ARTICLE IN BRIEF
Written-in responses from US neurologists to an open-ended question on an AAN survey on burnout revealed common themes — concerns about the time required for electronic health records and having to meet government mandates on quality standards. But they also reflecting a surprising sentiment: Many felt they were not appreciated or respected as professionals.
After answering 53 multiple-choice questions about burnout, career satisfaction, and work-life balance, survey respondents could have been forgiven if they passed on the final question: “Is there anything else you would like to share with the AAN regarding burnout and well-being?”
Yet, 676 AAN members seized the opportunity.
“People wrote extensively — more than a few lines,” said Janis M. Miyasaki, MD, FAAN, director of the movement disorders program at the University of Alberta and a member of the AAN Board of Directors. “Some people wrote pages of answers...and you can hear in their words their suffering.”
Burnout, a significant problem among United States physicians and other clinicians, occurs when a physician experiences one or more of these three factors: depersonalization, emotional exhaustion, or a low sense of accomplishment.
Neurologists' comments were given in response to a single open-ended question included in a survey of AAN US member neurologists between January and March of 2016. The comments were analyzed and reported in a study published in the September 20 online edition of Neurology.
For the purposes of this study, analysis was limited to comments made by survey respondents who are current practicing US-based neurologist members of the AAN. Dr. Miyasaki and Neil A. Busis, MD, FAAN, clinical professor of neurology at the University of Pittsburgh School of Medicine, were the principal physician coders, responsible for reading the comments and identifying the most prevalent themes.
That analysis added important insights to the survey's main findings — that six out of 10 AAN member neurologists reported at least one symptom of burnout — as reported previously in Neurology Today (“AAN Survey: Six out of Ten Neurologists Report Feeling Burned out What Can Be Done to Fix the Problem?” http://bit.ly/NT-burnout-survey).
“This further characterizes neurologists' burnout by listening to their own voices,” Dr. Busis, a member of the AAN Board of Directors, said. “This was astonishing.”
The new paper is the third Neurology publication stemming from the AAN's burnout survey. It is one of the few qualitative studies in the burnout literature, Dr. Busis said, and it confirmed some of the suspected causes of burnout — and revealed some surprises.
JUST AS WE EXPECTED
The qualitative analysis identified two broad themes — policies and people affecting neurologists and workload/work-life balance — that are frequently mentioned in discussions of burnout.
Respondents cited government mandates, including the electronic health record Meaningful Use program and the Physician Quality Reporting System, as hassles that reduce time with their patients and increased the costs of practice but do not benefit patients.
Other concerns included time-consuming fights with insurance companies to get approval to treat their patients appropriately; inadequate pay compared to other specialties, considering the difficulty of neurology practice; the stress and financial burden of the maintenance of certification process, which may not improve patient care; and leaders who focus on profits over patient care and force neurologists to accept more work than appropriate.
“They were often speaking not so much about remuneration, although that was an issue, but about how eroded they felt the relationship between them and their patients has become,” Dr. Miyasaki said.
Dr. Miyasaki said she hopes this analysis of neurologists' comments will stifle administrators who suggest physicians would suffer less burnout if they managed their time more wisely.
“Our results confirm those from other investigators who are looking at this deeply: The problem is not that doctors are bad time managers,” she said. “Health care has changed massively in the last 10 years, and this change in the environment has really impacted physicians to a large extent.”
Workload — defined as both direct patient care and work not related to patient care — generated more comments than any other issue. Many respondents lamented the amount of time they devote to electronic health record technology.
“Rather than spending time with their families, neurologists were often saying they were spending at least two hours for every clinical day at home doing their charting,” Dr. Miyasaki said. “Many administrations also expect physicians to answer immediately when patients email them through the electronic chart, which further adds to their burden and may not always be medically necessary. But this is a metric that is placed upon them.”
A SURPRISING RESULT
The concept of professionalism was not addressed in the AAN's multiple choice survey questions, but it surfaced in more than 300 comments.
“This was really a new theme that was brought up by the qualitative study, that we are no longer treated as professionals, but we are treated as widgets,” Dr. Busis said.
Dr. Miyasaki recalled comments from some respondents comparing themselves to “worker bees” and “hotel clerks” who are not treated as professionals. Others said they were not understood or respected by colleagues, management or policymakers, and that the demands for shorter appointments undermined their ability to diagnose complex conditions and properly care for patients with debilitating diseases.
SOLUTIONS WITH MIXED RESULTS
The survey did not ask neurologists to share or suggest solutions to burnout in neurology, but the open-ended question prompted many to share their thoughts.
Some suggested efforts to reduce time spent on EHR and prior authorization tasks; others said adequate pay for night call and money to hire skilled staff and advanced practice providers would mitigate burnout.
But another solution — curtailing practice in small or large ways — caught the coders' attention.
“Many members mentioned removing themselves from call and removing themselves from hospital service as a way to reduce burnout,” Dr. Miyasaki said. “We were surprised by the number of people who actually mentioned these strategies.”
Drs. Miyasaki and Busis both said they worry about how such strategies will affect patient care — and the well-being of those neurologists who maintain a traditional practice.
“A number of the solutions given were ‘I quit. I retired. I cut back my workload,’” Dr. Busis said. “That works great for them, but what about the system?”
WHAT US NEUROLOGISTS HAD TO SAY ABOUT BURNOUT
Following are excerpted comments from the latest paper from the AAN survey on burnout among US neurologists:
“The amount of non-patient care requirements, primarily government- and insurance company-generated idiocy so detracts from the ability to spend time caring for my patients, and that prevents the practice of neurology from being satisfying.”
“Another significant factor in physician burnout is the control of all aspects of patient care wielded by insurance companies. As a physician, I can only recommend or request a diagnostic test or medication since the ultimate decision will be made by the insurance company.”
“The [EHR] is useful for bean counters but has done nothing to improve medical practice/patient care and is very destructive to the doctor-patient relationship.”
“Patients with complex neurological conditions need a lot time. I am expected to see follow-ups in 15 minutes. It is taking a toll on my health because I don't have time exercise or cook healthy foods. [It is] taking a toll on my family.”
“What keeps me going is the sense of service, when in the middle of the night, in the ED, I am with a patient whom I can help and whose life I can help for the better.”
“I stopped all hospital-based practice including consultations because of burnout.”
“My oxygen is my colleagues and my intellectual curiosity.”
“I think that at the core, neurologists are burnt out because they do not feel adequately respected and reimbursed for choosing one of the most challenging and dynamic specialties in medicine. We feel that the ‘deck is stacked against’ cognitive specialists such as neurologists in favor of the proceduralists/surgeons.”
Source: Miyasaki JM, Rheaume C, Gulya, et al. Qualitative study of burnout, career satisfaction, and well-being among US neurologists in 2016. Neurology 2017; Epub 2017 Sept 20.
This article is part of an ongoing series in Neurology Today on burnout in neurology. Future issues will look at how institutions and practices are addressing specific concerns around burnout.