Saturday, March 03, 2007

Burnout: Embers

The medical director of my clinic once gave me a book on burnout. I never read it. Didn't have the time or energy.

Because a young reader considering a career in surgery referred to stories he's heard of depressed and disappointed surgeons and asked for my thoughts, I'll try to address it. Parenthetically, I've heard from more than a few readers that my blog and/or book has inspired them to consider surgery as a career. Don't know whether to smile proudly, or shoot myself.

I quit my practice much younger than I'd have predicted when I went into it. In thinking about the reasons, not all of which can I distill, I can't make the claim that one ought to generalize: I speak only for myself. In some things, the themes are universal; in others, maybe more particular to me than my colleagues. As with many others, it's true that my love for my work diminished over the course of my career: yet at its core, the rewards and pleasures remained. It's just that it was harder and harder to access them, as the layers of bullshit of all sorts increasingly hid it all from view. Maybe it's like this: early in my career a day of work had ten pounds of pleasure in it. By the end, it was still ten pounds (heck, maybe even twelve), but I had to wade through fifty pounds of crap to find it. Thirty years ago, it was only five.

Surgeons my age are transitional characters. When we first dipped our toes in the pool we were touched by ripples of the good old days: regulations were minimal, the default presumption was that we knew what we were doing, most of our time was taken up with actual patient care. The occasional meeting. Serving on a committee once in a while. And we could charge what we thought was a fair price for what we did. Let's get that last concept out of the way first. (Reality check: not everything about the good old days was good, especially for the consumer. I admit it enthusiastically. It's not necessarily better now; just different.)

I've yet to meet a medical doctor of any sort who went into the profession first and foremost for the money. (For some, that came later.) Nor would I claim that doctors deserve to be the highest paid of professionals. In fact, at the time I took up the scalpel, I thought many docs -- surgeons especially (general surgeons less so!) -- made way too much money. The public health would be much more adversely affected were garbage collectors to cease to exist than if doctors did. Yet there's a truism: most people willing to work very hard, who have an ethic of excellence, who take great and justifiable pride in what they do, expect some sort of reward commensurate with and in some way proportionate to the quality of their product. And money, for better or worse, is one of the vehicles for providing that reward. Not the only one; not, maybe, the most important one. But a very tangible one. Measurable. Whereas I recognize that speaking about it at the outset risks losing any sympathy (in fact, I'm not asking for sympathy: I'm just trying to explain, and to answer an honest question), I think it's central, symbolically, to understanding the unhappiness that I and many of my cohorts came to feel.

My brother is an attorney. A very successful one; a senior partner in one of the US's bigger international firms. I gather he's really good at what he does: the accolades he's received within his profession attest to it, as do (to the extent that I can understand them) the extremely complex cases he's guided to favorable outcomes. He charges by the hour, a hefty sum which has risen steadily over the course of his career. More, I gather, than many of his peers. And, I'd wager, his clients are happy to pay it: for their top dollar, they get a top echelon lawyer who can be counted on to work his ass off and most likely prevail in their cause. To them, he's worth it. (Makes four times more than I ever did, and is probably four times better at what he does than I was at what I did -- I'm thinking there may be greater divergence among good attorneys than among good doctors.) As in virtually every other profession, you get what you pay for. Not so, any more, with medicine.

Two things have happened to physician reimbursement, and both have had a perverse and adverse effect on professional morale. First, payments have steadily declined, to about a third of where they were when I started out. Second, fees have become standardized, meaning Doctor A gets exactly the same amount to take out a colon as Doctor B, no matter how much better at it one is than the other. By law and/or contract, doctors have no ability to establish their own charges or to collect the difference. In the first instance, the effect is that doctors have to work harder and harder every year just to stay even financially; in the second, it means there's no incentive -- financially anyway -- toward excellence. If money is a surrogate for acknowledgment of a job well done, the current system says "we don't give the slightest shit about whether you are doing your job better than the next guy or girl." Take it, and shut the f@*k up. Or so it seems. You may or may not believe this: doctors are, for the most part, altruists. The real rewards come from doing right by the patient. I love the relationship I have, as a surgeon -- especially and particularly as a surgeon -- with my patients. I love (except when all hell breaks loose) being in the operating room. (Heck, sometimes even then: as long as I can bail myself and my patient out, able to tell myself I did good, and seeing the instant proof.) But (or is it "so?") it's enormously deflating every year to get the latest announcement from Medicare, or Blue Cross, or for-profit Joe the insurer and its multimillionly paid exec, of the latest cut in what they'll pay me. Similarly, the notion that they'll be paying the same amount to some guy who I KNOW is not getting the results I am (or saving them the amount of money I am, by virtue of a passion for cost-effective care and willingness to work extra hard to achieve it.) Like I said, it's perverse. And my claim is that it's having an effect on who chooses to go to medical school, and who chooses to go into the most demanding specialties. My friends in academic medicine seem to agree. It's elsewhere that hard work and excellence are valued more.

