Rx for physician burnout: Let nurse-practitioners and PA’s do more l Opinion

A recent survey of 15,000 physicians from 29 specialties by the American Medical Association named paperwork and overwork as the leading causes of a serious problem in medicine today: physician burnout.

Many doctors will experience burnout in their careers, and burnout rates have reached an epidemic level with devastating consequences for affected doctors, their colleagues, their patients and the health-care system, according to the journal BMJ. Among the culprits: an estimated 10-1 ratio of administrators to medical professionals, bottlenecks in patient flow, and burgeoning paperwork.

Among the solutions the article proposes: rescheduling shifts, reducing workload and enhancing teamwork and leadership.

Perhaps a greater emphasis on delegation would help, too; let nurse practitioners and physician assistants handle some of the current physician workload.

The idea of a cozy collaboration and collegiality among health-care workers might sound pretty good, but it’s still not quite accepted universally. The AMA, for instance, despite evidence that nurse practitioners improve outcomes and access to care, is still determined to thwart their growing role in health-care delivery. The American Society of Anesthesiologists opposed the efforts of nonphysicians to dismantle physician-led, team-based models of care and, specifically, to oppose the “harmful advanced practice registered nurse compact."

The American Association of Nurse Practitioners’ president, Joyce Knestrick, has accused the AMA of “its commitment to put the profit of the physician membership ahead of patients and their access to high-quality health care.”

While nurse practitioners can work with physicians, they cannot at present assess and treat or prescribe medications for patients without a formal collaborative agreement. One former president of the Pennsylvania Medical Society said that even though there is a shortage of primary-care physicians, this is not something that’s going to be addressed by allowing nurse practitioners to practice medicine, given that their training and education don’t match those of the medical profession.

It may be a stretch, and by no means do I wish anyone to practice medicine without a license; but one could argue that physicians’ close guarding of their long-held hegemony and leadership might in fact contribute something to their anomie and burnout.

The AMA, in a “physician heal thyself” mode, says it is committed to making physician burnout a thing of the past. It defines burnout as “a long-term stress reaction characterized by depersonalization, which includes cynical or negative attitudes toward patients; emotional exhaustion; a feeling of decreased personal achievement; and lack of empathy for patients.”

Burnout can be associated with increasing bureaucratic demands leading to reduced time spent with patients. Therapy includes prioritizing and selecting interventions to deal with physician burnout where it exists by focusing on system-level changes such as workflow redesign or better communication between physicians and other members of the healthcare team.

In an article in the New England Journal of Medicine, titled “Out of the Straitjacket,” Philadelphia trauma surgeon Michael S. Weinstein describes his own battles with burnout and depression. He wrote that he had long experienced classic signs of burnout: emotional exhaustion, depersonalization, and low perceived personal achievement.

The problem for physicians, he says, is that even though they care for patients, they often don’t attend to their own health — especially mental health. He ascribes this to feelings of being in control and unconquerable. But in dealing with the perceived stigma surrounding mental health and depression, they are often reluctant to seek help.

For that reason, and in part to deal with his own experience, Weinstein cofounded Livewell Physicians, an organization dedicated to helping burnout sufferers. While many physicians are reluctant to avail themselves of the organization’s therapeutic efforts, he says, younger ones seem more accepting.

Burnout is a growing phenomenon, accelerated, according to Weinstein, by pressure on physicians brought about by increasing commodification, bureaucracy, regulation and user-unfriendly electronic health records.

The solution, beyond persuading physicians to seek medical help for themselves, is to share the work. Much of what they do can easily be shared with technicians, nurses and nurse practitioners. Culture change, destigmatization and valuing life/work integration are more constructive solutions than extreme self-sacrifice and reducing administrative burdens.

All of which would be healthier for physicians — and for patients.

David Woods, a Philadelphia resident, is a former editor-in-chief of the Canadian Medical Association Journal.