman of the American College of Rheumatology Committee on Rheumatologic Care, and partner at Articularis Healthcare, which has practices in South Carolina and Georgia, told Healio Rheumatology. “It is particularly difficult to manage these complex patients in an environment that does not value the cognitive workload involved.”
He added, “Examples include electronic medical records that do not offer easy documentation — but are instead often designed for clicking through algorithms intended for simpler medical problems — and undervalued evaluation and management codes for non-procedural physicians such as rheumatologists.”
However, although it is often cited that as many as half to two-thirds of practicing physicians in the U.S. are experiencing burnout, the definition for what burnout actually is remains widely inconsistent.
For instance, a recent study published in JAMA by Liselotte N. Dyrbye, MD, and colleagues found that 45.2% of second-year resident physicians experienced burnout, and 14.1% expressed regret in their choice of career. Yet, a systematic review published in JAMA that same month, by Lisa S. Rotenstein, MD, MBA, and colleagues, found that anywhere from 0% to 80.5% of physicians experience burnout based on which definition of the term was used.
According to Rotenstein, a resident physician in internal medicine at Brigham and Women’s Hospital, there has been a greater research focus on measuring and understanding burnout coincident with realization of its high prevalence.
“What we focused on in our JAMA paper is what we collectively mean by burnout,” Rotenstein told Healio Rheumatology. “We systematically searched literature from across the world, realizing that there are many different definitions of burnout, and significant variation in how this phenomenon is being measured.”
However, she added that despite such differences, there are many factors that contribute to burnout, regardless of how it is measured.
Not ‘Allowed’ to be Doctors
According to Edgerton, physicians, including rheumatologists, are happiest when they are “allowed to be doctors,” noting that physicians relish accurate diagnoses and relieving patient suffering.
However, he added that aspects of the job that inspire considerably less good will include EHRs, prior authorizations, coding problems and “trying to make ends meet.”
“Rheumatologists prescribe expensive medications often requiring prior authorizations,” Edgerton said. “The time required to complete these and the disruption of the physician-patient relationship and shared decision-making degrade the experience and satisfaction level of rheumatologists.”
Jonathan Ripp, MD, MPH, senior associate dean for well-being and resilience at the Icahn School of Medicine at Mount Sinai, said that while there is limited literature on burnout specifically among rheumatologists, the trends that drive well-being among physicians, and the lack thereof, tend to be common across medical fields.
“Think about it in terms of drivers — what is impacting the typical clinician, or typical rheumatologist, in terms of what would make them feel good about their work, and what are the suboptimal things that lead to burnout?” Ripp said. “We tend to look at work hours and work demand, but that is only one piece of a complex puzzle. That alone is not what is driving burnout.”
In their much-lauded and widely endorsed “Charter on Physician Well-being” commentary published in JAMA in 2018, Ripp and colleagues identified “meaningful work, strong relationships with patients, positive team structures and social connection at work” as important factors for satisfaction among doctors. According to Ripp, there is a sense of a loss of control and flexibility in the workplace that has contributed to burnout among physicians.
“If you enter a health system where you feel enabled to get the job done, you are more likely to derive meaning from that work and have a greater sense of well-being,” he said. “If you work somewhere in which the balance is shifted so that you are spending 2 hours each night catching up on notes after you get home, attending to clerical responsibilities and feel like you have no time with your patients, then you are going to be at greater risk.”
According to Neda Gould, PhD, an assistant professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine, and and director of the mindfulness program at Johns Hopkins, another contributor to burnout is that physicians commonly find themselves without the resources needed to meet the modern demands of the profession.
Demands include the constant pressure to see more patients while also being expected to complete increasing amounts of nuanced documentation for each of those patients.
“For physicians, in general, there are many factors that can contribute to burnout,” Gould said. “The most obvious may be the excessive workload placed on them — for example, the need to see many patients in short periods of time and electronic health record documentation. This excessive workload can interfere with self-care. These factors, coupled with the culture of the workplace and individual characteristics, can be a recipe for burnout.”
‘Technically Accurate and Medically Useless’
More than any other factor, EHRs attract the most blame and vitriol from physicians as a contributor to burnout.
