Concern for physician wellness and burnout are important matters that have been deserving of serious attention for quite some time.
Only now, likely in response to the COVID-19 pandemic, are these issues receiving needed recognition. But, make no mistake that the seeds for doctors’ discontent were sown earlier. As an example, during a routine visit to a recently hired hospital internist, he mentioned that he was “clicking his way through life,” in describing his current chore in dealing with “dropdown” menus of his electronic health records (EHR).
This was in distinction to his earlier and more satisfying life in private practice. For present day senior ophthalmologists, wellness, ergonomics, and burnout were rarely, if at all, considered in our training programs or the bulk of our days in practice. We might view our generational standard of overwork and “self-sacrifice” as a tradition and part of the dues that we voluntarily paid during training and then beyond in trade for what was once our autonomy and our elevated position in society. Loss of self-esteem clearly has a negative impact on physician wellness.
Figure 1 – Percentage of physicians sensing burnout prior to and after the COVID-19 pandemic (Kane L. ‘Death by 1000 Cuts’: Medscape National Physician Burnout & Suicide Report 2021. Medscape. Published January 22, 2021).
Retired senior ophthalmologists, removed from the trends of contemporary practice (employee status, private equity, etc.), may not share the pain of what our younger colleagues are experiencing. Among the generational differences is the debt that many young physicians have accumulated on their way through the educational process. It is not uncommon for them to have student loans to repay that are well in excess of $250,000, only to face reduced reimbursements on arrival in practice. That scenario fortunately didn’t apply to senior ophthalmologists, but is quite concerning for our junior colleagues.
Among the underlying causes of burnout are loss of physician autonomy, bureaucratic snafus, loss of the doctor-patient relationship, trivialization of medical expertise gained over time, reduced reimbursements, EHRs, etc. Some of these factors have required that physicians work longer hours and increase their “throughput” of patients, often leading to fatigue, both mental and physical. Burnout is a form of chronic stress that leads to the sense of exhaustion, detachment, pessimism and feelings of ineffectiveness; the signs of burnout may include chronic fatigue, insomnia, pessimism, and isolation and these feelings may lead to poor job performance and lessened productivity. Moreover, poor ergonomics in the workplace may increase the likelihood for musculoskeletal disease (MSD) and chronic fatigue. This is particularly problematic for ophthalmologists.
Figure 2 – Projected future US demographics. (U.S. Census Bureau).
Clearly, the pandemic and its effects on the overall healthcare community has brought to light concerns regarding physician wellbeing across the board. Much of the available information on these subjects comes not only from the peer reviewed literature, but from Medscape and other online medical information news services. In a February 2022 Medscape poll of 1,170 various types of U.S. health care workers, 23% indicated their intention to leave the industry. In a recent and more extensive physician specific survey of 13,000 U.S. physicians across a variety of specialties (conducted in fall 2021 and reported in January 2022), it is astounding to note that overall, 47% of all MDs sense burnout, up 5% from just one year before.
Ophthalmologists reported a lower incidence (40% rate of self-reported burnout), than did ER physicians where a 60% prevalence was noted. It is interesting to observe, however, that the great majority of those who sense burnout presently noted it prior to the pandemic, as can be noted in figure 1 from the January 2021 Medscape survey of 12,000 U.S. physicians (taken in the fall 2020). Also from the 2022 survey, we learn that the percentage of those who were very unhappy prior to COVID-19 has more than doubled from 4% to 10% since the pandemic.
If there is a positive side to the pandemic it is that society has gained respect for healthcare providers and that physician wellness is a growing concern. This is of particular significance as we face potential physician work force shortages. According to Dr. Roni Devlin, from her January 2022 Medscape blog, 43% of physicians are considering early retirement. Loss of a significant portion of the physician workforce could have dire consequences downstream as we are experiencing a “graying of society.”
Figure 3 – Physician demographics (Kane L. ‘Death by 1000 Cuts’: Medscape National Physician Burnout & Suicide Report 2021. Medscape. Published January 22, 2021.
Figure 2 depicts U.S. demographics with respect to the projected portion of the U.S. population over age 65 for the future. Note that between 2020 and 2040 there is an anticipated increase of more that 24 million people. That figure will certainly impact ophthalmologic care since cataract, glaucoma, macular degeneration and all age-related conditions will see a marked increase in incidence. Will we have enough ophthalmologists to handle the increased patient load? This is a problem because our profession is not presently growing. Added to this, senior ophthalmologists (above age 60) currently represent 43% of Academy membership. Doctors are ”graying” as well, perhaps even faster than the population at large. Figure 3, from the Medscape 2021 survey reveals that overall, 31% of U.S. physicians are above age 60.
Moreover, there appears to be a gender trend: More females exhibit burnout than their male counterparts. Again, from the 2022 Medscape survey, more than half of women physicians reported burnout, compared with 41% of males. What might account for the observed gender difference? In a Harvard Business Review article from January 2022 concerning diversity and inclusion, authors Jessica Dudley, Sarah McLaughlin and Thomas Lee cited a study that implicated the disproportionate role that female and male physicians have with regard to non-professional activities.
As examples, female physicians have a 25-fold greater likelihood for being responsible for child care and schooling and a 4.5-fold greater responsibility for household tasks. As the article indicates, these data suggest that female physicians have a far more difficult time in their ability to “decompress” upon returning home from work. Interestingly, this gap persists across all ages between 30 and 65, removing child rearing as the major cause.
