By Doctor Jeffery Hollis, M.D.
Abstract
This article discusses the topic of physician burnout and its causes and treatment, focusing in particular on the current and potential future role of artificial intelligence to assist in prevention of physician burnout. The issues related to dissatisfaction and burnout with medicine as a career have been concerns for quite some time. In his 1992 book “Margin: Restoring Emotional, Physical, Financial, and Time Reserves to Overloaded Lives” Dr Richard Swenson discusses many of the issues that have contributed to the rapidly growing incidence of burnout in American medicine. (1)
Introduction
Physician burnout has recently reached epidemic proportions in the United States and the numbers increased significantly during the COVID pandemic. Increases were reported to be from 43.9% in 2017 to 63% in 2022, according to a survey by the American Medical Association.(2) Also noted in another recent survey published by the Mayo Clinic, there has been a higher percentage of burnout in female physicians, reported at 51%, compared to that in male physicians, at 36% (3).
Burnout is not exclusive to medicine. It can occur in any occupation. It has been described using various parameters. The American Psychological Association defines burnout as “ physical, emotional or mental exhaustion, accompanied by decreased motivation, lowered performance and negative attitudes towards oneself and others.“ (4) The Agency for Healthcare Research Quality labels burnout as a “long term stress reaction marked by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment” (5)
In an article in 2018 Dr Herbert Fred and Mark S Scheid described burnout in physicians as “characterized by emotional exhaustion, finding work no longer meaningful, feelings of ineffectiveness, and a tendency to view patients, students, and colleagues as objects rather than as human beings. Associated manifestations include headache, insomnia, tension, anger, narrow-mindedness, impaired memory, decreased attention, and thoughts of quitting. In certain situations, physical exhaustion and moral distress are prominent features.“ (6)
Dike Drummond, MD, uses a metaphor to describe burnout as a negative “energy account”. “Like a bank account, it can have a positive or negative balance. You withdraw energy from this account for the activities of your life and medical practice. You deposit energy into this account during times of rest and rebalance. When you dip into a negative balance, the account does not get closed. You keep spending (or working) despite the fact that your energy account is depleted… Burnout is the constellation of symptoms that occur when your energy account has a negative balance over time. You can continue to function in this depleted state; however, you are a shadow of the doctor you are when your account has a positive balance… There are actually three types of energy accounts inside each of us:
- Your physical energy account. You make energy deposits here by taking care of your physical body with rest, exercise, nutrition – all the things we learned not to do in our training.
- Your emotional energy account. You make energy deposits here by maintaining healthy relationships with the people you love – your friends and immediate family. Recharge here is essential, if you are to have the energy necessary to be emotionally available for your patients, staff, family, and friends.
- Your psychological energy account. You make deposits here by regularly connecting with your personal sense of purpose. In your practice, this occurs when you have an ideal patient interaction. This is the visit where you say to yourself afterwards, “Oh yeah, that is why I became a doctor.” You can connect with purpose outside of work as well. One example for me is when I coach my children’s youth soccer teams. If you go long periods without connecting with purpose, this account is drained and you may have a lot of trouble seeing a reason to carry on.
As physicians, we each have a moral imperative to keep our energy accounts in a positive balance because of a physical reality I consider to be the first law of physician burnout: “You can’t give what you ain’t got.” If you remember nothing else from this article, please remember this law. “ (7)
The consequences of physician burnout are quite negative and far- reaching . For the physician, burnout certainly reduces job satisfaction and can cause early retirement and change of occupation, which leads to exacerbating the physician shortage in the US. It has been estimated that ”almost 3% of the (US) healthcare workforce ( this includes physicians and nurses and other health care workers ) is resigning from medicine each month, accounting for 1.7 million people who quit last year. More than a quarter of those resignations are credited to burnout”. (8) One estimate is that 71,309 physicians left the practice of medicine in 2021-2022. (9) Burnout is also is believed to contribute to drug or alcohol abuse in physicians (5) and to physician suicides (7).
From the patient’s perspective, physician burnout is believed to contribute to decreased patient satisfaction and decreased quality of medical care. It is also believed to contribute to medical errors. Factors that likely contribute to increased medical errors include “closed” thinking, impaired memory, decreased attention and viewing people as objects” (6).
Burnout can also be contagious. The physician’s words and actions as they are experiencing burnout can have a negative effect on their colleagues and other health care workers. A physician experiencing burnout might look to an observer as a person who is depressed, but there is a difference. Burnout tends to be a response to a specific environment or situation, depression is more generalized. The signs of burnout as noted by the Cleveland Clinic include fatigue, feeling apathetic or dissatisfied with work, headaches , and changes in diet or sleep patterns. (4).
The accepted standard for burnout diagnosis is the Maslach Burnout Inventory, developed by Christina Maslach at the University of San Francisco in 1970. Her team was the first to describe burnout and name the syndrome.” The following are the three main symptoms.
