- Email: [email protected]
Burnout Among Cardiologists
Accepted Manuscript Burnout Among Cardiologists Jeffrey B. Michel, MD, Denisse Menendez Sangha, MD, John P. Erwin, III, MD PII:
S0002-9149(16)31952-X
DOI:
10.1016/j.amjcard.2016.11.052
Reference:
AJC 22308
To appear in:
The American Journal of Cardiology
Received Date: 28 September 2016 Revised Date:
12 November 2016
Accepted Date: 15 November 2016
Please cite this article as: Michel JB, Sangha DM, Erwin III JP, Burnout Among Cardiologists, The American Journal of Cardiology (2017), doi: 10.1016/j.amjcard.2016.11.052. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Burnout Among Cardiologists
RI PT
Jeffrey B Michel, MDa,b,*, Denisse Menendez Sangha, MDa, and John P Erwin III, MDa,b,c
Cardiology Division, Scott and White Memorial Hospital, Temple, Texas
b
Texas A&M University Health Science Center College of Medicine, Temple, Texas
c
Department of Medicine, Scott and White Memorial Hospital, Temple, Texas
SC
a
Jeffrey Michel, MD 2401 South 31st Street MS-33-ST156 Temple, Texas 76508 [email protected] (512) 568-2494 CELL
M AN U
*Corresponding Author:
Manuscript received: September 27th, 2016
TE D
Revised Manuscript submitted: November 7th, 2016 List of Support/Grant Information: None
AC C
EP
Word Count: 1495 (including Abstract)
1
ACCEPTED MANUSCRIPT
Abstract Burnout is a loss of enthusiasm for work, cynicism and a low sense of accomplishment. Loss of
RI PT
autonomy and authority, complex regulatory requirements, report cards, quality metrics, the rise of large integrated healthcare systems and the demise of solo practice are just a few
realities of medical practice that contribute to physician burnout. Physicians suffering burnout
SC
often focus on compensation and perceived status as antidotes, though evidence suggests they play no role. Randomized controlled trials suggest that interventions designed to improve
M AN U
coping and resiliency including cognitive behavioral therapy and physical and mental relaxation to reduce stress can be effective. Reduced work-hours have also been shown mitigate burnout. Successful prevention and management requires adaptations by both physicians and the healthcare systems in which they work. We believe that burnout also involves a loss of faith in
TE D
the practice of medicine itself. Advances in cardiovascular medicine have led to large reductions in mortality and morbidity. However, the disruptive changes to healthcare that accompanied this success have contributed to physician alienation. In conclusion, we believe that to
EP
overcome burnout, cardiologists should dedicate themselves to a collective mission of patient
AC C
care and work to restore faith in their profession.
Key words: physician burnout; professional exhaustion; dissatisfaction
2
ACCEPTED MANUSCRIPT
weigh in the balance nor test in the crucible...
SC
Sir William Osler1
RI PT
Nothing in life is more wonderful than faith — the one great moving force which we can neither
Medical education is difficult, requiring long years of training. Once completed,
M AN U
expectations are high. Physicians are among society’s highest paid and most respected professionals. However, they report higher rates of dissatisfaction and burnout than other American workers.2 Cardiologists, who rank among the best compensated and most admired of all physicians, are among those most likely to suffer. Could loss of faith in the profession play a
TE D
role?
Burnout is defined as a loss of enthusiasm for work, feelings of cynicism and a low sense of personal accomplishment. It threatens the mental, physical and spiritual health of physicians
EP
and is generally believed to be a response to poorly managed stress, particularly in environments in which individuals lack control or autonomy. A 2015 Medscape survey of
AC C
physicians reported that 46% of Cardiologists had symptoms of burnout.3 Similar rates were reported by pulmonologists (47%), nephrologists (45%) endocrine/diabetes (45%) and orthopedic surgery (45%). Critical care and emergency physicians reported the highest rate of burn out in the survey (53 and 52% respectively) while dermatologists reported the lowest rate (37%). Physicians practicing on the front lines of patient care had the highest rates of burnout.