The article also notes that female physicians take more time per patient and more time in documenting the interaction on the EHR. Interestingly, the authors also suggest that the patients of women physicians have modestly better outcomes! But the net result is that female physicians have higher rates of burnout, lower rates of professional fulfillment, higher rates of depression, all resulting in women leaving medical practice. Given that women currently represent more than one-third of all U.S. physicians and a majority of current medical students, there are negative implications for the physician workforce over the long-term. In a Nov. 16, 2021 article from The Atlantic, author Ed Yong reports that roughly 20% of health care workers have left their jobs since the pandemic. He suggests that the workers aren't quitting because they can’t handle their jobs. They’re quitting because they can’t handle being unable to do their jobs.
Figure 4 – Proportion of physicians burned out by work setting. (Kane L. ‘Death by 1000 Cuts’: Medscape National Physician Burnout & Suicide Report 2021. Medscape. Published January 22, 2021.)
Even before COVID-19, many of them struggled to bridge the gap between the noble ideals of their profession and the realities of it as a business. The pandemic simply pushed them past the limits of that compromise.
Other than gender differences and the obvious impact of the pandemic on certain specialties, emergency medicine and infectious diseases as examples, what has led to the surprisingly high rates of physician burnout and how could this have occurred? Figure 4 shows that practice setting has a significant impact of the proportion of physicians sensing burnout, with those in solo practice revealing the lowest rate. Given that many physicians are now employed by larger health care systems, rather than self-employed, it is easy to recognize that filling out EHRs and other bureaucratic tasks take away from the traditional doctor-patient relationships; some practitioners sense that they have become typists rather than care givers.
Figure 5 – Factors responsible for physician burnout. (Kane L. ‘Death by 1000 Cuts’: Medscape National Physician Burnout & Suicide Report 2021. Medscape. Published January 22, 2021.)
Figure 5 presents the key reasons for current dissatisfaction among physicians, according to the 2021 Medscape poll. It is remarkable to note that bureaucratic snafus are reported to be 6-fold more significant than is the stress of caring for COVID 19 patients. How deep does the problem go? 54% of the 13,000 physicians in the Medscape 2022 survey reveal that burnout has a strong or severe impact on life. Remarkably, burnout is now recognized as a diagnosable condition and has been added to the World Health Organization’s 11th revision of the International Classification of Diseases (ICD-11). Certainly, burnout may result in suboptimal patient care, loss of physician productivity, medical errors, and personal concerns of the physician including depression, alcoholism, drug dependency and suicide. But on a positive note in our camp, according to Lucy Hicks, reporting for Medscape, ophthalmologists have lower rates of depression than do other specialists.
How are doctors coping with these issues? On one hand, doctors may alter the workplace environment, should they have the capacity to do so (figure 6). Of concern, is that more than a fourth have reduced their work hours, potentially contributing to workforce shortages, while a fifth have changed work settings. Overall, only 3% have placed their practices up for sale. Employed, rather than self-employed physicians have far less control over their work environments and that can create frustration and dissatisfaction. Employers have come to recognize that physicians want and need more direct control over patient care, and are not interested in corporate gifts, “trinkets” and coffee time snacks in exchange.
Figure 6 – Strategies to alter the workplace environment in response to burnout stress. (Kane L. ‘Death by 1000 Cuts’: Medscape National Physician Burnout & Suicide Report 2021. Medscape. Published January 22, 2021.)
Doctors have also adapted by improving their own mental and physical health. As mentioned, above poor ergonomics in the workplace contributes to physical pain and fatigue, leading to musculoskeletal disorders; these are among the underlying causes of burnout. Physicians have also adapted to the challenges of burnout by addressing “survival strategies” in their out-of-office lifestyle, employing positive methods such as increasing exercise time and allowing them to combat both physical fatigue and mental stress.
Where does ophthalmology stack up in these arenas? Although 40% of ophthalmologists sense burnout, only 2% of respondents in the Medscape survey were ophthalmologists, accounting for roughly 260. Quite similarly, a recently conducted online survey specific to ophthalmology, with approximately 600 ophthalmologists responding found that 38% self-reported symptoms of burnout. In keeping with the Medscape survey data, there was higher incidence among women and among ophthalmologists employed by hospitals, facilities, or academic centers as compared with those in private groups. Interestingly, among subspecialties, vitreo-retinal surgeons exhibited the lowest burnout ratio at 31% as compared with uveitis specialists at 45%; on a positive note, only 5.4% considered their burnout to be severe, while 65% indicated that it was mild.
Although it appears that burnout is presently a daunting problem in American medicine, the upside is that recognition of the problem is the first step toward its cure. That said, there remain large obstacles to overcome; the corporatization of medicine, reduced reimbursements for care, prior educational debts, “graying” of the populace and ergonomic challenges in office design, to name just a few. It is apparent that much needs to be done and it is uplifting to recognize that the Academy has begun to address these issues.
Of even greater significance is the Dr. Lorna Breen Health Care Provider Protection Act, just signed into federal law that recognizes physician burnout, provides grants to support related research and encourages mental health support for health care workers.
Further Resources
Physician Wellness, American Academy of Ophthalmology
Burned Out on Burnout? Ruth D. Williams, MD, EyeNet® Magazine, American Academy of Ophthalmology, 2022
5 Tips for Yoga and Mindfulness at Work, Camille V. Palma, MD, American Academy of Ophthalmololy.