According to Thomas L. Schwenk, MD, dean of the University of Nevada School of Medicine, EHRs are generally seen among physicians to be chiefly designed by “financial and legal people, for financial and legal purposes,” and contribute very little to the quality of care.
With some notable exceptions, the general state of affairs for most physicians, and most practices, is that EHRs represent an “incredible burden,” he added.
“There is a saying that EHRs contain information that is technically accurate but medically worthless,” Schwenk said. “There are no guts to them. You have all of the information there, for documentation, for billing, for legal purposes, yet you can read it and have no idea what actually happened in the encounter with the patient. I think it has created a lot of chaos.”
Schwenk believes that the key problem with EHRs is that they were never designed to capture the essence of medical care, but rather to have a certain legalistic approach to documentation.
Rotenstein identified EHRs as a systemic factor that contributes to burnout, adding that physicians are increasingly spending more time attending to clerical work rather than with their patients.
“I would say this is a key part of the issue,” she said. “We must ask ourselves whether we are enabling physicians to have those relationships and interactions with patients that make medical careers meaningful. Or is the system creating additional pressure that strips away that meaning and inevitably contributes to burnout?”
According to Rotenstein, there is evidence suggesting that for every hour physicians spend with patients, they could spend triple that amount subsequently documenting that encounter in their EHRs. She added that the increasing focus on paperwork in medicine, whether it be prior authorization or other requirements, has been leading physicians away from their relationship with patients. This, combined with the constant pressure to increase productivity to sustain a clinical career along with shorter time available to see each patient, exacerbates the problem.
“It is a significant amount of busy work,” Ripp said. “First of all, the way in which we document has changed dramatically in the past decade or two. The visit note used to serve two purposes: First, it served the actual provider so the next time they see the patient, they have a record of what they did. Second, it served as a means of communication, because as a rheumatologist, you could send it to a consultant or to the primary care doctor. A very small percentage of what we do in terms of documentation through EHRs meets that requirement; instead, the vast preponderance of what we do with documentation now are checklists of information that are included so that we can bill at a certain level and keep the health systems afloat.”
“It has really drifted far away from the original intent,” Ripp added. “All day long you are being asked to complete notes and input information, sometimes repeatedly, for the purposes of billing. That can be a source of extreme drudgery.”
Underlying Causes of Burnout
Despite the focus many physicians and researchers place on EHRs and other factors in terms of burnout, these may merely be a symptom, rather than an underlying cause of what is actually ailing the medical profession, according to Schwenk.
Much of what is attributed to burnout can instead be ascribed to the profit-focused mechanisms of the U.S. health care system, and how it is affecting work satisfaction and the physician-patient relationship, he said.
“Much of the other research is focused on external factors — such as EHRs, demanding patients, regulatory issues and management, financial issues — as causing great stress on physicians, and I don’t quite buy that,” Schwenk said. “There have always been stresses and we have always worked hard, and medical practices have always been stressful — and always will be.”
Schwenk instead described burnout itself as a catch-all for various troubles and work dissatisfaction experienced by physicians navigating a medical system that has alienated them from the work they had originally set out to do.
“I have taken to calling it — similar to the DSM in psychiatry — ‘misery not otherwise specified,’” he said. “There is a clear level of misery and work dissatisfaction among physicians, and I think it has to do with the way the health care system has become so commercialized and so monetized that it is causing enormous distress to the physician-patient relationship, to the physicians themselves and to the actual delivery of care.
“That is where the misery comes from,” Schwenk added. “I think what has to happen, in general, is that the medical profession has to take back the system. I don’t have a clue how that would happen, but health care in the U.S. has become so expensive and so incredibly commercialized that we have lost track of what I think was the point of medicine in the first place — taking care of the patient.”
Trickle-down Impact on Patients
Regardless of how it is defined, there is considerably less debate among researchers and physicians regarding the effect of burnout on patient care. Previous research has demonstrated that physician burnout can lead to suboptimal care, lower patient satisfaction, decreased access to care and increased costs.
“This is the really important point,” Rotenstein said. “There is evidence that physician burnout is associated with medical errors, with patients perceiving lower quality of care and with lower quality of physician interactions. Burnout has an effect not only on the care patients receive, but also on how patients perceive their care and overall satisfaction with their care. Burnout is not just a physician issue and not just a practitioner issue, but ultimately impacts the care we deliver and how patients feel about the care they are getting.”