3
ACCEPTED MANUSCRIPT
The prestige of medicine remains high, with surveys indicating that the American public rates physicians as one of the most highly regarded professions. Public trust in physicians has
RI PT
actually risen over the past 40 years. Gallup polling in 1976 revealed that 56% of Americans rated physician honesty as Very High or High. In 2015 the percentage was 67%. Members of Congress fell over that same period from 15% to 8%. Only nurses and pharmacists rate higher
SC
than physicians.4
Over that same period, incomes for physicians in general, and cardiologists in particular,
M AN U
have increased more than the national average. Cardiology is the second highest paid specialty behind orthopedic surgery. The combination of high income and high prestige enjoyed by American physicians has contributed to a rising demand for medical education and training. Applications in 2015 set new records for the number of applicants, reaching 52,550, an all-time
TE D
high.5 But how good will future healthcare be if physician burnout continues? And why are Cardiologists, some of the best-paid and most highly regarded physicians, becoming increasingly burned out?
EP
Doctors experiencing burnout have higher levels of divorce, depression, alcohol and drug addiction, and suicide. Additionally, they provide lower quality care, have higher levels of
AC C
medical errors and greater malpractice risk.6 Burnout among medical practitioners is not confined to the United States or even Western Nations. Research comparing physicians from across the globe finds it to be universal, suggesting that shared aspects of direct patient care likely account for much of the problem.6 As members of large healthcare entities, there is pressure for cardiologists to see more patients in shorter visits. Compensation is now often based on productivity, using simple
4
ACCEPTED MANUSCRIPT
formulas of relative value units (RVUs) for clinical work. Linking of pay to the volume of work done, rather than to the quality or outcomes of that work can be demoralizing. High RVUs
RI PT
reward invasive and interventional procedures and can encourage cardiologists to pursue aggressive rather than conservative treatment options. This compensation model leaves some physicians feeling coerced and punished for doing what they consider best patient care.
SC
Computerization and electronic records now allows physicians to work from home at the expense of rest and relaxation. Most believe they spend too much time doing data
M AN U
entry. Increased requirements for documentation and compliance can create a chronic sense of failure and diminished accomplishment.
“Burnout” was a term first coined by Herbert Freudenberger in 1974 to describe the diminishing interest in work and loss of energy he observed in volunteers working at a drug
TE D
addiction rehabilitation center.7 Since then it has been studied extensively and found to be present in all professional endeavors. Of interest, high rates of burnout are often found in individuals to whom others come with needs and demands. A study of Roman Catholic priests
EP
found higher levels of burnout among those serving parishioners (72%) than those living secluded in Monasteries (39%).8
AC C
The first large study of physician burnout was published in 2012.2 Of 7,288 physicians
surveyed, 45.8% reported at least one symptom. The highest burnout rates were seen in primary care including family medicine, internal medicine and emergency medicine. According to this study, 37.9% of US physicians had high emotional exhaustion, 29.4% had high depersonalization, and 12.4% had a low sense of personal accomplishment. Female physicians were more likely to be dissatisfied with their work-life balance than male physicians. Physician
5
ACCEPTED MANUSCRIPT
age was not a significant factor. Findings from a meta-analysis of interventions for burnout published in 2013 noted that
RI PT
poor work engagement, work attitudes and health/safety led to emotional exhaustion. It suggested that burnout risk could be minimized at three levels: individual (healthy
lifestyle/behaviors, adequate coping), the individual and the environment (social support
structures, relationships, improving person-organization fit), and at the organizational level
SC
(adequate working conditions, organization of work, design).9 Improvements in work processes
M AN U
and interpersonal relationships, coupled with a positive work environment, led to a reduction in emotional exhaustion.
