Compassion fatigue

As reported in a recent JAMA article, approximately fifty percent of physicians report burnout symptoms such as detachment, emotional exhaustion, and a low sense of accomplishment. Frontline specialties such as Internal Medicine, Family Medicine, and Emergency Medicine were reported to have the highest rates of burnout. Why are so many frontline physicians experiencing burnout? 

Most physicians decided on the occupation due to a combination of the following: altruism, love of science, and job security. Physicians, as a population, are a generally high functioning and high achieving group who endure years of oftentimes unsparing training in large academic centers. This training stresses autonomy, critical thinking, and patriarchal relationships with patients and staff. However, more mundane concepts such as leadership, teamwork, and customer service are oftentimes largely ignored. Once they enter the workforce, physicians quickly realize that community medicine is wildly different from the training they received in the ‘ivory towers’ of academia. The current health care landscape is morphing into an arena of standardized treatment plans, interdisciplinary care teams, checklists, patient quotas, and shift work. It is transforming into an elaborate assembly line with patients as the product and physicians as workers within this assembly line. 

  Moreover, healthcare has become a series of adversarial relationships most notably between the patient and the physician, the physician and “other” health care providers, and the general physician with the specialist.  Physicians are constantly weary of malpractice liability and approach each patient encounter with (different word) in the backdrop. This leads to additional, often times unnecessary testing and specialist consultations. In a salaried (non-fee for service) environment, this leads to resentment on the part of the respective specialists who are asked to see patients without a clear indication causing an adversarial interaction between providers.  Additionally, the emphasis on patient satisfaction scores and “customer service” has added an another layer of complexity to this patient interaction and frontline providers are more prone to relent to consumer demands for testing, prescriptions, and consultations. In reality, this mitigates a productive and honest physician-patient discourse, thereby eroding therapeutic alliance and ultimately leading to physician discontent. These have taken a noted toll on the psyche and morale of frontline providers. Delivering and receiving health is a two way interaction driven by relationship and trust. In our haste to achieve cost containment and improved access, we must not forget that the ultimate goal is to improve the quality of care and this will not be achieved until the physician – patient relationship is repaired. 

In my opinion, the strength of a health care system is directly related to the strength of its frontline providers. These providers are the most well equipped to treat the chronic disease epidemic that is overwhelming our health care system. (Chronic diseases account for 75% of the total dollars spent on health care).  As we improve access for 35 million Americans with the Affordable Care Act, the burden of this increased access will fall predominantly on frontline providers. Consequently, in order to have a well functioning health care system, we must develop tools, processes, systems, and policies that will empower the frontline clinician and will align the values of the frontline clinician with the needs of the consumer.