Combating the Rise of Physician Dissatisfaction

Abstract:
“Job burnout is a special type of work-related stress — a state of physical or emotional
exhaustion that also involves a sense of reduced accomplishment and loss of personal identity.” -
Mayo Clinic 1​

Currently, there is a global crisis among physicians. As the need for healthcare professionals
continues to grow, society continues to overlook the soaring rate of “physician burnout” amongst
residents, surgeons, and general practitioners. Physician burnout refers to the lack of enthusiasm
that healthcare professionals have for their jobs. This professional fatigue can be directly
attributed to an increased in strenuous educational demands, an influx of invasive and laborious
regulations across the industry, and a misalignment of values between administrators and
physicians. A recent survey conducted by the National Institute of Health found that out of
15,000 practicing physicians, forty-two percent reported that they were suffering from symptoms
of burnout​ 2​. Not only does this put stress on physicians, but it often leads to a sacrifice in patient
care.

Doctors preoccupied with stress and emotional exhaustion are less likely to provide optimal
patient care, experience errors while practicing, and engage in more frequent and riskier
prescribing patterns​ 3​. The combination of these factors has culminated a healthcare environment
that is detrimental to physicians and patients alike. While the majority of medical practices have
identified job related burnout as an issue, most policies and regulations are currently aimed at the
symptoms of the problem and not the problem itself. It is essential to bring to light the increased
prevalence of physician burnout at the social, political, and educational levels so that patients and
doctors alike are put at less of a risk for future medical mishappenings.
Effects on Doctors:
Dissatisfaction amongst healthcare professionals most often results in increased feelings of
depression and exhaustion. However, with almost half of practicing physicians reporting that
they experience such feelings, it is not uncommon for the negative mindsets to fester, resulting in
even more extreme feelings of resentment for their professions. As a result, substance abuse and
suicide rates are becoming commonplace amongst practicing doctors 4​​ . As a result, more and
more physicians are choosing to leave the medical field. The American Medical Association of
Colleges expects that by 2030, the United States will be lacking more than 100,000 doctors​ 5​.
The reality of these challenges will become more evident as time passes. While the ​need​ for
physicians, surgeons, and general practitioners will remain, the ​availability​ of medical help may
not; it is clear that action must be taken to combat this crisis.

Effects on Patients:
When people are distracted by thoughts of anxiety or depression, mistakes become more
common. The same goes for physicians. When doctors experience feelings of resentment
towards their work, they are less empathetic towards their patients, and as a result, they
communicate less effectively. A survey of patient satisfaction found that out of the care
provided by physicians that reported feeling symptoms of burnout, their patients were twice as
likely to leave dissatisfied with their care​ 6​. This correlates to a lack of professionalism and
respect from patients as well as from peers. Increased levels of dissatisfaction result in
malpractice suits and other increasingly stressful factors adding to the problem at hand. All of
these factors lead to the question: what are the causes of this global dilemma, and what is being
done to combat it?

What Prompted Change in Working Policies for Physicians:

Long shifts and unpredictable working hours are a staple part of being a physicians. Illness does
not run on a clock. The Agency for Healthcare Research and Quality explains that less than
three decades ago, it was common
culture for residents to work 90-100
hour work weeks in order to gain
their right of passage into becoming
an attending​ 7​. Clearly, feelings of
fatigue from these long work weeks
resulted in an inability to provide the
utmost care for patients at all hours
of the day. Additionally, the long
hours, combined with long work
weeks encouraged fatigue of doctors
at all levels of the chain. It was not
until the death of an eighteen year old girl as a result of a medication prescribing error from a
resident at the end tail of a thirty-six hour shift that regulations were put into effect for resident
working hours​ 8​.

Implemented Policies Intended to Increase Physician Satisfaction:

In 2011, the Accreditation Council for Graduate Medical Education put an eighty hour
work week limit for medical residents. Additionally, residents were limited to
twenty-four hours shifts, as well as being required to receive at least one day off per
week​9​. While this showed to reduce reports of increased quality of life amongst
practitioners, it also correlated to the reporting of a lack of educational quality. Spending
less time doing rotations and spending more time sleeping or working out, while giving
physicians more personal time, severely hinders their ability to view a wide range of
patient cases.

