• Summer 2022 Editorial - Getting to the Bottom of the Pyramid


    In the Spring issue of Scope, Samuel Masket, MD, wrote an important article on physician burnout.

    Physician burnout is an epidemic that began long before COVID-19 and has reached a point that requires our serious attention. Dr. Masket lists loss of physician autonomy, bureaucracy, lack of respect for medical expertise, reduced reimbursements, and the proliferation of electronic medical records (EMR) as causes.

    To this, I would add what concerns me most which is the loss of the doctor-patient relationship. The well-being of our patients, evidenced by their happiness, kindness, and gratitude, can be an antidote for all sorts of ills in the clinic. But when that is lost, everything else looks worse. Last year, about 50% of all MDs surveyed claimed a sense of burnout, and 23% planned to leave our profession. This tragedy victimizes each physician, but also produces a cascade of many other calamities, which is the subject of this editorial.

    This catastrophe manifests at many levels. Let’s start at the top of the pyramid. And since most of the readership of Scope are ophthalmologists, lets confine our analysis to our profession. We are a little luckier than other American physicians. “Only” 40% of ophthalmologists claim burnout, and perhaps “only” 20% are making plans to retire early or otherwise leave our profession.

    What are the implications of this on health care? Most of our patients are older adults, and yet this is the U.S. demographic that is expected to grow most rapidly. Our current residents may be expected to see 33% more elderly patients than we now do. If our ranks are reduced by 20%, then in 40 years each young ophthalmologist will need to see more than 60% as many patients than we currently do.

    What will that do to the already damaged doctor-patient relationship? What will that do to the quality of health care? What will that do to our profession when allied health professionals’ step into the void created and then attempt to elbow us aside? We may have had problems with health care delivery before, but with these changes we will be hard-pressed to claim that we still will have a first-rate health care system in ophthalmology.

    If the health care system is at the top of the pyramid, then one layer down will be the consequences on our profession as exemplified by our medical societies. In a decade or two, will we be enjoying our yearly meetings of the American Academy of Ophthalmology or our subspecialty societies? Will we be attending our regional and state society meetings? Are these venues sustainable for continued medical education and camaraderie and exchanges of resources?

    For these societies to work, several elements have to be continuously available including: 1) time for the clinicians to attend and attend with enthusiasm; 2) money for the clinicians to be able to forgo clinical revenues unavailable in their absence; 3) A cadre of volunteers who are energized by their pride and joy in their profession to feel the need to “pass it forward” to their colleagues; 4) educators, researchers and organizers who can draw on resources to participate in these less than lucrative activities; and 5) a cadre of employees sustained by membership dues.

    Those of us who have interacted with professional colleagues around the world know that we can’t take any of this for granted. And these shifts will likely undermine the political leverage of ophthalmologists in the face of the corporatization of medicine that is coming. A smaller number of overworked and underpaid and burned-out ophthalmologists are unlikely to be able to sustain our present system of medical societies.

    Three layers down from the top of the pyramid we can consider the effects on various types of practices. As an academician, I’m not qualified to comment on the strains on smaller private practices, except to say many of my colleagues are complaining that it’s much harder to make things work now. And in academics, the same is true. A department chair’s time and attention is now diverted almost entirely to issues of economic sustainability. And as new surveys reveal, the hospital system is not conducive to physician well-being.

    This brings us to four layers from the top (and only one layer from the base). This pertains to the consequences to each individual ophthalmologist undergoing burnout. I will summarize all these costs as “stress.” There are physical stresses as many ophthalmologists are putting in longer hours. There is the stress associated with long drive times in efforts to outreach to more distant patient communities. The physical and emotional stresses are myriad, such as social isolation, financial concerns, and marital stress as well as frequent worry about managing everything, including managing the stress. But what all these forms of stress have in common is that they lead to a biological stress response.

    Do you remember the biological stress response that you learned about in medical school? It starts simply but gets complicated as we look deeper into the neuroendocrinology. And much has been researched and understood recently. But let’s keep it simple. If you suddenly sense a lion stalking you, you are instantly stressed. You will get an immediate surge of your sympathetic system causing your blood pressure to rise, your heart to beat faster, your blood vessels to constrict (except to major muscle groups), your blood sugar to rise and your non-essential functions (like the digestive system), to be turned off (and indeed, starved of blood).

    The brain mediates this through the amygdala and other parts of the autonomic nervous system, and there’s no time for cognition to play much of a role. And, by the way, you will know that you are stressed, not by a cognitive calculation, but by sensing that your heart and vasculature are going crazy. We don’t tell our sympathetics to engage, they tell us. This epinephrine and norepinephrine mediated effect will only last a few minutes. It’s there to give you the best chance to run away from the lion. This is the first part of the famous, fight or flight response. But a few minutes later comes the second part, the release of glucocorticoid and related chemicals. This lasts longer and probably has the greater potential to be problematic when it occurs too often, and even worse, fails to abate. After all, lions either catch you or get tired when you scramble up a tree and then leave you be. But the aggravations of EMRs, hospital bureaucracy, cranky patients and governmental regulations can be near constant.

