ARTICLE IN BRIEF
A new analysis offers three main reasons for why neurologists are burned out. Experts comment on what neurologists can and should do to combat burnout.
Are physicians “burned out”? Yes, according to recent surveys — and the limited research suggests neurologists are among the most burned-out.
Writing in the Nov. 5 online edition of Neurology, former AAN President Bruce Sigsbee, MD, and James L. Bernat, MD, FAAN, cite three main aspects of physician burnout: emotional exhaustion, the loss of interest and enthusiasm for practice; depersonalization, a cynical attitude that results in treating patients as objects; and career dissatisfaction, a diminished sense of personal accomplishment and low self-value.
Burnout can result in reduced work hours, relocation, depression, and even suicide. What's more, burned-out physicians may harm patients because they lack empathy and make errors, Dr. Sigsbee and Dr. Bernat, the Louis and Ruth Frank professor of neuroscience and a professor of neurology and medicine at the Geisel School of Medicine at Dartmouth University, wrote.
They noted that a 2012 national survey of 7,288 physicians evaluating the rates of burnout across specialties found that 45.8 percent of the respondents exhibited at least one symptom of burnout. And physicians fared much worse on all three domains of burnout compared to the general population.
Most striking, the incidence varied substantially by specialty, with neurologists ranked third — even higher than family medicine. “More than 50 percent of neurologists exhibited at least one symptom of burnout,” Drs. Sigsbee and Bernat wrote. “Pediatrics, a specialty characterized by low income and high practice demands, fared much better, suggesting that the underlying causes of burnout are more complex than simply income or workload.”
Their views are affirmed in an accompanying editorial by Neil A. Busis, MD, FAAN, chief of neurology and director of community neurology at the University of Pittsburgh Medical Center-Shadyside.
“The American Academy of Neurology Workforce Task Force predicts a future shortage of neurologists,” wrote Dr. Busis, who is also a member of the Neurology Today editorial advisory board. “Physician burnout could contribute to the shortage, but could also result from a shortage. If burned-out neurologists continue to practice, patient care may suffer due to poor medical judgment and more errors. If neurologists drop out of the workforce, access to care will decrease. If medical students consider neurology undesirable, few will enter the field.”
PERSONAL AND PROFESSIONAL FACTORS
In comments to Neurology Today, Drs. Busis and Sigsbee agreed that personal factors such as poor coping and adaptive skills may contribute to physician burnout and that these may be amenable to counseling. But they also emphasized the role of systemic factors in physician burnout, especially the loss of autonomy, increasing financial pressures to see more and more patients, and “hassle work” associated with technology that is not user-friendly and clinically irrelevant administrative requirements.
“Looking back at my own career, there have been several points where I was terribly burned out,” Dr. Sigsbee said. “There was not a good supportive group of neurologists working in a collegial fashion, and the workload was off the charts.”
He said that as more and more physicians become employed in large health systems, there is a loss of the autonomy doctors have traditionally enjoyed and a growing pressure to see more and more patients. And both Dr. Sigsbee and Dr. Busis pointed to the imposition of electronic health records (EHRs) — many of which are not user-friendly or clinically helpful — as a prime target for remediation of job dissatisfaction.
“There is a great deal of promise in electronic health records to capture data and have it immediately at hand,” Dr. Sigsbee said. “But the way it has been implemented is awkward, slows us down, and amounts to a huge change in how we conduct our practice.”
Dr. Busis added, “If we can come up with more meaningful quality measures, that would help. If you are just checking boxes in an EHR, that's not quality. We really need to work with EHR vendors to make the technology easier and more clinically helpful. But current policies mandate the opposite. EHRs have been imposed on practices and physicians have been told, ‘Adapt your practice to them.’”
Two clinicians who spoke with Neurology Today agreed that burnout is a problem. But Sarah Benish, MD, a neurologist with the Minnesota Clinic of Neurology, added that she is not certain whether burnout is more common now, or whether a better vocabulary has simply emerged for discussing it.
“I think all physicians need to recognize that they are human and need to turn off from the job to make them better at the job when they are there,” she told Neurology Today. “I often counsel patients and caregivers about the importance of taking care of themselves to enable them to care for others. Now it is time for physicians to take their own advice.”