Surprisingly, the limitation of hours allowed in a work week had little-to-no effect on
patient care or satisfaction​ 10​. Even more surprising was the reality that even physicians
were not happy with the consequences of these changes. Residency is one of the most
critical stages in the career of healthcare professionals. It is during this time that
physicians take their Board Exams. As a result, all professional exposure is more than
welcomed.

Instead of viewing time limits in a work week as a positive, many doctors viewed it as a
hindrance to their education. In 2014, a holistic view at the medical system showed that
residents had the lowest case volume of all time, and scored lower on certification exams
​ . On top of all of this, it is common for attendings to schedule their
than in the past 11​
residents over the eighty hour limit under the curtain, adding more stress to the already
highly-regulated schedules of residents.

Hours worked are not the only source of exhaustion and stress for physicians. Based on
an influx of lawsuits, regulations, and policies, doctors are now required to document
anything and everything that they come in contact with, including patients, surgical
instruments, and other staff. As an effect, physicians and residents have even less time to
spend with patients. The American Medical Association found that in 2017, doctors
spend an average of forty-four percent of their day documenting their cases 12​​ . The harsh
reality is that physicians did not go through more than a decade of schooling to sit at a
desk and type notes all day. Yet, as a result of the malpractice crisis, rigorous
documentation has become a compulsory part of the work day for all practicing
physicians.
 Suggestions to Improve Job Satisfaction:
The grueling workload of doctors directly affects the doctor-patient relationship. It is
clear that the limit on resident working hours was needed to combat safety mishaps and
doctor fatigue. While these regulations help address fatigue issues, they also augment the
stress associated with the academic demands of residents preparing for the Boards. In
parallel, an increase in required documentation has significantly shortened the amount of
time spent on doctor-patient interaction. This is where the disconnect is. Both patient
care and job quality can be dramatically improved with an increase in face-to-face time
spent between patient and doctor. This can be accomplished by designating a healthcare
profession, seperate from physicians, to file paperwork and finish documentation. This
role would serve three purposes: make up for the lost educational time for residents, help
to professionally invigorate attendings by allowing them to spend more time with
patients, and improve patient satisfaction through faster and more interactive medicine.

Combating malpractice is a double edged sword. It is clear that electronic records are an
essential tool utilized to protect the patient as well as to help combat the risk of
malpractice suits that are closing practices and ending careers of respected physicians.
While the idea of decreasing the amount of electronic records has been toggled with, no
official policies have been put in place. The creation of a documentation-centric role
within the healthcare industry would avoid sacrificing the legal protection provided by
documentation and free invaluable time for physicians to invest in diagnosis, research,
and interactive patient care.

Physician Vs. Administrative Needs:

Additionally, a dramatic surge in healthcare costs has resulted in the roles of administrators and
physicians becoming more entwined. A lack of mutual appreciation among these occupations
has manifested in conflicting agendas that drive culture and procedure within hospitals today.
Currently, the United States is in the midst of a malpractice crisis. In order to evade malpractice
suits, large medical practices are putting more emphasis on rule regulation and the roles of
hospital administrators. As a result, the income of healthcare administrators is skyrocketing,
while the income of physicians is steadily decreasing. On average, a practicing physician makes
on average $185,000 per year. In contrast, the average hospital administrator will earn a yearly
salary of $237,000​ 13​. Although the roles of those that oversee hospitals are crucial, it can be
argued that the responsibilities of physicians are equally as important.

The reality is, administration jobs are more coveted than the jobs of physicians when viewing
medicine from an economic point of view. The hospital or practice makes money by satisfying
patients and avoiding lawsuits. This is achieved by implementing strict regulations on the duties
of doctors in order to ensure that there is a standard of care that is expected from any and all
healthcare workers, mostly through the usage of electronic record systems. However, in the
process of acknowledging the needs and wants of patients, administrators often neglect to
acknowledge the wants and needs of the doctors, resulting in doctor dissatisfaction.

Take for example the issue of increased regulation through documentation and the feelings of the
majority of physicians towards this reality. While increased documentation does help establish a
standard of care that decreases the amount of malpractice suits filed against medical practices, it
is a large contributor to why a large portion of
physicians are choosing to leave their jobs.
According to the American Medical
Association, the top three causes of
dissatisfaction of doctors with their jobs is:
electronic record systems, lack of
communication between team members, and
lack of engagement with their healthcare
​ . While administrators are
institutions 14​
pushing for the need for increased electronic
record system usage, they are neglecting the
impact this has on physicians.