Our evolving system of healthcare delivery appears to offer some potential solutions for burnout. There was a time when many cardiologists practiced solo or in loose affiliations that
TE D
shared overhead and call coverage. Large integrated healthcare systems now offer greater support and coverage for physicians as well as opportunities for reduced work hours. Most cardiologists could work reduced schedules and still be among society’s highest paid
EP
professionals
Many cardiologists struggle to maintain competency in the face of exponential growth
AC C
in knowledge, treatments and procedures. Cardiology has multiple subspecialties each with their own credentialing; training and testing including advanced heart failure, interventional cardiology, electrophysiology, echocardiography and adult congenital heart disease. More are sure to come. To provide complete care, cardiologists must work as members of larger teams and in doing so are reminded that such care is a group effort, with shared risks and rewards. Working collaboratively can limit isolation, encourage ongoing medical education, and foster an
6
ACCEPTED MANUSCRIPT
outwardly focused professional vision. Physicians suffering burnout are often disengaged, have low energy and no longer see
RI PT
value in their day to day work. They are frequently isolated, suffering silently and ashamed. They have lost faith in themselves and in the importance of their work. Ultimately faith may be what is needed to combat burnout. Religious believers have long drawn strength from shared
cardiologists can draw similar strength and resiliency.
SC
beliefs and service to others. Through service and greater participation in our communities,
M AN U
Faith is by definition a focus outside of oneself and a belief in something greater and more important than oneself. Greater faith might be kindled through participation in community education, medical societies, hospital staffs, charity work, advocacy on the local, state and national level, and through helping to teach the next generation of medical students,
TE D
residents and fellows. Most religious faiths place emphasis on service to others as a way of promoting greater individual happiness and contentment. Our profession should do the same. Physicians must avoid he trap of narrow repetitive clinical duties without engagement in a
EP
larger mission of education, teaching and self-renewal. Burnout may result from what Osler called “a penny-in-the-slot sort of practice, in which each symptom is at once met by its
AC C
appropriate drug”.10 Cardiologists should embrace all aspects of patient care, from immediate symptoms and remedies to the long term health of patients and their communities. Significant progress has been made in the war on cardiovascular disease. In one lifetime
mortality has been halved. We should take collective pride in what has been achieved, and have faith that with continued advances in knowledge, our future will outshine the past.
7
ACCEPTED MANUSCRIPT
1.
Osler W. The faith that heals. BMJ 1910;1:1470-1472.
2.
Shanafelt, TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, West CP, Sloan J and
the general US population. Arch Intern Med 2012;172:1377. 3.
RI PT
Oreskovich MR. Burnout and satisfaction with work-life balance among US physicians relative to
Peckham C. Physician Burnout: It Just Keeps Getting Worse. 2015. Available at
4.
SC
www.medscape.com/viewarticle/838437. Accessed November 10, 2016.
Saad L. Americans faith in honesty, ethics and police rebounds. 2015. Available at
M AN U
www.gallup.com/poll/187874/americans-faith-honesty-ethics-police-rebounds.aspx. Accessed November 10, 2016. 5.
Brooks M. Medical school applicants, enrollees reach new highs. 2015. Available at
www.medscape.com/viewarticle/853133. Accessed November 10, 2016. Sablik Z, Samborska-Sablik A and Drożdż J. Systematic review/meta-analysis universality
TE D
6.
of physicians’ burnout syndrome as a result of experiencing difficulty in relationship with patients. Arch Med Sci 2013;3:398-403.
Freudenberger HJ. Staff burn-out. J Social Issues 1974;30:159-165.
8.
Virginia SG. Burnout and depression among roman catholic secular,
EP
7.
9.
AC C
religious, and monastic clergy. Pastoral Psychology 1998;47:49.
Lee RT, Seo B, Hladkyj S, Lovell B and Schwartzmann L. Correlates of physician burnout
across regions and specialties: a meta-analysis. Human Resources for Health 2013;11:48. 10.
