Physician Burnout and Stress While Interacting with Patients
Am Fam Physician. 2019 Nov 1;100(9):537-539.
Case #1. A 25-year-old patient presents to your clinic with viral upper respiratory tract symptoms that have been present for two days. The patient requests antibiotics based on her experience of past care at a local retail clinic. Antibiotics are not indicated; however, you oblige, recognizing that the patient may choose other health care options for future care, including retail and urgent care clinics. You also fear that the patient will give you poor patient-satisfaction ratings in the postvisit survey conducted by your hospital employer and on online physician-review sites.
Case #2. A 67-year-old patient with poorly controlled type 2 diabetes mellitus presents to your office for her quarterly follow-up appointment. Her A1C level remains high at 9.6%. The patient tells you that she is unable to afford the insulin you prescribed because she is in the Medicare Part D “doughnut hole.” You empathize with the patient's dilemma, but you are inwardly concerned that her misfortune will adversely affect your quality scores and Medicare Shared Savings Program status.
Case #3. A 54-year-old patient presents for a consultation regarding ongoing fatigue and myalgias related to her fibromyalgia diagnosis. While you are typing into the electronic health record, she asks whether you are listening. She then challenges your recommendations with information from online sources, including message boards and blogs. You respond by stating that you cannot help her if she does not want your opinion or expertise. You immediately regret your words and apparent lack of compassion.
Physicians, especially family physicians, face multiple stressors in modern medicine that can lead to disillusionment and burnout, which occur when the reality of practicing medicine does not match physicians' previous naive expectations. Physician burnout is a syndrome that includes emotional fatigue, cynicism, depersonalization, and a loss of meaning in work. Nearly 43% of American physicians, including 54% of primary care physicians, exhibit at least one symptom of burnout.1 The emotional, mental, and physical toll associated with burnout places physicians at risk of developing mental health issues, such as depression and substance abuse.2,3 Furthermore, ongoing emotional distress causes physicians to be at higher risk of suicide. Male physician suicide rates are currently 1.4 times that of the general population, and nearly 300 physicians annually take their own lives. Female physicians are even more vulnerable to suicide, with rates 2.3 times higher than the average for women in the general population.4
Burnout adversely affects the ability to provide quality care to patients, even to the point of becoming a public health crisis. One study showed that self-reported major medical errors among surgeons increased 3% to 10% as measures of burnout increased.5 Also, the risk of losing capable physicians through attrition or dysfunction will further affect patient care and access.
Studies have shown that patients of engaged physicians are more apt to adopt their physicians' recommendations and have greater compliance with clinical treatment plans.6 Some experts have proposed expanding the Triple Aim (enhancing patient experience, improving population health, and reducing costs) into the Quadruple Aim to include health care professionals' health and happiness as the fourth tenet.7 This transformation could reinforce the importance of ensuring that physicians stay healthy and professionally fulfilled.
Identifying the external and internal root causes of burnout and creating actionable initiatives and strategies may be a start in improving stress and physician morale. External factors include increased electronic health record documentation requirements; perceived loss of control and autonomy; medicolegal stressors; administrative tasks, including quality reporting, payer preapproval, and billing demands; a shift from professionalism to consumerism; patient access to online medical resources and physician reviewing platforms; and patient demands and expectations of physicians.2 Many patients regard the primary care physician as the face of American health care, resulting in transference of their frustrations with the entire system onto those front-line physicians.
Internal factors contributing to
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2. Shanafelt TD, Dyrbye LN, West CP. Addressing physician burnout: the way forward. JAMA. 2017;317(9):901–902.
3. Patel RS, Bachu R, Adikey A, et al. Factors related to physician burnout and its consequences: a review. Behav Sci (Basel). 2018;8(11):E98.
4. American Foundation for Suicide Prevention. Healthcare professional burnout, depression and suicide prevention. Accessed August 23, 2019. https://afsp.org/our-work/education/healthcare-professional-burnout-depression-suicide-prevention/
5. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995–1000.
6. Studer Q. Engagement is key to healing physician burnout. October 15, 2015. Accessed August 23, 2019. https://www.modernhealthcare.com/article/20151015/SUPPLEMENT/310159997/engagement-is-key-to-healing-physician-burnout
7. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573–576. Accessed September 30, 2019. http://www.annfammed.org/content/12/6/573.full
8. Nedrow A, Steckler NA, Hardman J. Physician resilience and burnout: can you make the switch? Fam Pract Manag. 2013;20(1):25–30. Accessed September 30, 2019. https://www.aafp.org/fpm/2013/0100/p25.html
9. Brennan J, McGrady A, Tripi J, et al. Effects of a resiliency program on burnout and resiliency in family medicine residents. Int J Psychiatry Med. 2019;54(4–5):327–335.
10. Armato CS, Jenike TE. Physician resiliency and wellness for transforming a health system. May 2, 2018. Accessed August 23, 2019. https://catalyst.nejm.org/leadership-development-program-physician-resiliency-wellness/
11. Moss M. Creating ever better ways to provide cost-effective care for our community: the coastal medical journey. In: Austin J, Bentkover J, Chait L, eds. Leading Strategic Change in an Era of Healthcare Transformation. Springer; 2016:107–118.
12. Lyon C, English AF, Chabot Smith P. A team-based care model that improves job satisfaction. Fam Pract Manag. 2018;25(2):6–11. Accessed September 30, 2019. https://www.aafp.org/fpm/2018/0300/p6.html
13. Smith TM. Ethics of physician well-being: what the AMA code says. April 12, 2017. Accessed August 23, 2019. https://ama-assn.org/delivering-care/ethics/ethics-physician-well-being-what-ama-code-says
14. Wellbery C. Curbing inappropriate antibiotic prescribing: what works? Am Fam Physician. 2016;94(3):203–204. Accessed September 30, 2019. https://www.aafp.org/afp/2016/0801/p203.html
15. Weiss BD. Communicating risk to patients who get their information from the internet. Am Fam Physician. 2019;100(5):306–308. Accessed September 13, 2019. https://www.aafp.org/afp/2019/0901/p306.html
Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to email@example.com. Materials are edited to retain confidentiality.
This series is coordinated by Caroline Wellbery, MD, associate deputy editor.
A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside.
Please send scenarios to Caroline Wellbery, MD, at firstname.lastname@example.org. Materials are edited to retain confidentiality.
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