Dr. Benish said she has been with the Minneapolis Clinic of Neurology, a physician-owned practice, since 2007. “I have learned that I need to take some days off to help manage burnout,” she said. “I now take the Monday off after working the whole weekend so I can reboot from the emotional exhaustion. I often take Wednesdays off the other weeks, which allows me to get the kids to their orthodontic appointments, catch up on laundry, complete my CME, and finish paperwork from the office. I have found that even though my income has taken a hit from taking this time off, my mental wellbeing is stronger for it.”
But, she added, “I can do this because I am in a physician-owned practice where I can decide my schedule. As an employee, I am not sure how it would work.”
There may also be differences in how senior physicians and junior physicians experience burnout, Dr. Benish said. “Senior physicians seem to be dealing with the change in how medical care is provided compared with their past way of practicing,” she said. “The movement toward EHR, quality improvement, and measurement documentation seems to be quite a shift for them, and I think they may feel their loss of independence more than some of the younger neurologists. Junior neurologists are more likely to experience burnout trying to find a balance between work and home while advancing their careers. The solution they often find is to consider employed work rather than running a practice.”
Edward Manno, MD, a neurologist and intensive care specialist at the Cleveland Clinic, agreed that burnout is ubiquitous and may be especially prevalent among neurologists. “At my bedside I have a book entitled Spiritual Life for the Overbusy,” he said. “But I haven't had time to read it.”
Dr. Manno emphasized the aspects of neurology that are intrinsic to the specialty as a source of burnout, especially the profoundly life-changing nature of some of the conditions neurologists treat. “In neurology you have to deal with conditions that affect the very essence of the person,” he said. “If you have a heart attack or liver disease, that makes you sick but it doesn't affect your personhood. But anything to do with the brain has the capacity to change the nature of that individual. A patient can have a very small stroke, but if it's in a targeted area it can have a profound effect on someone's life. Neurologists have to deal with the emotional toll of discussing this with the patient and the family.”
He added, “There are a lot of diagnostic dilemmas in neurology. Patients are miserable, and treatment options may be limited.”
And, he said, the systemic factors discussed by Drs. Sigsbee and Busis — loss of autonomy, administrative demands, burdensome technologies — combined with the grave nature of many neurologic conditions mean less satisfaction for clinicians. “Many of the administrative demands are demoralizing and devalue the role of the physician,” he said. “And they take you away from the bedside, caring for patients and their families and dealing with some of these grave issues associated with neurological disorders.”
WHAT CAN BE DONE?
Something immediate that clinicians can do to combat burnout is to assert control over their professional lives through involvement with professional associations that are looking out for their interests, Dr. Busis said. “The thing that has prevented me from burnout has been being active in organized medicine,” he said. “It helps to restore the sense of control over your professional life. I look forward to those meetings with colleagues in the field because I am participating in helping the profession.”
He predicted that physician wellness will continue to be a concern. “This is going to be a topic of growing importance in the future — how best to react to things you can't change, and how to change the things you can.”
Dr. Sigsbee added that there is room for optimism as the entire field of medicine moves toward integrated, team-based care. This sort of practice redesign can help neurologists “get off the treadmill,” he said.
“Rather than just trying to integrate electronic health records into the way we have always done things, there is now a lot of movement toward real practice redesign,” he said.
He noted, for instance, that many neurologists now have advanced practice nurses to help with a lot of clinical issues. “Some academic medical centers have moved to a completely team-based approach to care, which means that the individual physician does not have to feel like he or she has to do everything. This requires an active process of reorganizing what people are doing and giving them guidance on how best to use their talents and interests as they move through their career.”
The effort is worth it, Dr. Sigsbee said. “Neurology is a great specialty. Over the next 20 or 30 years it's going to be extremely exciting with all the new treatments for disorders that, so far, we have not been able to touch.”
AAN President-elect Terrence Cascino, MD, FAAN, professor of neurology at the Mayo Clinic in Rochester, MN, said the problem of neurologist burnout will be very high on the agenda of his presidency in 2015. Dr. Cascino will chair a task force on the subject charged with two tasks: to study why neurologists — who are subject to the same pressures as many other physicians — should have such a high rate of burn-out; and to look at tools for remediation.
“There are valid survey tools designed to measure burnout,” he said. “So we want to scientifically study why neurologists have such a high rate of burnout,” he said. “A lot of people have opinions, but the truth is no one knows. So the first thing we need to do is study this phenomenon in a scientific way.”
“Ultimately what we really want to do is help to lower the rate of burnout for the next generation of neurologists,” Dr. Cascino said.