On Point: Responding to Burnout Today (Without Burning Out Ourselves) by Dr. Damian McHugh

On Point submissions are individual member viewpoints and not North Carolina Medical Society policy.

Dr. Damian McHugh, MD

Are you burnt out on burnout? Many clinicians are. They are tired of hearing about burnout without meaningful guidance to ease their personal pain. Dike Drummond at The Happy MD postulates that, like politics, “all burnout is local.” If that’s true, walk with me for a few minutes through the current burnout landscape in the great state of North Carolina, our collective home and the place that we live and serve.

There are over 40,000 medical providers (MDs, DOs) licensed by the NC Medical Board, with over 14,000 or so practicing out of state. If the data published by the Mayo Clinic are somewhere close to correct, 60% of these providers are functioning daily despite shouldering significant burnout. Depending on the source you use for mortality data, approximately 400 medical providers take their own life each year, and a significantly higher number of nurses sadly succumb to that same tragic end.

Based on Freudenberger and Maslach’s early 1980s work, I want to reiterate for the purposes of this piece, that true job-related burnout is that triple whammy of ICE-—Inefficacy, Cynicism with callous dehumanization, and Exhaustion that frequently overwhelms those of us who are involved in caring professions. The tip of the burnout ICEberg is what we see; however, there is much more below the waterline. We know this dilemma also encroaches into the C-suite of companies within and outside of healthcare.

Research and policy literature is chock full of well-written summaries published previously by subject matter experts, including the National Academy of Medicine, the Federation of State Medical Boards, the Surgeon General, as well as multiple other bodies on this topic. So there is no need to assume that there is something new under the sun when it comes to this issue. Numerous State Medical Societies, hospital systems, such as Stanford or Mayo Clinic, and even the American Medical Association, among other stakeholders, have also weighed in heavily to describe this pervasive dilemma and suggest temporizing factors. There is no doubt that you have seen at least one, possibly more, of these papers.

Given that the House of Medicine and its ancillaries have been describing, studying, and lamenting this deleterious and destructive process for close to fifty years, the question I repeatedly have asked myself is, “Why does the chasmic width of the ‘data-action gap’ seem to be growing precipitously as time ticks on?” If so much has been researched and published about the causes of burnout, why then, even in the presence of a coronavirus pandemic, has the discussion escalated in parallel with the complexities of our medical system with little to no resolution?

The U.S. Surgeon General, Dr. Vivek Murthy has even identified this crisis as a threat to America’s present health and economic security. My personal worry, as a former practicing physician who is now a leader for a firm that serves its physician owners, is that it may already have become an existential threat to the future provision of NC healthcare services.

Six Key Drivers of Physician Burnout

Maslach originally identified six key drivers of burnout in physicians. Below, I’m parsing in some of my feelings and observations on top of hers.

1. Work overload – The current genre of EHRs bring information overload, task overload with CPOE, and stimulus overload from alarms and flashes. I ask nonmedical friends who bring up this item at dinner parties, “Would you expect the pilot of your 747 to take the fares, scan your boarding pass, give out the peanuts and give you the safety demo before take-off?”
2. Lack of control – Key healthcare decisions are often regulated by a cadre of bean-counters and micromanagers at health insurance companies and within large employer systems. As such, the autonomy and joy in medical decision-making has been eroded as medical care has been commoditized.
3. Insufficient reward – The reputation and recognition once associated with our noble profession has been eroded. Patients question our integrity and wonder if we truly have their interests at heart, or simply our own paychecks.
4. Absence of fairness – A close friend of mine tells his teens, “Fair is what happens for two weeks in Raleigh in the Fall. Pay $10 and buy a ticket.” Most docs know that life is not fair, and health inequities alongside concerns of race, poverty, religion, and gender do little to make this aspect of our vocation easier to accept.
5. Conflicting values – Moral distress is said to occur when one has made a professional judgement but is unable to act upon it. Should a payer contract direct a test or treatment that the doctor knows is ineffectual, it’s distasteful for them to compromise their principles for the sake of the purse of an insurer. Moral distress is a term borrowed by Wendy Dean from early psychology and military literature, and I believe it has some value, but I can’t quite be as vocal as ZdoggMD. I also know that our colleagues in hospital C-suites must be our allies, not our enemies, as we fight together to tame the flame.