    Before we analyze this cortisol mediated stress response, we need to consider its purpose. Basically, it’s there to shift our focus from far to near. As ophthalmologists, we’re familiar with accommodation: great for seeing something at 14 inches, lousy for scanning the horizon. Only this time, we’re talking about time. So, the biological stress response doesn’t worry about the distant future but works to get you out of an immediate jam by using the sympathetic system and glucocorticoids, while simultaneously getting your parasympathetic system to take a break so you don’t waste energy and resources that are immediately needed. As Robert M. Sapolsky, a famed Stanford professor and neuroscientist, says in his book “Why Don’t Zebra’s Get Ulcers,” “If the lion is on your tail, two steps behind you, worry about ovulating or growing antlers or making sperm some other time.”

    In contradistinction, the parasympathetic system is optimistic that you will have a future worth investing in. And so it devotes resources to the future. We had better spend most of our time in parasympathetic maintenance mode, or the infrastructure will start to crumble.

    There is a lot of lay literature that suggests that the stress response is bad for you. Not only is that not true if a lion is on your tail, but short periods of the stress response may well be generally good for your health. The idea, though, is that you need both systems, sympathetic and parasympathetic in some sort of balance. So, the occasional stress response (both the adrenergic and cortisol components), doesn’t have to be bad. For example, certain parts of the immune system are enhanced by short term stress. As long as it comes and goes. But pretty soon, it has to go in order for the parasympathetic system and general body maintenance and repair systems to work. But what if the stress response is there chronically? Now you have a problem.

    We know that because we sometimes administer prednisone or some other glucocorticoid du jour to our patients and we know how dangerous our drugs or that part of the stress response is if continued over the long term. This includes osteoporosis, sarcopenia, immunosuppression, fluid retention, hypertension, diabetes, impairments of mood and memory, insomnia, GI problems and fat deposits in your abdomen. My full list (occasionally provided to my patients) goes on to describe 57 long term negative consequences of glucocorticoids. But you don’t have to take prednisone or other synthetic corticosteroids to get this. You can do it endogenously by suffering from chronic stress. Your pituitary and adrenals will mediate the response.

    Back to the issue of the doctor who suffers burnout. We all suffered from stress when we were on call. We all had moments in the OR that terrorized us. We all had the emotionally difficult job of telling a patient that they would go blind (or die). But we, hopefully, also had periods of peace and joy at play, relaxing or appreciating our work. We had a sense of control over our environment notwithstanding interruptions of stress. Despite the occasional crisis, seeing patients we could treat, having pleasant social interactions with many of our patients, having that special connection with a grateful patient, allowed us to enjoy many periods when our parasympathetic systems were purring. Most of us were able to leave most serious worries behind when we got back home and enjoyed the fruits of our labors with our spouses and kids (except when we were on-call).

    But if the next generation of doctors comes home angry and frustrated having spent the day arguing with patients and insurance phone representatives and having been told by hospital administrators and other regulators that our medicine must be done differently to maximize billings, then it’s really problematic. And if the main source of social contact is a computer that keeps spitting out a menu of must-dos and sends out unintelligible error messages, then the stress never ends, and the body and mind never heal. By the way, talking with friends and relatives lowers blood glucocorticoid levels. I doubt that “talking” to a computer does.

    I would like to see the application of science to our problem with physician burnout. Science is measurement and with that, we can begin to address these problems at the bottom of the pyramid. Do you know how scientists measured the chronic biological stress response a century ago? They weighed the thymus gland in experimental animals (or humans) that would be reduced to 1/3 of its size with chronic exposure to endogenous cortisol from chronic stress (reflecting the immunosuppressive effects of glucocorticoids). Do current physicians have a smaller thymus, or more osteoporosis? I suggest that having these outcome measures in hand might be a good first step in demanding changes. And such measures can also be used to see what changes are effective.

    We currently have plenty of hospital or academic medical center wellness programs. And I don’t doubt that for some, yoga, mindfulness, or transcendental meditation programs help. But which programs help which people succeed is currently unknown. The reality is that the institutional forces that have created this crisis are happy to toss programs at us, but they won’t take the problem seriously until we present it in a less touchy-feely way. When we show them science, they may listen. And when we show them not only the problem but clear solutions, they may even help us. So, this essay is a call for scientific outcome measures to what both Dr. Masket, and I fear is an imminent crisis.