Osler W. Aequanimitas: With other Addresses to Medical Students, Nurses, and
Practitioners of Medicine. Philadelphia: Blakiston’s Son; 1925:329.
8
S0002-9149(16)31952-X
DOI:
10.1016/j.amjcard.2016.11.052
Reference:
AJC 22308
To appear in:
The American Journal of Cardiology
Received Date: 28 September 2016 Revised Date:
12 November 2016
Accepted Date: 15 November 2016
Please cite this article as: Michel JB, Sangha DM, Erwin III JP, Burnout Among Cardiologists, The American Journal of Cardiology (2017), doi: 10.1016/j.amjcard.2016.11.052. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Burnout Among Cardiologists
RI PT
Jeffrey B Michel, MDa,b,*, Denisse Menendez Sangha, MDa, and John P Erwin III, MDa,b,c
Cardiology Division, Scott and White Memorial Hospital, Temple, Texas
b
Texas A&M University Health Science Center College of Medicine, Temple, Texas
c
Department of Medicine, Scott and White Memorial Hospital, Temple, Texas
SC
a
Jeffrey Michel, MD 2401 South 31st Street MS-33-ST156 Temple, Texas 76508 [email protected] (512) 568-2494 CELL
M AN U
*Corresponding Author:
Manuscript received: September 27th, 2016
TE D
Revised Manuscript submitted: November 7th, 2016 List of Support/Grant Information: None
AC C
EP
Word Count: 1495 (including Abstract)
1
ACCEPTED MANUSCRIPT
Abstract Burnout is a loss of enthusiasm for work, cynicism and a low sense of accomplishment. Loss of
RI PT
autonomy and authority, complex regulatory requirements, report cards, quality metrics, the rise of large integrated healthcare systems and the demise of solo practice are just a few
realities of medical practice that contribute to physician burnout. Physicians suffering burnout
SC
often focus on compensation and perceived status as antidotes, though evidence suggests they play no role. Randomized controlled trials suggest that interventions designed to improve
M AN U
coping and resiliency including cognitive behavioral therapy and physical and mental relaxation to reduce stress can be effective. Reduced work-hours have also been shown mitigate burnout. Successful prevention and management requires adaptations by both physicians and the healthcare systems in which they work. We believe that burnout also involves a loss of faith in
TE D
the practice of medicine itself. Advances in cardiovascular medicine have led to large reductions in mortality and morbidity. However, the disruptive changes to healthcare that accompanied this success have contributed to physician alienation. In conclusion, we believe that to
EP
overcome burnout, cardiologists should dedicate themselves to a collective mission of patient
AC C
care and work to restore faith in their profession.
Key words: physician burnout; professional exhaustion; dissatisfaction
2
ACCEPTED MANUSCRIPT
weigh in the balance nor test in the crucible...
SC
Sir William Osler1
RI PT
Nothing in life is more wonderful than faith — the one great moving force which we can neither
Medical education is difficult, requiring long years of training. Once completed,
M AN U
expectations are high. Physicians are among society’s highest paid and most respected professionals. However, they report higher rates of dissatisfaction and burnout than other American workers.2 Cardiologists, who rank among the best compensated and most admired of all physicians, are among those most likely to suffer. Could loss of faith in the profession play a
TE D
role?
Burnout is defined as a loss of enthusiasm for work, feelings of cynicism and a low sense of personal accomplishment. It threatens the mental, physical and spiritual health of physicians
EP
and is generally believed to be a response to poorly managed stress, particularly in environments in which individuals lack control or autonomy. A 2015 Medscape survey of
AC C
physicians reported that 46% of Cardiologists had symptoms of burnout.3 Similar rates were reported by pulmonologists (47%), nephrologists (45%) endocrine/diabetes (45%) and orthopedic surgery (45%). Critical care and emergency physicians reported the highest rate of burn out in the survey (53 and 52% respectively) while dermatologists reported the lowest rate (37%). Physicians practicing on the front lines of patient care had the highest rates of burnout.