1) Exhaustion
The physician’s physical and emotional energy levels are extremely low and in a downward spiral over time. A common thought process at this point is, ‘I’m not sure how much longer I can keep going like this’
2) “Depersonalization”
This is signaled by cynicism, sarcasm and the need to vent about your patients or your job. This is also known as “compassion fatigue”. At this stage you are not emotionally available for your patients, or anyone else for that matter. Your emotional energy is tapped dry.
3) “Lack of Efficacy”
You begin to doubt the meaning of your work. ‘What’s the use, my work doesn’t really serve a purpose anyway.’ Or you may worry that you will make a mistake if things don’t get better soon.” (10)
The causes of burnout are multifactorial and vary between clinicians . They involve the personal make-up of each clinician ( e.g. depth of commitment, upbringing, role models, expectations, moral values, level of stress tolerance, and resiliency). Other factors include a loss of autonomy, treating the data and not the patient, “ a world of rules”, asymmetric rewards , a sense of powerlessness and issues related to the use of electronic medical records. (6) Additionally, family responsibilities, time pressure, chaotic environment, low control of pace at work, and unfavorable organizational culture contribute to physician burnout. (5)
The prevention and treatment of burnout are also multifaceted. There are factors that can be controlled by the physician and those that are under the control of the healthcare system in which the physician practices. Much has been said about how a physician can become more resilient and less likely to experience burnout . Suggested areas of focus include some basic interventions for the physician to implement, such as working on a healthier personal lifestyle, including adequate sleep, a healthy diet, physical activity, stress management, avoidance of substances, and positive social relationships. (11) Dr Dike Drummond, on his website, The HappyMD.com presents 235 suggestions on interventions a physician can perform in order to prevent physician burnout.
There are also many factors that are outside of the physician’s control. This is an area where hospital administrators and clinic leaders can have a major impact . The AMA has been quite active in helping health care leaders and physicians prevent and treat burnout . They have developed a survey to assess the level of burnout in a medical organization, called an “Organizational Biopsy”. They also have become quite active through a program called the “AMA Recovery Plan for America’s Physicians “. This program focuses on initiatives that can be used to help strengthen physicians and prevent and treat burnout. It is intended to be “ an ambitious but doable roadmap to address major challenges physicians are facing.” (12) It focuses on five areas:
- Fixing prior authorization
- Reforming Medicare payment
- Fighting scope creep ( the gradual addition to the scope of practice of nonphysicians)
- Supporting telehealth
- Preventing physician burnout
In addition they have a program called “ Joy in Medicine Health System Recognition Program” . This program recognizes and rewards organizations that are making positive changes to improve physician wellness
The prevention and treatment of physician burnout has also been addressed by the US Surgeon General, Dr Vivek Murthy. He suggested that the following interventions would be helpful for physicians :
- Providing easily accessible mental health services
- Reduce the administrative burden on physicians
- Maximize the physician’s time at the bedside
- Place more emphasis on compassionate care
- Decrease the time spent on progress notes and other documents
- Make precertifications and preauthorizations easier and faster (13)
The AMA also has a “Steps Forward “ program , which has an evidence-based module on burnout prevention. They recommend “ Seven steps to prevent burnout:
- Establish wellness as a quality indicator for your practice
- Start a Wellness Committee and/or Choose a Wellness Champion
- Conduct an Annual Wellness Survey
- Meet Regularly with Leaders and/or Team Members to Discuss Data and Interventions to Promote Well-Being
- Initiate Selected Interventions
- Repeat the Survey Within the Year to Reevaluate Well-Being
- Seek Answers Within the Data, Refine the Interventions, and Continue to Make Improvements (14)
An article in the AMA News Wire dated 10/19/2023 had a blunt approach to reducing burnout in their article “Slash burnout – and boost patient safety – by ditching ‘stupid stuff’ ”. They describe ‘stupid stuff’ as “ tasks that create a burden without adding value to the care patients get.” (15)
In 2023 there has been much discussion of artificial intelligence and how it could or should be incorporated into the practice of medicine. In the context of this article, the issue becomes how AI can be used to prevent or treat physician burnout.
There are actually several areas where AI is already being used and is having a positive impact on physician wellness . One area is the use of an AI scribe to create progress notes and other clinical documents. Initially these AI produced notes were sent to a human reviewer before being routed to the physician for editing and incorporation into the EHR. But in 2023 the AI scribe has improved to the point that many companies now send the document to the physician directly after its creation, so it can be edited and placed in the EHR within just a few minutes of its creation. Reports back from physicians have noted that this has allowed for a substantial reduction in time spent creating these documents, thereby reducing the stress related to the time and energy needed to produce progress notes . For instance, an article in the New York Times describes how one physician has reduced his daily time needed to produce progress notes from 2 hours down to 20 minutes. (16) Other physicians have also reported substantial time savings.
Secondly, AI is being used to reduce the number of emails that a physician needs to address personally . For instance, AI can help redirect an email to another member of the healthcare team, when it has determined that the physician’s input is not needed to address that particular email.
