Editorial

Rheumatology and Burnout: Causes, Concerns and Hope

Leonard H. Calabrese
Leonard H.
Calabrese

The topic of burnout in medicine is certainly at the top of everyone’s list of critical issues. Consequently, we thought it timely that Healio Rheumatology take a deep dive into burnout in rheumatology by gathering an outstanding expert panel.

A critical question to begin with before we discuss causes and solutions, or even define burnout, is whether rheumatology providers are an afflicted population. This is easy, for burnout has no quarter, though as we will note, some specialties are more or less affected than others.

Burnout itself has varying definitions, but I consider it a combination of emotional exhaustion and depersonalization that often manifests as a cynical attitude in the workplace — the sense that we are ineffective in doing the thing we have chosen to do. Like the eminent jurist, Hugo Black, said on the topic: burnout, like pornography, may be difficult to define but we certainly recognize it when we see it in our colleagues. With this definition in mind it is curious — though the data are not always consistent — that the hardest workers are not necessarily the most burned out.

Surgeons, arguably are a group with formidable challenges in achieving work-life balance, yet are often rated as having lower than average rates of burnout, while ED physicians — who have great schedules — are often rated as among the highest. It should be no surprise that when we are doing what we love and maintain a fire in the belly for our work, we are buffered from burnout.

Reducing burnout




















So what are the root causes? As our panel discusses, there are personal issues, system issues and institutional issues all at play; however, for rheumatologists, one of the biggest is the electronic medical record. Like all cognitive specialties, we spend increasing amounts of our lives in front of the computer: writing our notes, placing orders, traversing the stops/warnings and roadblocks that often preclude us from even closing a note. I analogize our increasingly “tricked-out” EMR to an experience in an escape room where you have to find the right hidden button to get out! The EMR has increased, literally and figuratively, the distance to what has traditionally been the source of joy for doing what we do, namely, the patient.

If you have not already, I encourage you to read Atul Gawande’s treatise, “The Upgrade: Why doctors hate their computers,” in the Nov. 12, 2018 issue of The New Yorker — he really lays it out. This is not to say that I do not recognize some of the EMR’s redeeming qualities in terms of patient safety, but for those of us who are daily users, the sheer volume of blather that now constitutes what we informally recognize as “EMR speak” is depressing.

Formerly, in the handwritten note era, our clinical notes represented our internal thinking as to what we considered important to patient care, and evidence for this has recently been provided by Downing and colleagues in “Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause,” published in the May issue of Annals of Internal Medicine. In this article we are reminded that in the United States, the EMR is primarily a billing tool that is designed to satisfy the master of the ex-checker by including as many components as possible to justify higher reimbursement. As a result, and as Downing and colleagues clearly demonstrate, our EMR notes in the U.S. are often a log phase lengthier than EMR notes in other developed countries where the EMR is only a tool for patient care.

Solutions have been proffered widely, including at my own institution, which is increasing the use of scribes and other intermediaries to reduce our screen time and spend more time with patients. Of course, such solutions require even greater productivity to pay for themselves and perhaps this just may be worth it in order to bring us back to our source of satisfaction, ie, the patient. However, as Gawande points out, it all seems just a little bugnutty that the EMR was introduced to replace paper with computers and now we are hiring more humans to rescue us from our runaway computers!

If you want to find out how we actually arrived here, read Robert Wachter’s The Digital Doctor — I would do it while sipping a glass of Scotch, for you will need to have your nerves calmed as to how it has occurred.

Rheumatology though, by all accounts, is still a pretty fine place to be. Our fellowship applications have risen dramatically and just about every program director I know is bowled over at the increased quality of our incoming fellows compared to the dark days of a generation ago. Similarly, among the varying polls that attempt to codify who is the most (and least) burned out among specialties, several show us as among the happiest of all specialties and I tend to agree despite the challenges.

It is my belief that rheumatologists, including advanced practitioners in our field, still take joy in the daily pattern of patient care. I have heard repeated comments from colleagues which go something like “I am so much happier when I can just take care of patients.” I think what is unsaid is that this refers to those quality moments of hearing their stories, empathizing and coming up with solutions rather than logging into the EMR and trying to bail from the escape room screen.

To buffer and even reduce our threat of burnout, solutions are needed that emanate both from the providers, as well as from the institutions for whom we work: not just one or the other. Share your insights and stories with me about burnout at calabrl@ccf.org or through Twitter @LCalabreseDO.

Disclosure: Calabrese reports serving as an investigator and a consultant to Horizon Pharmaceuticals.

