February 2019

NEWS & OPINION

Insights
Part III: The weariness, the fever, and the fret


by J.C. Noreika, MD, MBA


J.C. Noreika, MD, MBA

The third installment on physician burnout investigates job-related research describing factors that contribute to work’s meaningfulness and career satisfaction

More than 400 physicians die by suicide annually, the highest rate of any professional group in the United States.1 They are twice as likely to take their own lives as the general population. A presentation at the 2018 American Psychiatric Association (APA) Annual Meeting found comorbidities include mood disorders, alcoholism, and substance abuse. At any given time, 12% of American male physicians and 19.5% of female physicians manifest symptoms of depression. International studies report comparable findings. Percentages are higher in medical students. Experts attest that stress arising from job-related physical and emotional demands, competitiveness, and sleep deprivation impact clinicians from medical school into late career practice. Self-medicating with drugs and alcohol heightens the likelihood of burnout, depression, and suicide.
Recognition of factors contributing to burnout is growing. Professional organizations, medical schools, and the healthcare industry have initiated programs to combat the problem. A recent article assessed proactive projects launched by hospital systems to enhance the well-being of their professionals. Cleveland Clinic, Mayo Clinic, Yale, John Hopkins, and Stanford Medicine were included among the nine investigated.2 These experiments confirm the increasing anxiety physicians experience due to time constraints, new technology, managerial oversight, financial pressure, and bureaucratic mandate. The electronic health record (EHR) is frequently cited as a driver of frustration in the clinic. An alternative hypothesis proposes that it’s not the technology per se but the “garbage in, garbage out” requirements of documentation that is resented. A program designed to “get rid of stupid stuff” by employing collaborative efforts to eliminate unnecessary data collection, capture necessary information more efficiently, and explain obligations perceived irrelevant by end-users was recently described.3
Investigators postulate that loss of autonomy, depersonalization of the physician-patient relationship, patient face-time expropriation by computer screens, economic imperatives demanding impossible patient throughput, “chart biopsies” to winnow clinically significant data buried amid irrelevant noise, uncompensated administrative demands, and other daily vexations promote burnout. Mental health professionals allege the loss of work’s meaningfulness a fundamental source of physicians’ discontent.
British researchers Bailey and Madden studied 135 individuals representing artists, lawyers, academics, entrepreneurs, nurses, soldiers, stonemasons, and garbage collectors.4 They conclude that quest for meaning is an innate human attribute. Their goal was to identify factors that promote work’s meaningfulness and provoke meaninglessness. Others report that meaningful work is more important to wage earners than compensation, promotions, and working conditions.
Meaning and its antithesis are driven by different factors. The perception of meaningfulness is singularly personal and episodic; it is found in gratifying events but not always rooted in pleasant experience. A pivotal insight is that the task transcends the individual by benefiting others in a broader context. It is rarely recognized in the moment in which it is experienced but found only upon later reflection. In contrast to meaningfulness, job satisfaction is one-dimensional, transactional, and more ephemeral.
Meaninglessness manifests itself when workers ask themselves, “Why am I doing this?” Meaningfulness originates within the individual; meaninglessness stems from actions or neglect by managers and overseers. For example, if an organization’s practices run contrary to its employees’ values, conflict ensues. Bailey and Madden found that dictating work perceived pointless, desultory, and not critical to the organization’s mission has a mind-numbing affect and reinforces disempowerment. It is exacerbated by exclusion, rejection, and lack of recognition. Camaraderie is cited as an important contributor to purposeful work; connection with peers and a supportive network can help mitigate burnout.
The authors propose that “holistic meaningfulness” is forged when organizational values are consistent, communicated, and understood, personally pertinent tasks not intrinsic to the bottom line are encouraged, banal routine is demonstrated important to the care of the beneficiary, and one’s efforts are recognized. Non-judgmental collegial coaching and approval is a powerful redress of meaningless work.
Tait Shanafelt, a pioneer in the field, addressed physician burnout in a 2009 editorial.5 To enhance well-being of at-risk physicians, he underscores the merit of self-reflection on those components of work found most compelling. Individuals weigh a job’s responsibilities idiosyncratically. Some clinicians find fulfillment in doing research, others in the classroom, performing surgery, or engaging with patients. Gratification is intensified when people work at tasks that are intellectually challenging, valued by others, and help advance interpersonal connection. People gravitate toward tasks in which they are proficient and competent.
Sharing insights gained through introspection and meditation can bolster contentment. Balancing discussion of frustrating matters by noting improvement and successful accomplishment is an antidote to cynicism. Physicians trained in mindfulness skills “had large, durable improvements in burnout, mood disturbance, and empathy.”6 Buttressing assertions that quality of care is enhanced when stress is systemically reduced, he references a 1988 study conceived by a medical malpractice insurer contrasting 22 hospitals that launched job-stress reduction programs and 22 control hospitals. Malpractice claims were reduced by 70% at intervention hospitals and only 3% in controls.
Most physicians are satisfied with their professional careers. Enthusiasm’s inevitable ebb and flow is intrinsic to all jobs. But as medicine becomes more depersonalized, industrialized, and commoditized, practitioners hazard greater risk of experiencing emotions emblematic of meaninglessness.
Efforts to educate and support healthcare’s most important resource—physicians—will be required of all interests vested in its provision, delivery, and regulation. Next month’s final installment will provide insight and advice from an individual at the cutting edge of this undertaking.

References

1. Anderson P. Doctors’ Suicide Rate Highest of Any Profession. WebMD. May 8, 2018.
2. Berg S. 9 major institutions create healthier environment for physicians. American Medical Association. Dec. 3, 2018.
3. Ashton M. Getting rid of stupid stuff. N Engl J Med. 2018;379:1789–1791.
4. Bailey C, Madden A. What Makes Work Meaningful—Or Meaningless. MIT Sloan Management Review. Summer 2016.
5. Shanafelt TD. Enhancing meaning in work: a prescription for preventing physician burnout and promoting patient-centered care. JAMA. 2009;302:1338–40.
6. Ibid.

Editors’ note: Dr. Noreika has practiced ophthalmology since 1981 and has been a member of ASCRS for more than 35 years.

Contact information

Noreika: jcnmd@aol.com

Part III: The weariness, the fever, and the fret Part III: The weariness, the fever, and the fret
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