Every year I was in practice I made more than in the previous year, despite the fact that in virtually every year, reimbursement declined. The reason is obvious: I simply kept working harder and harder. Partly it's because that's who I am: I never took as much time off as I was allowed, I always took call on my own patients, rounded whether I was on or off. So here's an instance in which my behavior contributed particularly to my burnout. But the milieu was the same for everyone. And it compounds itself: as you work harder and harder to stay even, you'd like to hire some help. But anticipating further cuts, you feel you really can't afford to. As I got older I came to think I'd be happy to trade time for money; but my younger partners -- with young kids and longer futures -- didn't want to take the financial hit. And whereas they were taking the same amount of call as I was, they (perhaps wisely!) kept fewer office hours, saw fewer patients, and took more vacation. And why shouldn't they? Coming along in the new era, maybe they saw that hard work wasn't recognized and rightly concluded it wasn't worth it. Yep, you get what you pay for.

So that's a foundational background. Money isn't an explanation, but it is sort of a microcosm. I'll think some more about the rest of it, and let you know what I come up with. Next.


SeaSpray said...

Ha! (Off topic for a minute) Your Picture and title amused me because it reminded me of my husband's birthday cake last night. My sweet m-i-l made his cake but didn't bring candles and I didn't have any left. There just has to be at least one candle on the cake, so I put one of those wooden candles in the center and even though I cupped my hand around it -it burned out before getting the cake to him. So, we stopped singing happy birthday, I went back to the kitchen and did the same thing, only this time being extra careful with the flame.

So, as I got near him and we are all singing the birthday song, I could see that darn flame was going to burn out again. So in the middle of the song I lunged toward him and said BLOW! He did. It was a draw. :)

Your article concerns me regarding the future quality of health care. We, the public need surgeons and quality ones. I truly hate that we have an insurance system that is increasingly becoming counterproductive to the recruitment of doctors, or that prevents a patient from having the necessary care required because someone who is a non-medical person determines what is allowed, etc.,etc.,etc. ad nauseam.

I don't understand why surgeons and hospitals that participate with the plans have to take such drastic cuts as opposed to the non-participants. I realize that more business comes their way. I have experienced it both ways and obviously I would choose what I can financially afford. I did choose an ortho surgeon because of his reputation in our area even tho he wasn't on our plan. He did a meniscal repair twice on the same knee - 8 yrs apart. After the 2nd surgery I noticed on his bill that he reduced my 1200.00 out of pocket balance by 600.00 and that was also reflected on my insurance EOB. I didn't expect it and he certainly wasn't obligated to do it, but I was most grateful to him.

I know based on what you have written that you went the extra mile with your patients and even though you were a busy surgeon, not only did you care about their physical well being, but their emotional as well. Obviously, you couldn't do it all the way you would have liked and something had to give - in time. I know from listening to doctors and nurses over time that they do feel a certain level of frustration because they feel they can't give the quality time that they would like to. If I were a nurse, especially if I had first worked in an era where a nurse could give quality time to a patient and then had to do it like they do today - I too would be frustrated because I would want to help then physically but also minister to their mind and spirit.

New regulations and piled on paperwork! So much time spent with that over quality time with "hands on". Obviously, everyone gives the best care they can but then it's like you said - more pressure. EVERYTHING needs to be documented. Of course, this protects patient and medical personnel should any future questions arise. I have seen where doctors feel they need to publicly verbalize something if they are with a group of their peers and a patient makes a statement, even if innocently in front of them where possibly it could be construed as a future complaint. That's sad that a doc would need to feel so defensive because of our overly litigious society. It's like everyone is walking on egg shells.

I know a surgeon who (about 10 or so yrs ago) said if he could, he would get out of the business - but he stayed until regular retirement age. He was unhappy with the insurance companies.

It is good to take vacation or find some sort of recreation so one can detach from the job stressors or any other stressor. Recreation is key. Re - create. You are giving yourself a chance to re-create and then will have so much more to give back. It must be really hard for doctors to do that tho just by the very nature of their profession.