Leonard H. Calabrese
Leonard H.
Calabrese

The topic of burnout in medicine is certainly at the top of everyone’s list of critical issues. Consequently, we thought it timely that Healio Rheumatology take a deep dive into burnout in rheumatology by gathering an outstanding expert panel.

A critical question to begin with before we discuss causes and solutions, or even define burnout, is whether rheumatology providers are an afflicted population. This is easy, for burnout has no quarter, though as we will note, some specialties are more or less affected than others.

Burnout itself has varying definitions, but I consider it a combination of emotional exhaustion and depersonalization that often manifests as a cynical attitude in the workplace — the sense that we are ineffective in doing the thing we have chosen to do. Like the eminent jurist, Hugo Black, said on the topic: burnout, like pornography, may be difficult to define but we certainly recognize it when we see it in our colleagues. With this definition in mind it is curious — though the data are not always consistent — that the hardest workers are not necessarily the most burned out.

Surgeons, arguably are a group with formidable challenges in achieving work-life balance, yet are often rated as having lower than average rates of burnout, while ED physicians — who have great schedules — are often rated as among the highest. It should be no surprise that when we are doing what we love and maintain a fire in the belly for our work, we are buffered from burnout.

Reducing burnout




















So what are the root causes? As our panel discusses, there are personal issues, system issues and institutional issues all at play; however, for rheumatologists, one of the biggest is the electronic medical record. Like all cognitive specialties, we spend increasing amounts of our lives in front of the computer: writing our notes, placing orders, traversing the stops/warnings and roadblocks that often preclude us from even closing a note. I analogize our increasingly “tricked-out” EMR to an experience in an escape room where you have to find the right hidden button to get out! The EMR has increased, literally and figuratively, the distance to what has traditionally been the source of joy for doing what we do, namely, the patient.

If you have not already, I encourage you to read Atul Gawande’s treatise, “The Upgrade: Why doctors hate their computers,” in the Nov. 12, 2018 issue of The New Yorker — he really lays it out. This is not to say that I do not recognize some of the EMR’s redeeming qualities in terms of patient safety, but for those of us who are daily users, the sheer volume of blather that now constitutes what we informally recognize as “EMR speak” is depressing.

Formerly, in the handwritten note era, our clinical notes represented our internal thinking as to what we considered important to patient care, and evidence for this has recently been provided by Downing and colleagues in “Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause,” published in the May issue of Annals of Internal Medicine. In this article we are reminded that in the United States, the EMR is primarily a billing tool that is designed to satisfy the master of the ex-checker by including as many components as possible to justify higher reimbursement. As a result, and as Downing and colleagues clearly demonstrate, our EMR notes in the U.S. are often a log phase lengthier than EMR notes in other developed countries where the EMR is only a tool for patient care.

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Solutions have been proffered widely, including at my own institution, which is increasing the use of scribes and other intermediaries to reduce our screen time and spend more time with patients. Of course, such solutions require even greater productivity to pay for themselves and perhaps this just may be worth it in order to bring us back to our source of satisfaction, ie, the patient. However, as Gawande points out, it all seems just a little bugnutty that the EMR was introduced to replace paper with computers and now we are hiring more humans to rescue us from our runaway computers!

If you want to find out how we actually arrived here, read Robert Wachter’s The Digital Doctor — I would do it while sipping a glass of Scotch, for you will need to have your nerves calmed as to how it has occurred.

Rheumatology though, by all accounts, is still a pretty fine place to be. Our fellowship applications have risen dramatically and just about every program director I know is bowled over at the increased quality of our incoming fellows compared to the dark days of a generation ago. Similarly, among the varying polls that attempt to codify who is the most (and least) burned out among specialties, several show us as among the happiest of all specialties and I tend to agree despite the challenges.

It is my belief that rheumatologists, including advanced practitioners in our field, still take joy in the daily pattern of patient care. I have heard repeated comments from colleagues which go something like “I am so much happier when I can just take care of patients.” I think what is unsaid is that this refers to those quality moments of hearing their stories, empathizing and coming up with solutions rather than logging into the EMR and trying to bail from the escape room screen.

To buffer and even reduce our threat of burnout, solutions are needed that emanate both from the providers, as well as from the institutions for whom we work: not just one or the other. Share your insights and stories with me about burnout at calabrl@ccf.org or through Twitter @LCalabreseDO.

Disclosure: Calabrese reports serving as an investigator and a consultant to Horizon Pharmaceuticals.

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