According to Ripp, the literature is definitive.
“There are so many examples of this, because burnout is so common and because these drivers are so common,” he said. “Most patients can probably recount an experience they have had with someone who was burned out. The physician walks into the room and seems rushed, they seemed not to be caring much about the patient, spending a short amount of time with them, much of which was spent looking at the computer.”
The stress and emotional toll exerted by daily practice may also cause physicians to experience what some have described as “compassion fatigue,” or an emotional exhaustion, which often “overlaps with burnout,” Ripp said.
This, he added, is troubling as it can lead physicians to depersonalize their patients, worsening the quality of care. “Burnout has a depersonalization component, in which you stop seeing people as people,” Ripp said.
According to Rotenstein, physicians are privy to and experience many emotionally challenging experiences on a daily basis, including difficult social situations and death and suffering. Although all physicians enter medicine with compassion, the rigors of daily practice combined with burnout could potentially lead to depersonalization with patients.
“You have lower compassion and you are less able to show it in situations where it is appropriate and where you might have in the past,” Rotenstein said. “That is actually a key component of burnout as it is currently defined. There is emotional exhaustion, and there is depersonalization. Lastly, there is the loss of personal accomplishment.”
Choosing Healthy Coping Strategies
Burnout and compassion fatigue can lead to some poor, ill-advised and sometimes dangerous coping mechanisms, according to researchers. According to Edgerton, among the first entities physicians typically target when feelings of dissatisfaction arise are organized medical groups, such as the AMA and the ACR.
“When faced with adversity, there is a tendency to ‘circle the wagons’ instead of taking the more difficult, yet more effective step of working together to advocate constructively. Targeting our physician organizations weakens our position.”
However, Edgerton advised against this, as such organizations can be important tools for enacting positive change, he said.
“It takes some time and effort to make a meaningful difference by working through organizations such as the AMA and the ACR, but it is well worth the effort,” Edgerton said. “Advocating in an organized fashion, such as maintaining memberships in the ACR, AMA, state and local medical organizations — and volunteering for leadership in these entities — can help,” Edgerton said. “Only by working to improve the environment of medicine through physician leadership will we see positive change.”
Some physicians, when faced with burnout, turn to maladaptive behaviors, including isolating themselves, making unhealthy food choices, alcohol and drug abuse, Gould said. These behaviors may seem helpful in the moment, but involve serious long-term health hazards that often lead to greater impairment, thus magnifying the problem, she added.
“I think self-care needs to be a priority in order to prevent and combat burnout,” Gould said. “However, this is often the most overlooked and hardest to prioritize.”
According to Gould, mindfulness and stress management techniques can help physicians reduce burnout and maintain a proper work-life balance. At the institutional level, changes in the work environment can reduce the burden on physicians. Additionally, activities such as engaging in mindfulness programs and facilitated reflection groups, where physicians meet with peers and discuss the stressful aspects of their work, have been associated with less burnout.
Other individual-level ways to prevent and lessen burnout can include creating space and time for one’s self, Rotenstein said.
“This means limiting pajama time — when you come home after a 10-hour day and then you work on the EHRs and all of the other documentation that you didn’t get to finish,” she said. “That doesn’t leave time for whatever wellness means for that individual.”
However, according to Ripp, the burden should not be on the individual to address burnout; that responsibility lies chiefly at the administration and regulatory level.
The use of medical scribes and speech-to-text software that allow dictation, for example, can reduce the EHR documentation burden for physicians, while improving workflow and job satisfaction, and enhancing physician-patient interactions, as demonstrated by Mishra and colleagues in JAMA Internal Medicine.
Additionally, a team-based approach to care could allow a physician to make the high-level clinical decisions while other responsibilities, such as prior authorization and other documentation needs, could be delegated to medical assistants, Rotenstein noted.
“What can be done? Health systems can start directing resources toward improving the efficiency aspects of the workplace, that will enable you to do your best work, and in doing so derive greater meaning, more professional fulfillment and less burnout,” Ripp said. “There are things individuals can do, and we do have a shared responsibility — we should want to perform self-care and not feel ashamed about it — but the emphasis should not be that it is the physician’s responsibility to get better. The onus is on the system.”