You said your brother was 4x better than you professionally speaking, but it sounds like you both have the same family work ethic that you have spoken of in past posts. :)

Eric, AKA The Pragmatic Caregiver said...

This post *really* gets me going; I think Sid's the greatest thing to happen to surgical practice since, say, ether, but I'm biased. Still, there's this giant pachyderm around rewards-for-good-work that virtually every physician I've spoke with isn't upfront the good doctor is about to find himself standing in the line of fire for something he's not 100% personally responsible for, but is certainly a party to...

I agree wholeheartedly that quality work should be rewarded more than the minimum standard of care . . . the question is, of course, how to do it.

A bit of background: I have what you think would be dreamy health insurance; no significant PPO features, essentially good old-fashioned traditional indemnity get-sick-we-pay. There's a little UR and some pre-auth requirements, but overall, I go where I want and they don't count the Tylenol. (It's *breathtakingly* overpriced, but it's what my group chose and it was a smart choice, given that they are, actuarily speaking, *dead*). I'm also responsible for $2750 of the first $5250 of care I receive in a year, exclusive of Rx costs, so I've got serious skin in the game. Our esteemed prez swears this is the future of healthcare. I'm doing the right things - I've got an open market to buy from, I'm paying with my own money, I'm an informed consumer.

Scratch that last one. The problem is there's an astonishing lack of quality data out there. Sure, I can find out which hospitals had the best outcomes on CABGs, but I can't tell if they had great demographics going in, crappy surgeons or what - lots of academic medical centers that take on complex cases have worse composite outcomes because they're operating on sicker patients. I can't always tease that out of the data.

So, I can't make a decision based on composite outcomes. Nor can I make a decision based on who had the best results on cases just like mine - the data do not exist.

I can't really tell who hacked someone to bits through negligence or stupidity or intoxication versus who settled a malpractice claim brought by a chronic malcontent - all the parties involved work very, very hard to make sure those pearls of insight aren't available to consumers when they're making a purchase decision.

So I'm left to go on "reputation" (read: marketing) and my gut, which isn't a great way to buy things - if I did it with cars, I'd probably buy something bespoke and British, which any auto enthusiast can tell you is a setup to a lifetime of heartbreak. Consumer Reports can tell me how often the alternator is likely to fail in a 2007 Guzzleator S450 and what it's likely to cost to repair. Most doctors can't even tell you what a relatively common surgical procedure they perform comes in at, tax, title and license inclusive.

Thus, as a consumer who wants to reward excellence, I operate in an information vacuum - no matter how much I'd be willing to pay 20% more to get someone *REALLY* good to make me well again, I lack the information to do so.

I thought the problem was access; I figured that the information existed, but that the medico-legal-industrial complex was somehow conspiring against me to hide this data. There's outcomes data in education, in industry, in finance....but healthcare as delivered in the US is so incredibly disconnected from modern information management techniques that it is impossible to analyze the (literal) reams of data generated for every patient.

No other industry, and certainly not one that represents such a large and growing proportion of GDP as American healthcare could get away with such incredibly sloppy, inefficient, costly data management practices. I am *appalled* that there is no meaningful structure to the data collection in healthcare *except* around who needs to pay for what. If banking ran the same way medicine did, we'd get hand-scribbled notes about what was in our account with every check we'd ever written stuck behind them, and god forbid you should switch banks - they'd xerox the whole pile and start adding on to the top.

Point-of-care data collection is finally starting to become a reality, but the industry resisted, led in no small measure by a faction that claimed medicine was "too sacred" of a task to be categorized and quantified by mere automated tomfoolery. Instead of working on ways to make the data collection something that actively improved care rather than a chore to be done to satisfy overseers, the industry dug in their heels and let the Luddite factions run the show. Now modernization is being forced on them, and I personally think most of the attempts are a little bit ham-handed and inelegant, but at this stage of the game, I have to say it's better than nothing.

So, bringing this back's not that payors (both individual and insurers) wouldn't *like* to reward excellence. They simply do not have the data needed to do so. Inelegant attempts to cull through the effluvia to derive outcomes have been rejected en masse (and with good reason) by doctors - see also the brouhaha about the Regence "Boeing Select" network pogrom in 2006. Because there were no better data sources available, 500 doctors were going to get dropped from the network for "lacking quality and efficiency" based solely on billing data. If I were a physician, and the payor for a significant number of my patients told them that I was a shitty doctor and they needed to go elsewhere, I'm not even sure mere words could adequately express my feelings of utter apoplexy. But if you don'ts got the systematic, orderly, consistent collection and analysis of data, you don'ts got a leg to stand on in these matters.

