I have read many essays on physician burnout over the years. However, I feel that the nail has yet to be hit directly on the head regarding this insidious scourge afflicting our profession. Most articles discussing burnout focus on the gross inefficiencies/redundancies of electronic health records, inadequate reimbursement, and the growing lack of respect from the public. While I cannot deny that these are important contributors to physician burnout, I do not think they are the main drivers. After all, low pay, widespread disrespect, and copious redundancies are present in a plethora of other professions that do not share the same burnout rate as physicians. Therefore, there must be something unique to our profession that is bolstering burnout rates to epidemic levels. It should be noted that I am writing this essay as an internal medicine physician practicing as a hospitalist for the past 15 years, and I admit that the main factors for burnout in my field may be very different for others working in a different medical specialty.
In my experience, two primary drivers for physician burnout outweigh all other factors combined. These two factors work symbiotically to create the mess in which we find ourselves. These two factors are (1) unsafe staffing and (2) lack of medical malpractice reform. Many of us have had to treat an impossibly high number of patients on a relatively frequent basis. Experiencing this is truly an awful feeling. It is a feeling that causes anxiety and even dread while working under such conditions. Such feelings do not go away when one finishes his or her shift. They are present when coming into work indefinitely, due to the anticipation of having to manage a number of patients that no human is capable of caring for. You know that you are a competent physician, but you are human. There is a number of admissions per shift that is clearly unsafe, even for the most seasoned and intelligent physician, and yet you know with certainty you will far exceed that number in the near future. To make matters even worse, no matter how many times you have informed the administration of unsafe staffing, nothing is done. Our pleas are either ignored or denied outright. This leads to another feeling in addition to the dread: Hopelessness.
It might be possible to mitigate these sensations of dread and hopelessness if physicians were treated like police officers, congressional representatives, or judges and had qualified immunity. At least then we might feel that the weight of the world is not on our shoulders. At least then, we might feel that society understands that we are only capable of safely managing a number of patients possible for a human being, and should therefore not be held responsible when bad outcomes occur in such a chaotic environment. However, this is unfortunately not the case. On the contrary, our civil legal system holds physicians to a deity-like standard where they can be sued for any unfavorable outcome, regardless of whether the physician had a role in causing the outcome by deviating from the standard of care, and regardless of whether the physician was dealing with unsafe staffing on the date the poor outcome occurred.
This godlike degree of responsibility would be absurd if it were not our daily reality. Additionally, I feel this preposterousness would be seen as obvious when it comes to other fields. For example, nobody would advocate for suing teachers over the poor academic outcomes of their students if they had more than double the number of students in their class than standards deem appropriate. Nobody would blame the firefighters of a small town with one firetruck if they failed to put out three fires that occurred simultaneously. Yet, when it comes to physicians, we are treated as if we literally have superhuman abilities and that the physical laws of the universe somehow do not apply to us. This treatment is both demoralizing and dehumanizing, and it needs to stop.
I would even go as far as advocating for the curtailing of the use of the term “medical error.” After all, how can we consider something an “error” if the person who allegedly made this “error” was set up for failure? If I were to give you a first-grade level math test comprised of 100 questions and only give you 15 seconds to complete it, you would certainly fall short of correctly answering the 70 questions required for a passing score. Would it be right to consider all of the questions that you failed to correctly answer “errors?” Of course not. Here, we immediately recognize the impossible standard. Yet, we somehow fail to spot this unattainable standard when it comes to our profession. Thus, the term “medical error” should be reserved for those instances where staffing actually was appropriate, and the physician still deviated from the standard of care, thereby causing an adverse outcome. In any other context, the use of the phrase “medical error” is inappropriate, and we should identify its misuse in those many occasions.
In the same vein, recommending “therapy” for burnout, such as meditation, also needs to stop. Doing this makes it seem like physician burnout is due to an individual moral failing, rather than due to an unmitigated systemic failure of vast proportions. All the meditation in the world will not fix the fact that I have to admit 20 patients in a 12-hour shift. In recent years, we have recognized that, in our patient populations, systemic societal issues can be attributed to individual health problems. For instance, we recognize that a child growing up in poverty and food deserts is not to be blamed for their obesity. Yet, somehow, when it comes to physician burnout, we continue to fail to recognize that there are systemic issues, not personal moral failings, which cause burnout.
The fact that personally makes me feel most defeated is that these are solvable problems, and yet I see no progress. That failure needs to end now. First, hospital administrations should recognize unsafe staffing as the commonplace occurrence that it is and provide safe staffing immediately. If the administration makes some excuse why they are unable to provide safe staffing, then physicians should be able to document the date(s) that unsafe staffing occurred. Nurses can do this, and there is no reason why physicians should not be provided with the same outlet for recording an unsafe working environment. Doing so would also provide a hedge against the inevitable lawsuit by implicating the hospital rather than solely the physician tasked to see an impossibly high number of patients.
Second, large physician organizations and medical societies should make tort reform a priority. It is inexcusable that these organizations have made no significant progress in the realm of civil legal reform during the COVID-19 pandemic, where physicians were literally dying for their patients. We should expect far better from these organizations whose raison d’être is to advocate for the well-being of physicians. These organizations need to start treating the ludicrous medical malpractice environment that physicians must work under as a menace and as the serious driver of burnout that it truly is. If that means abandoning less important issues to refocus on this issue as an urgent matter, then so be it.
In addition, these physician organizations and medical societies should similarly fight against flagrant misinformation when it comes to “medical errors.” I have seen multiple publications stating that “medical errors” or “malpractice” cause 100,000+ patient deaths each year. Despite this claim being unsubstantiated, I have seen no effort from physician organizations to fight this baseless assertion. This is unacceptable from organizations that are supposed to be our advocates.
In summary, although I agree that there are many factors (lack of autonomy, overburdening amount of regulations, harassment, ineffective electronic health records, long hours, lack of respect, poor pay, etc.) that drive physician burnout, I believe that two factors (unsafe staffing and lack of medical malpractice reform) reign supreme. Once we deal with these two issues, I truly believe burnout rates will significantly improve nationwide. However, if these problems are not rectified, then it is only reasonable to expect a progression of physician burnout to record levels. This essay is meant to be a wake-up call for those who are in a position to enact the remedies that I described above. Unfortunately, I fear this message will be ignored. Please prove me wrong.
Dr. Breitbart
Dr. Breitbart is a nocturnist at Englewood Hospital and Medical Center in Englewood, N.J.