6. Breakdown of community – In offices and hospitals, we worship at the altar of the computer screen. Water cooler and coffee cup conversations between doctors sharing care have evaporated as we leave messages and recommendations deep within a computer system that few have time to sift through. Physicians seem to have few friends and even fewer opportunities to organize, share, and band together to fight what we know ails our broken system.

Six Ways We Can Respond to Burnout

In response to these drivers, I suggest a similar six-fold approach to responding to clinician burnout in North Carolina.

1. Create an environment where clinicians feel safe to admit if they feel broken and are unable to manage their typical daily tasks. Our failure to fess-up to the paralyzing chronic stress that precipitates burnout can cost a life—our patient’s or our own. It’s OK not to be OK, as Naomi Osaka stated in a Times magazine feature story. This includes providing support and cover for one of your partners or colleagues if they voice trembling knees or a failing spirit. That is how you begin the shift of organizational culture. What goes around comes around.
2. Be the change you want to see in our profession/world. There has always been strength in numbers, and any chain is only as strong as its weakest link. The more people who are speaking out either in support of colleagues or advocating for themselves, the more we normalize the conversation and ebb away the stigma of needing assistance with mental health.
3. Familiarize yourself with the state medical board. Oftentimes, there is guttural fear of the medical board. Fortunately for us, since 1859, we have been overseen by the NCMB and are still afforded the privilege of self-regulation. I encourage fellow physicians to serve a term on the Board, or at least familiarize themselves with their policies in regards to wellness. Still not happy or reassured? Click here to read NCMB President John Rusher’s remarks in his Forum articles over the last year.
4. Familiarize yourself with the NCPHP. An ounce of prevention is better than a pound of cure. If you can, hold up your hand at the earlier stage of your burnout journey, knock on the back door of the PHP, and get help. Doing so may help you avoid heading very publicly in the front door of the PHP under direction of your superior, your spouse, a concerned coworker, or a regulator. Joe Jordan and Clark Gaither continue to improve and save many lives with their work at this organization.
5. Ask around. If you work in a small practice, check in with your medical society or community physician leaders. If you are part of a university or large health system, seek out the chief wellness officer or someone similar, offer to help, and ask questions or get a list of local resources. Your NCMS is a cofounder of the NC Coalition for Provider and Clinician Wellness and Resilience (NC CPR-W). This collaborative body will soon have its own website. The constituent members included the NC society of PAs are dedicated experts, many of them full- or part-time physicians. Watch this space, share any ideas with Monecia Thomas ([email protected]), and lastly, renew your NCMS membership. If you can’t fight the fight, know that there are many who can and are fighting right now, with your interests directly in mind. Duck under their shield and they’ll keep you partially covered.
6. Watch the national horizon for nuggets that can be applied at your home. I named some of the major thought leaders earlier. Others to be followed along with the AMA are the Lorna Breen Foundation, the American College of Emergency Physicians, and a whole host of folks who know way more about this crippling issue than you and I.

This is not easy and there is no simple or quick solution. However, I do believe that if we begin to start addressing the issue of clinician burnout from a perspective that moves beyond simply talking about the issue to applying what we have learned, we will move away from where we are now, which in my opinion is what the Rev. Dr. Martin Luther King Jr, referred to as the “paralysis of analysis,” to results-driven action.

Dr. Damian McHugh is a longtime NCMS member who practiced emergency medicine for 21 years in Raleigh, NC, and now serves as Managing Director, Physician Liaison, for Curi—a full-service advisory firm dedicated to helping physicians in medicine, business, and life.

Between Dec. 9, 2021, and Jan. 24, 2022, nearly 2,500 U.S. physicians responded to a survey by researchers from the AMA, the Mayo Clinic, Stanford University School of Medicine and the University of Colorado School of Medicine. The researchers found that, overall, 62.8% of physicians had at least one manifestation of burnout in 2021, compared with 38.2% in 2020, 43.9% in 2017, 54.4% in 2014 and 45.5% in 2011. These trends were consistent across nearly all specialties.

Published in Mayo Clinic Proceedings, the study, “Changes in Burnout and Satisfaction With Work-Life Integration in Physicians Over the First 2 Years of the COVID-19 Pandemic,”

No one specific source

by Randy Aldridge