I agree that the system rewards mediocrity and the lowest common denominator. It sucks, and I wouldn't want to practice what I do in a market that doesn't reward excellence. Please recognize that to move beyond this, though, there's got to be some parting of the veils by providers and improved outcomes data. "Knowing" you're the best isn't the same as proving it.


Sid Schwab said...

eric: yours is a really excellent comment. I touched on the problem a little bit in an otherwise sort of silly post recently. I couldn't agree more that there are virtually no reliable ways for the consumer to judge: in part it's because the widgets aren't ever identical, in the way that the Guzzleators are coming off the assembly line; and as I said in the referenced post, data collection is subject to all sorts of errors. And it's sadly true that doctors themselves have scuttled several attempts to provide data, although the reasons are entirely selfish: it's that the data, as stated, is so highly suspect. I think it's worth a separate post on the subject: in fact it's in my "ideas" file already. But first I have to finish the burnout thing. Thanks for your well-realized thoughts.

seaspray: yours is also right on. Thanks. Some days I'm pretty pessimistic about the future. Others -- and truly much of it comes from reading medical/nursing blogs and the comments and emails I get -- I feel better about those in the health professions.
And happy b.d. to your husband!

Anonymous said...

Add in the fact that doctors really don't want to give anyone an estimate on anything (well, except maybe cosmetic surgery?).

We don't get quality information, and we don't get pricing information.

When I buy a car or whatever, I can get both. I can't afford the most expensive car, but I balance as best I can my needs, the car's qualities, and the pricing.

How would you make that information available to patients to make decisions?

Sid Schwab said...

Actually, a surgeon, at least, ought to be able to provide exact price for his/her services. The unknown factor is hosptial costs, unless the operation is done at a surgical center where they usually have specific fees for each procedure. All that should be available easily, in advance. How much a patient actually has to pay depends on insurance policy, or lack thereof. A given insurer ought to be able to answer that. The hell of it is that a person with no insurance is really screwed: by law a doctor can't discount a fee in that situation, because it's seen as medicare fraud: if you charge a person less than you charge medicare, that's a crime.

Anonymous said...

Eric: I agree with your assessment regarding the lack of quality measurements, but I disagree with the reasons behind it. It's not entrenched forces in medicine and it's not fear. It's that there simply aren't good ways to measure these things that do not cause perverse incentives. Rank doctors based on outcomes? Well then, good luck getting that operation when you're an obese diabetic. The "solution", such as it is thus far, has been to measure adherence to standards that are often (at best) tangentially related to good outcomes - this has reached its ridiculous extreme in the UK where government mandates result in doctors having more incentive to spend their time doing useless "quality boosters" than actually taking care of patients.

I don't necessarily have a great answer for you. My best suggestion is to ask other doctors who they would go to and why. When we work with these people we usually know who's average (or below average) and who goes above and beyond as far as putting the effort in and having their patients like them.

SeaSpray said...

Thanks Dr S - i will relay the message. :)

Oh and don't shoot yourself! We need the doctors - so keep on inspiring and blazing a trail for the good in medicine. :)

A few years ago, our younger son was considering becoming an architect and a friend of ours who owns his own firm said "I'll have to see what I can do to talk him out of it."

Eric, AKA The Pragmatic Caregiver said...


I totally agree that the quality booster thing is totally useless; CMMS has been doing the same thing here in the US with oncologists, paying (tens? hundreds?) millions of dollars to collect "outcomes data" that is essentially unusable. That's why I'm so emphatic that "outcomes" can't be a discrete process from patient care; the patient care systems and standards have to be reimagined to provide useful "breadcrumbs" - atomic data that someone with a need can go back later and make sense of.

Dr S: what I find most galling is that cash customers don't just pay the same amount Medicare pays - that seems fair. What I *loathe* is the practice of uninsured cash customers paying the highest price in the joint - it's endemic. Professional services, hospital fees, labwork, prescriptions - he who pays with his own money pays the most. I'm all for a reasonable volume discount, but I object to paying 4, 5, even 10X what Medicare is buying at.

