What’s Really Ailing Physicians
June 23, 2022
John McCracken, PhD
For over a decade the term burnout has been used to describe the growing trend of physician distress. Stretched thin dealing with loss of autonomy and ever expanding administrative and regulatory burdens, physicians have increasingly reported feelings of frustration, exhaustion and reduced sense of accomplishment.
The term burnout was first coined almost a half century ago to describe symptoms of psychological exhaustion among those in emotionally demanding professional roles. Since then, it has become widely used to describe the increasing emotional distress reported by physicians. Many physicians, however, have resisted being characterized as burned out, citing a disconnect between what they’re experiencing and what the term implies.
Burnout suggests that the problem resides within the individual, who in some way is incapable of dealing with the demands of the workplace. It implies a lack of resilience and internal resources required to withstand the work environment. Hence, many of the proposed solutions focus on wellness, stress management and seeking emotional support.
The first step in dealing with this epidemic of physician distress, however, is to accurately identify what‘s causing it. A more accurate diagnosis may be moral injury. Moral injury is the consequence of being forced to behave in ways that transgress an individual’s deeply held values and beliefs. Physicians are trained and deeply committed to their oath of putting the needs of their patients first. But in deciding on treatment, they are increasingly forced to consider the demands of other stakeholders—including insurers, hospitals, regulatory agencies and corporate employers—which may be in conflict with their idea of the patient’s best interests. Navigating an ethical path through multiple competing interests is emotionally exhausting. The moral injury that results from providers being forced to act in ways that contravene their deeply held beliefs about how to deliver the best care possible can be a significant factor in causing a loss of resilience and emotional fatigue.
There are two important trends that have contributed to this situation: the rise of the healthcare kludgeocracy, and the accelerating trend toward physician corporate employment.
Healthcare Kludgeocracy
A dictionary definition of a kludge is “an ill assorted collection of parts assembled to fulfill a particular purpose…a clumsy but temporarily effective solution to a particular fault or problem.” A kludgeocracy is an apt description of healthcare. It’s become an industry built on patches and quick fixes, where complex problems are dealt with in haphazard ways lacking any obvious principle of consistency. This is the result of a political culture that combines a long-standing American preference for market-based solutions with a public that simultaneously thinks that most important issues should be subjects of government action and oversight. The attempt to preserve a market orientation while at the same time be a kind of social welfare state has resulted in policy complexity and dysfunction.
A textbook example is the Affordable Care Act. It seeks to preserve a market-based system for the organization, financing and delivery of healthcare services. Yet at the same time, 906 pages of legislative language and 265 major rules comprising over 9,000 pages of regulations have created a mind-numbing level of overarching complexity. Forced to bend to the demands of confusing and often conflicting administrative and regulatory constraints, healthcare providers face increasing barriers to putting the needs of their patients first.
Organizational Control
A second development that has contributed to moral injury has been the trend toward corporate ownership of physician practices. Important goals of most private sector business organizations—including both for-profit and non-profit—include financial profitability, market share and growth. Most healthcare organizations are structured as professional bureaucracies, where process efficiency and standardization of skills are important to achieving these objectives. Process efficiency focuses on reducing waste, lowering cycle time and increasing throughput. Standardization of skills is manifest in physician report cards whose objective is to limit provider outliers. All of these measures—whether socially desirable or not—serve to reduce physician autonomy and limit provider flexibility.
A recent Avalere survey of physician employment estimates that 74% of all physicians are now employed by a hospital, health system or other corporate entity, a percentage that continues to rise. Corporate employment virtually never turns out to be a haven for greater professional autonomy and decision-making flexibility. There is no shortage of doctors who have opted for corporate employment who subsequently found that what they expected and what they discovered turned out to be far apart.
Dealing with Moral Injury
Dealing with moral injury will not be simple, nor will it happen quickly. The long-term solution requires a healthcare environment that acknowledges the value of the physician-patient relationship and trusts physicians’ judgment in putting their patients’ interest first.
Physicians need to recognize the true source of their frustration and empower their leadership to communicate effectively on their behalf with administrators and legislators about the needs of patients. A more difficult challenge will be reestablishing a sense of community among clinicians, including doctors, nurses and advance practitioners. That historical sense of community has been eroded by increasing stress levels and internal competition for resources and patient referrals, but reestablishing it is an essential step in delivering patient-centric care.
Effective change has to be a bottom-up process, starting within the individual clinic or organization. The clinicians within the organization first have to acknowledge that they are all working together toward a common goal of providing patients the best care possible. Leading a rekindling of that common, shared interest is and always will be an essential task of physician leadership.
John McCracken is Clinical Professor of Healthcare Leadership and Management in the Jindal School of Management, The University of Texas at Dallas.