Ultimately, however, any changes, either enacted by administration or governmental entities, must be scrutinized to ensure that they do not add to the burden currently faced by physicians, Edgerton said.
“Any new requirements that are foisted on clinicians must be scrutinized as to the impact on physician workflow and bandwidth,” he said. “Too often, we add requirements without realizing that there is no more time in a physician’s day for these things to be done without further degrading the care of patients.”
At a Tipping Point
According to two recent studies published in Arthritis Care and Research and Arthritis and Rheumatology, the need for rheumatologists will greatly exceed the specialty’s expected workforce growth during the next 15 years, suggesting that a significant rheumatologist shortage is looming.
An increasing deficit of rheumatologists, combined with the effects of widespread physician burnout, could lead to a potential workforce crisis in the coming years, Edgerton said.
“We cannot afford to lose anyone,” he said. “Patient access to care suffers when burnout reduces workforce numbers and productivity. This is the type of problem that can definitely pass a ‘point of no return.’”
According to Schwenk, “while the morale of the medical profession has hit a low point, the fundamental value of what physicians do will always prevail.” However, in the short-term, the low morale is affecting the career choices of medical students.
“I think we are already seeing this — students are choosing disciplines that they think come with more satisfaction and less stress,” he said. “They are going into radiology, dermatology, anesthesiology and emergency medicine — where they believe there is more control over their time and less stress. This contributes to shortages in many of the medical specialties, and many of the pediatric subspecialties, adult and pediatric rheumatology being two of the major ones, as well as primary care.”
In addition, burnout has already caused physicians to cut back the number of hours that they work, exacerbating physician shortages, Rotenstein noted.
Further, she said she believes this situation could potentially lead to a “reevaluation of what it means to provide care in the modern medical era.”
“As physicians, we have many responsibilities, and many priorities,” she said. “That includes serving our patients while also being available as much as possible, completing necessary paperwork, and being stewards of resources. There is going to be a reevaluation to figure out what the balance of all those things looks like, so we don’t have to have pajama time every night. I’m not sure what that will look like in the long-term, but it’s important that we have started the ongoing discussions about that.”
However, current trends must change soon, Edgerton stressed, or else physicians — including rheumatologists — could be even further squeezed.
“We are at a tipping point,” he said. “Recent developments such as the CMS proposal to reduce reimbursement and thereby devalue the E/M codes used by rheumatologists make me deeply concerned about the future of the specialty and its ability to attract new physicians — they are very sensitive to these perceived stresses on the practice of rheumatology.” – by Jason Laday
- Battafarano DF, et al. Arthritis Care Res. 2018;doi:10.1002/acr.23518.
- Bolster MB, et al. Arthritis Rheumatol. 2018;doi:10.1002/art.40432.
- Dyrbye LN, et al. JAMA. 2018;doi:10.1001/jama.2018.12615.
- Mishra P, et al. JAMA Intern Med. 2018;doi:10.1001/jamainternmed.2018.3956.
- Rotenstein LS, et al. JAMA. 2018;doi:10.1001/jama.2018.12777.
- Schwenk TL, et al. JAMA. 2018;doi:10.1001/jama.2018.11703.
- Thomas LR, et al. JAMA. 2018;doi:10.1001/jama.2018.1331.
- For more information:
- Colin C. Edgerton, MD, FACP, can be reached at 2001 2nd Avenue, Suite 201, Summerville, SC 29486; email: firstname.lastname@example.org.
- Neda Gould, PhD, can be reached at 5300 Alpha Commons Drive, Baltimore, MD 21224; email: email@example.com.
- Jonathan Ripp, MD, MPH, can be reached at 1 Gustave L. Levy Pl., New York, NY 10029; email: firstname.lastname@example.org.
- Lisa S. Rotenstein, MD, MBA, can be reached at 75 Francis St., Boston, MA 02115; email: email@example.com.
- Thomas L. Schwenk, MD, can be reached at 1664 N. Virginia St., Reno, NV 89557; email: firstname.lastname@example.org.
Disclosures: Edgerton, Gould, Ripp, Rotenstein and Schwenk report no relevant financial disclosures.