As for the comorbidities issue; were there enough data on the demographics and comorbid conditions of the people undergoing procedures, in forms that were amenable to analysis, trends would in fact start to emerge. In the large aggregate, trends in quality, adjusted for confounding factors will bubble up. It's also a good way to incent working on sicker patients - in Medicare-paid mental health services, additional problems (medical or behavioral) result in additional per-diem. No reason that operating on a fat guy with kidney problems, a fatty liver and a 30-pack-year smoking habit shouldn't pay more than a relatively healthy 20-something.


Sid Schwab said...

eric: anesthesia fees in fact are modifed for severity. Comorbidities increase the degree of difficulty. For operations, there are a couple of codes for complexity (which are often rejected, in my experience) but they relate only to operative issues as opposed to medical comorbidity which may affect outcome. To get all parties -- docs, governments, insurers -- together on methodology seems completely impossible.

Anonymous said...

Years ago, one of my economics professors--who had very strongly advocated managed care as the way out of the health care economic crisis, when confronted with a family health crisis of his own (cancer)--sought out quality care--outside of an HMO. That spoke volumes to me. Not that HMOs don't offer quality care; I have received great care from them at times over the years. What they don't offer is choice of provider when choice may make a difference (and when the informed patient can make an informed choice, as this professor could).

When I worked in a hospital myself and needed care, I asked the heads of the nursing service whom they recommended. In the years since, I have always tried to use a similar approach: find someone in the medical business and get a recommendation (or a reference check for a referral). With Google, it was become much easier to learn about medical conditions and have more educated discussions with providers (and understand test results myself). And I always, always, double check Rx script as well--have found mistakes there as well (perhaps because MDs don't have time to do things right?). Sad but necessary in all these cases.

Bottom Line: On the patient side, I too must invest spend more & more time (and money) to get quality medical care now.

Lynn Price said...

All I can say is "Who is John Galt?" Atlas Shrugged should be required reading for every human being. It presents this very notion of taking the power away from those who perform the work and putting it into the hands of idiots who get rich for doing nothing. Sid, I so hear you!

Anonymous said...

Actually, one of the interesting things about healthcare vs. guzzleator buying decision making: in healthcare there are two buying decision points (for most of us, anyway)--(1) the insurance open enrollment decision point, where folks try to guestimate their future health needs (and the new health savings accounts are designed to incent us towards high deductible plans & save money in the process) and (2) the actual 'point of sale,' if you would, the time when we need care. For the most part, that point is routine care and HMOs/PPOs (or, as Sid might point out, less than stellar medical care) are just fine. But every now & then, the decision really matters, for yourself or a loved one--and then dollars don't matter. Find the best! Go for extreme care! All that careful, economic decision-making that went into getting the most cost-effective insurance plan goes out the window.

Incentives & measures in health are muddled as a result. Saving money may be one goal (although using it more wisely would be a better goal--but very difficult as Oregon discovered). Finding out how money is actually being spent, with what result is another goal. The trick there is what measure actually=quality? HMOs use #patients seen/day for primary docs as a metric: net result is more prescriptions written (to make up for less talk time?) and more primary MD turnover. Around where I live the trend is for 'better' MDs to establish boutique practices with limited patient loads that don't accept any insurance--the patient either pays an enormous amount/year for instance access 24/7 (plus a fee/visit) or pays substantial amounts for care and gets a bill nicely preformatted for submission to their insurance in return (for which they’ll only get a partial reimbursement as the fee was well above U&C). These boutique MDs cater to patients who can afford to pay out of pocket up front for presumed quality care: the MDs will spend lots of time with patients & then bill them $350 for an office visit or $10,000 for annual care. Is this better quality? It certainly is more expensive.

I’m coming to the opinion that we need to change the whole mechanism of payment & incentives (for providers & for patients) to get to a system that doesn’t lead to burnout.

scalpel said...

There do seem to be more and more barriers to care installed by "those who make the decisions" every year. Whether it's the 80 hour resident workweek, the electronic medical record (which I ranted about this week), many of the ridiculous JCAHO guidelines, the good-intentioned (but often detrimental to patient care) EMTALA and HIPAA regulations, or the labyrinth of insurance/payer reimbursement schedules.

Once such a bureaucracy becomes established, it's almost impossible to get rid of it. My suspicion is that if we were somehow able to go back to a more basic free market system that the actual cost of medical care would decrease dramatically.

I've often thought about opening up a little cash-only emergency clinic, but the endless regulative barriers are too prohibitive. Why should a sprained ankle or a simple laceration cost several hundreds of dollars to evaluate in the ER? Because of all the administrative costs.


Moving this post to the head of the list, I present a recently expanded sampling of what this blog has been about. Occasional rant aside, i...