3
ACCEPTED MANUSCRIPT
The prestige of medicine remains high, with surveys indicating that the American public rates physicians as one of the most highly regarded professions. Public trust in physicians has
RI PT
actually risen over the past 40 years. Gallup polling in 1976 revealed that 56% of Americans rated physician honesty as Very High or High. In 2015 the percentage was 67%. Members of Congress fell over that same period from 15% to 8%. Only nurses and pharmacists rate higher
SC
than physicians.4
Over that same period, incomes for physicians in general, and cardiologists in particular,
M AN U
have increased more than the national average. Cardiology is the second highest paid specialty behind orthopedic surgery. The combination of high income and high prestige enjoyed by American physicians has contributed to a rising demand for medical education and training. Applications in 2015 set new records for the number of applicants, reaching 52,550, an all-time
TE D
high.5 But how good will future healthcare be if physician burnout continues? And why are Cardiologists, some of the best-paid and most highly regarded physicians, becoming increasingly burned out?
EP
Doctors experiencing burnout have higher levels of divorce, depression, alcohol and drug addiction, and suicide. Additionally, they provide lower quality care, have higher levels of
AC C
medical errors and greater malpractice risk.6 Burnout among medical practitioners is not confined to the United States or even Western Nations. Research comparing physicians from across the globe finds it to be universal, suggesting that shared aspects of direct patient care likely account for much of the problem.6 As members of large healthcare entities, there is pressure for cardiologists to see more patients in shorter visits. Compensation is now often based on productivity, using simple
4
ACCEPTED MANUSCRIPT
formulas of relative value units (RVUs) for clinical work. Linking of pay to the volume of work done, rather than to the quality or outcomes of that work can be demoralizing. High RVUs
RI PT
reward invasive and interventional procedures and can encourage cardiologists to pursue aggressive rather than conservative treatment options. This compensation model leaves some physicians feeling coerced and punished for doing what they consider best patient care.
SC
Computerization and electronic records now allows physicians to work from home at the expense of rest and relaxation. Most believe they spend too much time doing data
M AN U
entry. Increased requirements for documentation and compliance can create a chronic sense of failure and diminished accomplishment.
“Burnout” was a term first coined by Herbert Freudenberger in 1974 to describe the diminishing interest in work and loss of energy he observed in volunteers working at a drug
TE D
addiction rehabilitation center.7 Since then it has been studied extensively and found to be present in all professional endeavors. Of interest, high rates of burnout are often found in individuals to whom others come with needs and demands. A study of Roman Catholic priests
EP
found higher levels of burnout among those serving parishioners (72%) than those living secluded in Monasteries (39%).8
AC C
The first large study of physician burnout was published in 2012.2 Of 7,288 physicians
surveyed, 45.8% reported at least one symptom. The highest burnout rates were seen in primary care including family medicine, internal medicine and emergency medicine. According to this study, 37.9% of US physicians had high emotional exhaustion, 29.4% had high depersonalization, and 12.4% had a low sense of personal accomplishment. Female physicians were more likely to be dissatisfied with their work-life balance than male physicians. Physician
5
ACCEPTED MANUSCRIPT
age was not a significant factor. Findings from a meta-analysis of interventions for burnout published in 2013 noted that
RI PT
poor work engagement, work attitudes and health/safety led to emotional exhaustion. It suggested that burnout risk could be minimized at three levels: individual (healthy
lifestyle/behaviors, adequate coping), the individual and the environment (social support
structures, relationships, improving person-organization fit), and at the organizational level
SC
(adequate working conditions, organization of work, design).9 Improvements in work processes
M AN U
and interpersonal relationships, coupled with a positive work environment, led to a reduction in emotional exhaustion.