How to Open Lines of Communication​:

In order to combat the conflicting natures of documentation and the roles of physicians,
electronic health record systems are in the process of being redesigned to be more
suitable to the busy schedules of physicians. The hope is that by implementing these new
systems, doctors will be able to spend more time with patients and less time at their
desktops. Ironically, in research conducted by MD Stephen Swenson, 72% percent of
administrators and 52% of physicians blamed clerical paperwork for the main cause of
​ . It is clear that changes must be made, but the problem lies in ​how​ these
dissatisfaction 15​
must be made.

While the hope is that new forms of electronic record systems that are less time
demanding for doctors will hopefully lessen the resentment towards paperwork, this is
not a guarantee. Instead, there can be a much simpler alternative solution. While doctors
are continually being angered by administration’s inability to understand their values,
these misunderstandings can be extremely lessened with the use of administrative staff
who also have background knowledge in the scientific field. This way, administration
has an understanding of the value of patient care economically and scientifically. This
idea has already been implemented in some hospitals. ​Forbes Magazine ​notes that
 hospitals overseen by physicians rank 25% higher on the U.S. News and World Report's
​ . Making this common
"Best Hospital List" than hospitals not run by physicians 16​
practice is something that can create less conflicting agendas amongst those that run
hospitals and practices and those that work in them. While this addresses the issue at the
top levels of the medical professions, changes must work their way down to the
fundamentals of the medical system to fix the root of unhappiness in doctors: the
education system.

How the Medical Education System Fails its Students:

Stress is a common byproduct of most professions. Physicians are no different. However, what
is​ unique to the medical field is the length of time these feelings affect medical students,
residents, and attendings. Between 2014 and 2016, the Mayo Clinic conducted research in which
they found that thirty percent of students experienced feelings of prolonged distress, and by their
third year of medical school, those numbers doubled in size 17​ ​ . While medical school is intended
to challenge its students, it should not bring students to the breaking point of emotional sanity.

Getting into medical school in the first place is a huge feat. Each year, the applicant pools for
medical schools continue to grow, but the selection process continues to get narrower and
narrower. ​USNews n​ otes that some of the top medical programs only accept a little under four
​ . As a result, it is not a surprise that medical students are
percent of their applicant pool 18​
universally competitive and very driven. This
competition does not end upon being accepted into a
medical school; there are minimum grade point
averages, class ranks, and requirements for matching
into residencies and fellowships. The fight to the top of
the class is a long and brutal one, but the reward is what
keeps people going.

The stress to achieve success is unrelenting throughout

all eight years of undergraduate and graduate schooling,
so it is not surprising that most medical students
experience some level of burnout by their third year of
medical school. By the time students reach residency,
​ . It is clear that
suicide and depression rates peak 19​
changes must be promptly made in the medical
educational system to significantly reduce this
eye-opening reality.
Current Failing Education Reforms:
Many medical schools are eliminating formal grading scale systems as a whole. Instead,
students are graded on a pass-fail system. The hope is that by eliminating the need for
grades, students are less inclined to contribute to the cut throat culture of medical schools.
Instead of stressing about what the next peer got on the latest exam, the hope is for
students to truly be able to focus on what they need to learn, affirm that they know it, and
move on to study new casework. Despite this hope, the implementation of pass-fail
grades has yet created another source of stress: an increasing emphasis on Board Exam
scores.

With an inability to distinguish one applicant from another for residency programs, one
of the few limited ways to judge applicants are by interviews and Board scores. Brenda
Sirovich, a recent graduate of Dartmouth Medical School who also adhered by the
pass-fail policy, states, “Many may not realize that the readiness of aspiring doctors to
enter the world of clinical medicine is now based overwhelmingly on a single,
standardized, closed-book, multiple choice test.” 20​ ​ While pass-fail medical schools are
still a relatively new concept, it is clear that this is not the solution to the long term
problem of physician dissatisfaction.

In addition to reinventing the medical school system, the American Medical Association
has begun to require residents early on in their careers to complete online training that
creates awareness of the the risk factors for physician burnout and how to avoid such
​ The problem with
feelings through stressing self care and the need for “personal time.” 21​
this idea is that with the online training being a computer program, many physicians view
the training as yet another thing that they need to check off their todo lists for the day.
Burnout must be addressed on a more personal level; depression and unhappiness cannot
be solved with a computer program.

