A slightly different version of this post was posted in Psychology Today on March 11, 2018.
Physician burnout has been much in the news of late, and appropriately so. As many as one-half of primary care physicians are burned out, meaning they have become exhausted, cynical, depressed, and disconnected from the patients they care for.
Burned out physicians have higher rates of medical errors and, not surprisingly, lower patient satisfaction scores. More broadly, patients and society suffer because burned out physicians are twice as likely to leave their practices, either retiring or moving to non-patient areas like administration. To replace a departing physician can cost upwards of $1 million to their organization.
By Michael Barera – Burnout
Despite yeoman efforts to address the problems inherent in the medical health care system that contribute to burnout—such as doing away with excessively long work hours and having staff handle the electronic health records—one key cause of burnout is consistently overlooked. The patient. Certain types of patients, often referred to as “difficult patients,” regularly create the greatest problems for physicians. Nor is this a small problem: 15-20% of patients are in this category.
What are the features of difficult patients? Difficult patients tend to be depressed, anxious, narcotic-seeking, experiencing chronic pain, presenting with unexplained physical symptoms, and many are angry, scared, or resist effective care. Other features make patients difficult, but often are not remediable, such as poverty, social isolation, language barriers, and being physically very ill.
Are difficult patients bad people trying to cause problems? Far from it. They are people who are suffering considerably, often from the failure of the medical system to meet their needs. I’m sure you see already that the patients most often considered difficult have the common denominator of mental health problems or, at least, serious psychosocial issues.
Now we get to the heart of the burnout problem, one that medicine rarely acknowledges. Physicians other than psychiatrists are not trained to care for such patients. They have not been adequately trained to treat chronic pain, depression, anxiety, panic disorder presenting as chest pain, narcotic-seeking patients who demand refills, and angry or frightened patients who constitute such a large portion of a physician’s daily practice.
Despite four years of medical school and three years of a medical residency, no more than 1-2% of a physician’s training is devoted to mental health issues—even though they are more common than heart disease and cancer combined. In other words, mental disorders (which includes addictions) are the most common problem encountered in medicine. Paradoxically, in light of modern medicine’s focus on disease, severe diseases such as heart failure, stroke or diabetes are frequently complicated by depression and anxiety. However, unless the latter are recognized and treated, which is not usually the case, the medical disease treatment does not work as well as it could.
It’s not surprising that a recent comprehensive report from the National Academy of Medicine (NAM) fails to identify poor training in mental health care as a key factor in burnout. Nor, in fact, do literally hundreds of others who have weighed in on the burnout topic over the last few years. That is because the practice of medicine has been governed rigidly for over 100 years by a near isolated focus on diseases. It simply is not in the profession’s consciousness to consider training that prepares physicians to provide mental health care—even though mental and other psychosocial problems are the commonest patient issues its graduates will encounter.
What’s the answer to burnout? Well, to begin with, we must keep up the current efforts, well outlined in the NAM report, but we must also do two additional things. First, we need to train all students and residents to be as competent with mental health issues as they are with physical disease problems. This will greatly reduce the very common burnout during training, and it will minimize our graduates’ burnout when they go into practice. Medical schools and residencies could begin training in mental health and addictions tomorrow. They must simply decide to do it. Granted, it is no small task to change a system geared to physical diseases, especially when it will require intensive experiential training in all years of medical school and residency. The goal is not to create psychiatrists but, rather, that our graduates be as competent in mental health care as they are in care of physical diseases. We still need to train psychiatrists to serve in a consultation role.
Second, and far more difficult, we need to provide remedial training for our beleaguered, often ready-to-retire practitioners. Unfortunately, this does not mean adding a few lectures here and there at a conference. Rather, it means providing supervised experiential training. At present, there are few venues for this, which, of course, points to a need our leaders can address. A ray of hope, although not addressing mental disorders, is the Academy on Communication in Healthcare. They provide experiential training in how to interact with difficult patients during an annual intensive 4-day course as well as in consultation with hospitals and clinics in 1-2 day courses throughout the year at interested locales. Physician, nurse, and other attendees at these courses have developed considerable confidence in managing difficult patients.
Recalling that ever-decreasing numbers of psychiatrists provide less than 15% of all mental health care, the burnout problem in significant part reflects modern medicine’s dereliction in failing to train the medical people who provide almost all mental health care.
Who wouldn’t get burned out when asked, day in and day out, to face severe problems for which they’ve not been trained? It would be like asking most physicians to do the next cardiac bypass surgery—every day. It’s no wonder many are quitting practice.
Think about it. When you or your family member goes to the doctor, don’t you want to be assured that the doctor is trained to treat you not just from the neck down, but the neck up as well? For the price you’re paying for your healthcare, you deserve complete care. Expecting it doesn’t make you difficult; it makes you better.
Copyright Robert C. Smith