Thirdly, AI is also being used to answer patient questions . The clinician does not need to produce an answer to a patient question. The physician needs only to review and edit, and many clinicians and studies have found that the chatbot answers are generally very good in terms of accuracy and overall quality and even empathy. (17)
Finally, there are other areas in which AI is being incorporated into clinical practice. One of those is to automate (with AI) the process of pre-authorizations and pre-certifications. These are a frequent cause of frustration and can consume significant amounts of the clinician’s time. As AI is able to do much of this without prolonged direct physician involvement, this then has the potential to reduce stress and save time
A survey published in July 2023 looked at clinician preferences for interventions to address clinician burnout in a hospital setting. This survey found that clinicians preferred “action by management to address insufficient nurse staffing, insufficient clinician control over workload, and poor work environments; they were less interested in wellness programs and resilience training.”(18) These are areas where there is potential for AI to be helpful in various ways, including using an AI scribe to help nurses and doctors create progress notes.
AI is currently being implemented in medicine in several practical ways, some of which will likely reduce the stress and burnout in physicians, and AI will undoubtedly be integrated into medicine in many more applications over the next several years. We have a responsibility to use it in ways it can be beneficial, while minimizing the risk of any harm. Sami Inkinen, CEO of healthcare startup Virta Health, has stated that AI gives doctors “superpowers”. We need to be wise in how we use those “superpowers” (19).
Footnotes:
- Margin: Restoring Emotional, Physical, Financial and Time Reserves to Overloaded Lives by Richard A. Swenson, M.D. copyright 1992, Navpress
- Mayo Clinic Proceedings, “Changes in Burnout and Satisfaction with Work-Life Integration in Physicians During the First Two Years of the COVID-19 Pandemic”, Volume 97, Issue 12, pp. 2248-2258, December 2022 by Tait D. Shanafelt et al
- The Permanente Journal, June 12, 2023, “Gender Differences in Physician Burnout: Driving Factors and Potential Solutions” by Radmila Lyuborova, M.D., et al.
- Cleveland Clinic Health Essentials, February 2, 2022, quoting the American Psychological Association
- Agency for Healthcare Research: www.ahrq.gov/sites.default/files/wysiwyg/professionals/clinicians-providers/ahrq-works/impact-burnout.pdf
- Texas Heart Institute Journal, August 2018; 45(4): pp. 198-202 “Physician Burnout: Causes, Consequences and (?) Cures” by Herbert L Fred and Mark S. Scheid
- Family Practice Management, 2015, 22(5), pp. 42-47. “Physician Burnout: Its Origin, Symptoms, and Five Main Causes” by Dike Drummond, M.D.
- Healthcare IT Today, October 5, 2023, “The New Pandemic: Burnout Threatens to Wipe Out a Generation of Providers” by Amanda Ford (Amandaford@healthcareittoday.com)
- Becker’s Hospital Review, October 16, 2023, “Healthcare workforce lost 145,213 providers from 2021 through 2022” by Kelly Gooch
- Missouri Medicine, July-August 2016, 113(4), pp.252-255, “Part I: Burnout Basics – Symptoms, Effects, Prevalence and the Five Main Causes” by Dike Drummond, M.D,
- Healio Ocular Surgery Notes, October 9, 2023, “Lifestyle Medicine Mitigates Burnout, Prioritizes Wellness”, by Anthony DeFino
- Health Prime, July 4, 2022, ‘AMA released a new recovery plan to support Physicians” www.hplinc.com>educational-blog>ama-released-a-new-recovery-plan-to-support-physicians/
- Healis, June 3, 2023, “Surgeon General: Burnout has Many Health Care Workers ‘in Crisis’ “ by Mark Leiser, healio.com/news/hematology-oncology/20230603/surgeon-general-burnout-has-many-health-care-workers-in-crisis
- AMA Ed Hub, “Physician Burnout. Improve Physician Satisfaction and Patient Outcomes” at AMA Ed Hub > AMA Steps Forward (edhub.ama-assn.org/steps.forward/module/2702509)
- AMA News Wire, October 19, 2023, “Slash Burnout – and boost Patient Safety – by Ditching ‘Stupid Stuff’ “ by Tanya Albert Henry (ama-assn.org/practice-management/physician-health)
- New York Times, June 26, 2023, “AI May Someday Work Medical Miracles. For Now, It Helps Do Paperwork” by Steve Lohr
- JAMA Internal Medicine, April 28, 2023, pp. 589-596, “Comparing Physician and Artificial Intelligence Chatbot Responses to Patient Questions Posted to a Public Social Media Forum” by John W. Ayers, PhD MA, et al.
- JAMA Health Forum, July 7, 2023, “Physician and Nurse Well-Being and Preferred Interventions to Address Burnout in Hospital Practice. Factors Associated With Turnover, Outcomes, and Patient Safety” by Linda H. Aiken, PhD R.N., et al
- TechCrunch+, August 27, 2017, Twitter by Sami Inkinen, CEO Virta Health