Altering Educational Reforms to Reflect Personal Needs:

Human to human interaction is essential in creating lasting bonds and relationships.
These relationships establish feelings of unity and trust amongst medical school and
residency peers. Only so much can be gained from a computer program in which
participants read what they are supposed to be doing to make themselves resist feelings of
depression, something already extremely difficult to resist on its own. Instead, broader
communication lines amongst attendings and residents and residents and medical students
should be established in order to create assurance that feelings of dissatisfaction for their
current work is not confined to one or two people. These feelings are widely dispersed,
and it is important to raise awareness about this reality to encourage change.
 Possible Positive Impacts of Increased Mentorship:
Physicians are often taught to take the emotion out of their work. Mistakes arise as a
result of doctors becoming attached to their patients. Attachment often results in
physicians going to extreme lengths to ensure their patients receive what they perceive as
the “best care possible.” Therefore, it is often difficult by nature for physicians to
address their own feelings towards their work in the first place.

Establishing an educational relationship rooted in a mentorship program can help doctors

and future doctors create a line of communication that allows for the expression of
emotion about their work. It is not always easy to address the fact that one's profession
results in unhappiness, so it can be beneficial to establish a line of mutual understanding
at all levels of the healthcare professional system.

The Total Impact of Physician Burnout:

The broad range of causes of physician dissatisfaction are not going to resolve themselves.
While more and more awareness is being brought to the forefront of headlines, there is no clear
solution to physician burnout. Changes must be made at the educational, administrative, and
political level to start the process of returning joy back into the medical profession. In the
absence of real progress, the risk is run of losing good medical students, residents, physicians,
and surgeons. In parallel, it is likely to continue to see a decline in the quality of patient care.
Increased communication at all levels of the healthcare system, coupled with a weaker reliance
on the need for documentation can potentially reduce such distress. In the meantime, however,
doctors are continuing to leave their professions, and patient care will continue to be sacrificed.
Changes must be made, not only for the fate of the medical community, but for the fate of patient
safety across the globe.
Endnotes:
1​
"Know the Signs of Job Burnout." Mayo Clinic. November 21, 2018. Accessed March 26,
2019. https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/burnout/art-20046642.
2​
Collier, Roger. "Addressing Physician Burnout at the Systems Level." CMAJ : Canadian
Medical Association Journal. February 12, 2018. Accessed March 26, 2019.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5809223/.
3​
Wallace, Jean E., Jane B. Lemaire, and William A. Ghali. "Physician Wellness: A Missing
Quality Indicator." Lancet (London, England). November 14, 2009. Accessed March 26, 2019.
https://www.ncbi.nlm.nih.gov/pubmed/19914516​.
4​
Wallace, Jean E., Jane B. Lemaire, and William A. Ghali. "Physician Wellness: A Missing
Quality Indicator." Lancet (London, England). November 14, 2009. Accessed March 26, 2019.
https://www.ncbi.nlm.nih.gov/pubmed/19914516.
5​
Grinspoon, Peter. "Physician Burnout Can Affect Your Health." Harvard Health Blog. June 22,
2018. Accessed March 26, 2019.
https://www.health.harvard.edu/blog/physician-burnout-can-affect-your-health-2018062214093.
6​
Cheney, Christopher. "Physician Burnout Impacts Safety, Professionalism, Patient
Satisfaction." September 13, 2018. Accessed March 26, 2019.
https://www.healthleadersmedia.com/welcome-ad?toURL=/clinical-care/physician-burnout-impa
cts-safety-professionalism-patient-satisfaction.
7​
"Duty Hours and Patient Safety." Patient Safety Network. January 2019. Accessed March 26,
2019. ​https://psnet.ahrq.gov/primers/primer/19/Duty-Hours-and-Patient-Safety​.