Our evolving system of healthcare delivery appears to offer some potential solutions for burnout. There was a time when many cardiologists practiced solo or in loose affiliations that
TE D
shared overhead and call coverage. Large integrated healthcare systems now offer greater support and coverage for physicians as well as opportunities for reduced work hours. Most cardiologists could work reduced schedules and still be among society’s highest paid
EP
professionals
Many cardiologists struggle to maintain competency in the face of exponential growth
AC C
in knowledge, treatments and procedures. Cardiology has multiple subspecialties each with their own credentialing; training and testing including advanced heart failure, interventional cardiology, electrophysiology, echocardiography and adult congenital heart disease. More are sure to come. To provide complete care, cardiologists must work as members of larger teams and in doing so are reminded that such care is a group effort, with shared risks and rewards. Working collaboratively can limit isolation, encourage ongoing medical education, and foster an
6
ACCEPTED MANUSCRIPT
outwardly focused professional vision. Physicians suffering burnout are often disengaged, have low energy and no longer see
RI PT
value in their day to day work. They are frequently isolated, suffering silently and ashamed. They have lost faith in themselves and in the importance of their work. Ultimately faith may be what is needed to combat burnout. Religious believers have long drawn strength from shared
cardiologists can draw similar strength and resiliency.
SC
beliefs and service to others. Through service and greater participation in our communities,
M AN U
Faith is by definition a focus outside of oneself and a belief in something greater and more important than oneself. Greater faith might be kindled through participation in community education, medical societies, hospital staffs, charity work, advocacy on the local, state and national level, and through helping to teach the next generation of medical students,
TE D
residents and fellows. Most religious faiths place emphasis on service to others as a way of promoting greater individual happiness and contentment. Our profession should do the same. Physicians must avoid he trap of narrow repetitive clinical duties without engagement in a
EP
larger mission of education, teaching and self-renewal. Burnout may result from what Osler called “a penny-in-the-slot sort of practice, in which each symptom is at once met by its
AC C
appropriate drug”.10 Cardiologists should embrace all aspects of patient care, from immediate symptoms and remedies to the long term health of patients and their communities. Significant progress has been made in the war on cardiovascular disease. In one lifetime
mortality has been halved. We should take collective pride in what has been achieved, and have faith that with continued advances in knowledge, our future will outshine the past.
7
ACCEPTED MANUSCRIPT
1.
Osler W. The faith that heals. BMJ 1910;1:1470-1472.
2.
Shanafelt, TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, West CP, Sloan J and
the general US population. Arch Intern Med 2012;172:1377. 3.
RI PT
Oreskovich MR. Burnout and satisfaction with work-life balance among US physicians relative to
Peckham C. Physician Burnout: It Just Keeps Getting Worse. 2015. Available at
4.
SC
www.medscape.com/viewarticle/838437. Accessed November 10, 2016.
Saad L. Americans faith in honesty, ethics and police rebounds. 2015. Available at
M AN U
www.gallup.com/poll/187874/americans-faith-honesty-ethics-police-rebounds.aspx. Accessed November 10, 2016. 5.
Brooks M. Medical school applicants, enrollees reach new highs. 2015. Available at
www.medscape.com/viewarticle/853133. Accessed November 10, 2016. Sablik Z, Samborska-Sablik A and Drożdż J. Systematic review/meta-analysis universality
TE D
6.
of physicians’ burnout syndrome as a result of experiencing difficulty in relationship with patients. Arch Med Sci 2013;3:398-403.
Freudenberger HJ. Staff burn-out. J Social Issues 1974;30:159-165.
8.
Virginia SG. Burnout and depression among roman catholic secular,
EP
7.
9.
AC C
religious, and monastic clergy. Pastoral Psychology 1998;47:49.
Lee RT, Seo B, Hladkyj S, Lovell B and Schwartzmann L. Correlates of physician burnout
across regions and specialties: a meta-analysis. Human Resources for Health 2013;11:48. 10.
Osler W. Aequanimitas: With other Addresses to Medical Students, Nurses, and
Practitioners of Medicine. Philadelphia: Blakiston’s Son; 1925:329.
8