8​
"Duty Hours and Patient Safety." Patient Safety Network. January 2019. Accessed March 26,
2019. https://psnet.ahrq.gov/primers/primer/19/Duty-Hours-and-Patient-Safety.
9​
"The ACGME’s Approach to Limit Resident Duty Hours 12 Months After Implementation: A
Summary of Achievements." Accreditation Council for Graduate Medical Education. April 2004.
Accessed March 21, 2019.
https://www.acgme.org/Portals/0/PFAssets/PublicationsPapers/dh_dutyhoursummary2003-04.pd
f.
10 ​
"Duty Hours and Patient Safety." Patient Safety Network. January 2019. Accessed March 26,
2019. ​https://psnet.ahrq.gov/primers/primer/19/Duty-Hours-and-Patient-Safety​.
11​
"Duty Hours and Patient Safety." Patient Safety Network. January 2019. Accessed March 26,
2019. https://psnet.ahrq.gov/primers/primer/19/Duty-Hours-and-Patient-Safety.
12​
Berg, Sara. "Family Doctors Spend 86 Minutes of "pajama Time" with EHRs Nightly."
American Medical Association. September 11, 2017. Accessed March 26, 2019.
https://www.ama-assn.org/practice-management/digital/family-doctors-spend-86-minutes-pajam
a-time-ehrs-nightly.
13 ​
Rosenthal, Elisabeth. "Medicine's Top Earners Are Not the M.D.s." The New York Times.
May 17, 2014. Accessed April 01, 2019.
https://www.nytimes.com/2014/05/18/sunday-review/doctors-salaries-are-not-the-big-cost.html.
14​
"Three Leading Causes of Physician Burnout - and What You Can Do." ScribeAmerica. July
11, 2018. Accessed April 01, 2019.
https://www.scribeamerica.com/blog/3-leading-causes-of-physician-burnout-and-what-you-can-d
o/.
15​
"Why Physician Burnout Is Endemic & How Health Care Must Respond." NEJM Catalyst.
December 01, 2017. Accessed April 01, 2019.
https://catalyst.nejm.org/physician-burnout-endemic-healthcare-respond/.
16 ​
Knapp, Alex. "Do Doctors Make the Best Hospital Administrators?" Forbes. August 09, 2011.
Accessed April 01, 2019.
https://www.forbes.com/sites/alexknapp/2011/07/10/do-doctors-make-the-best-hospital-administ
rators/#5839adff2a40.
17 ​
Murphey, Brendan. "Where Physician Burnout Starts-and How to Help Stop It." American
Medical Association. June 14, 2018. Accessed April 01, 2019.
https://www.ama-assn.org/residents-students/resident-student-health/where-physician-burnout-st
arts-and-how-help-stop-it.
18 ​
Kowarski, Ilana. "Why It's Hard to Get Into Medical School Despite Doctor Shortages." U.S.
News & World Report. December 3, 2018. Accessed April 01, 2019.
https://www.usnews.com/education/best-graduate-schools/top-medical-schools/articles/2018-12-
03/why-its-hard-to-get-into-medical-school-despite-doctor-shortages.
19 ​
Murphey, Brendan. "Where Physician Burnout Starts-and How to Help Stop It." American
Medical Association. June 14, 2018. Accessed April 01, 2019.
https://www.ama-assn.org/residents-students/resident-student-health/where-physician-burnout-st
arts-and-how-help-stop-it.
20 ​
Strauss, Valerie. "A Disturbing Truth about Medical School - and America's Future Doctors."
The Washington Post. May 08, 2017. Accessed April 01, 2019.
https://www.washingtonpost.com/news/answer-sheet/wp/2017/05/08/a-disturbing-truth-about-m
edical-school-and-americas-future-doctors/?noredirect=on&utm_term=.45a0981f37e7​.
21​
Woo, Jong-Min, and Teodor T. Postolache. "The Impact of Work Environment on Mood
Disorders and Suicide: Evidence and Implications." International Journal on Disability and
Human Development : IJDHD. 2008. Accessed April 10, 2019.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2559945/​.

Visual Endnotes:
22 ​
Rosenberg, Ethan. “Physicians/General Population on Burnout Measures, 2014.” U.S. News,
Mayo Clinic Proceedings, 2015. Accessed April 01, 2019.
www.usnews.com/news/articles/2016-09-08/doctors-battle-burnout-to-save-themselves-and-their
-patients.
23 ​
Slabodkin, Gregory. “How Physicians Use Their Computers.” Health Data Management ,
University of Wisconsin. March 8, 2018. Accessed April 01, 2019.
www.healthdatamanagement.com/news/onc-cms-set-their-sights-on-reducing-ehr-clinical-burde
n.
24​
Stephen, Shannon. “Are Medical Students More Burned Out Than the Rest of the Population?”
American Association of Colleges of Osteopathic Medicine. 2018. Accessed April 01, 2019.
www.aacom.org/become-a-doctor/mental-health-awareness-in-ome.