Physician career management: organizational strategies for the 21st Century. (Physician Anger).

"You SOUND LIKE YOU'RE burned out talking about burn out," reflected a reporter interviewing me on yet another article on "Physician Stress and Burnout."

"I keep reading articles written about physician stress and burnout, but the things they suggest to do about it don't really help. It makes me feel like there's something wrong with me!" reflected the cardiologist tearfully as we began the career consultation session.

Historically, discussions about physician burnout within the profession have focused, to a large extent, on causal factors that lie within the individual and relate to how they do, or do not, cope with the stresses of medical practice. (1,2,3,4) Burnout came to be associated with an Individual's failure to cope, and their intrinsic vulnerability to impairment, where one's dysfunctional behavioral responses to stress led to a compromised ability to perform professionally. Euphemistically labeled "physician wellness" programs were established to manage the approximately 10 percent of physicians who are "impaired." Understandably, discussions about stress and burnout among colleagues were rare, due to legitimate fears that one might be labeled as impaired.

Fortunately, one of the byproducts of the managed care era is that physician stress arid burnout has emerged from the closet. A good illustration of this lies in statewide physician wellness programs that historically have been used primarily by physicians with psychological or behavioral problems, referred to them by state boards of medical registration or hospital peer review groups. Over the past decade the user base of these programs has shifted substantially to include a dramatically increased number of self-referred individuals, many of whom request help with "psychosocial" problems that relate to general career management in the changing industry. The physician wellness programs do not have the expertise or resources to assist with these new issues, which do not fall within the charter of their institutions.

I have had the opportunity over the past six years to perform interviews with hundreds of self-referred physicians seeking assistance with career-related stress. Some critical patterns emerge from these interviews that have important practical implications for preventing physician career burnout within health care organizations.

What is burnout?

Burnout is a state of physical, emotional, and mental exhaustion caused by long-term involvement in situations that are emotionally demanding. The emotional demands result from the combination of high expectations and chronic situational stresses. Individuals at greatest risk are those who enter their professions with a high level of motivation and Idealism, and who select their work because It is a calling," expecting it to provide a sense of meaning to their life.

It is not stress, per se, that causes burnout, as many thrive In stressful, demanding careers. Rather, burnout results when stress continuously outweighs the sense of effectiveness, accomplishment, and reward. And, this fate is sealed when one feels helpless to affect significant change in the conditions that fuel the stress.

Organizational causes of burnout

Figure 1 represents a simple overview of the key spheres of physician work life that are important to consider in the ongoing process of strategic career management. (5) This article focuses primarily on the organizational sphere, although it is important to recognize that the spheres cannot really be considered or addressed in isolation from each other.

Fortunately, a great deal is known from social science research about the environmental conditions that fuel career burnout. Unfortunately, this knowledge has not been applied in any practical way within the medical profession. Indeed, the forces of managed care have reshaped the daily work life of physicians within health care organizations almost as if following the perfect recipe for professional burnout.

Sample ingredients include:

* Lack of autonomy

* Excessive bureaucratic interference and paperwork

* Quantitative work overload

* Role conflict (for example, professional versus business)

* Inadequate recognition and reward

* Helplessness to influence policy

* Lack of variety in daily work

The infusion of these characteristics into the work culture of physicians in recent years has been dramatic and powerful. They have fundamentally changed the job description, the quality of daily work life, and the professional identity of physicians. They converge to insidiously erode the sense, for many, that their professional efforts have meaning and significance. Consequently, many highly committed individuals find themselves in an unprecedented state of existential uncertainty about their profession and career. Their uncertainties evolve further into discouragement and even despair when they realize that their narrow range of expertise and skills have limited applicability and marketability within the health care marketplace, minimizing the number of career alternatives available to them. Their growing dissatisfaction with their daily work lives, compounded by the lack of apparent career options, results in a sense of being trapped, helpless, and hopeless.

Cost of physician burnout

Research done at The Center for Physician Development, a national research and consulting program established by Boston's Beth Israel Hospital in 1992, linked certain organizational characteristics within a staff model HMO with chronic stress and burnout among the clinical staff. The characteristics identified led to the perception by clinicians of chronically compromised quality and safety in patient care, and were experienced as highly stressful by workers, particularly physicians and nurses. Symptoms of burnout were reported by a number of those interviewed, and were manifested by a range of forms of morbidity, including:

* Overeating and massive weight gain

* Chronic low back pain resulting from weight gain, leading to consideration of filing a disability claim

* Inappropriate temper outbursts in patient care areas leading to patient dissatisfaction and public relations problems

* High turnover of nursing and physician staff, leading to acute staffing shortages and morale problems

* New onset of anxiety and depressive disorders requiring medication

* Increased incidence of errors in clinical care

* Stress "spilling over" into workers' personal lives, leading to marital discord 

There has been no significant effort undertaken within the health care industry to define the qualitative and quantitative costs associated with physician burnout. However, my research findings strongly suggest that burnout increases a number of potentially costly risks including:

* Error and adverse events

* Malpractice suits

* Disability claims

* Worker's compensation claims

* Medical costs

* Patient and staff dissatisfaction and turnover

Furthermore, characteristics of staff turnover reveal that it is often the physicians who are the most creative and committed to clinical quality who choose to leave, feeling that there is no further opportunity for growth and professional satisfaction within the organization. Interestingly, turnover is particularly high among medical directors in managed care organizations, where according to several human resource directors interviewed, the average tenure is approximately 18 months.

Quantifying the costs associated with physician burnout represents a complex challenge, and one that no stakeholder apparently has the desire or incentive to analyze. But the greatest risk of all may be one that is simply not quantifiable, and is suggested by the compelling and stark reflection of one primary care physician interviewed in The Center for Physician Development study:

"I stopped caring so much about the patients.

I had to.

It was the only way to save my sanity and my marriage."

Practical implications and approaches

It is helpful to have an understanding of the root causes of stress and burnout among the physicians within your organization, but insight alone does not solve the problem. Establishing an organizational environment that reduces the risk of physician burnout requires a new commitment of resources, one that can be challenging to justify to decision-makers with a strictly short-term, bottom line orientation.

Let's imagine for a moment that some organizations begin to recognize that their long-term success in the competitive marketplace will depend upon the recruitment and retention of motivated, committed, and caring physicians. And they decide to create a new line item on their budget that targets physician career management (including the prevention of career burnout). What might be some of the key issues to consider in shaping this program?

1. Entry of new physician employees into the organization

The "fit" between an individual and an organization in terms of values, work style, and culture is crucial for a successful placement. Because physicians still do not receive any formal training about organizations, they lack sophistication in assessing a potential new work environment. A bad fit often leads to physician anger and frustration, with a range of undesirable behavioral sequelae. The utilization of a systematic approach to evaluating the potential fit, often including formal individual! organizational assessment tools, can be helpful to hiring personnel. Once hired, new physician employees should then be oriented into the organizational culture through formal orientation processes, as well as mentoring by experienced physicians from within the system.

2. Productivity measures

One of the most commonly heard complaints from physician employees today is that productivity demands placed upon them are excessive, and that productivity-based reward systems fail to consider important qualitative factors in their calculations. Policies defining productivity should balance revenue-generation with potential costs associated with work overload. Reducing the amount of time a physician can spend with patients beyond a certain point compromises critical communications and the quality of the doctor-patient relationship to the extent that the risk of errors and malpractice suits rise. In addition, as the financial rewards of medical practice have diminished, it is more important than ever before that the intrinsic rewards of clinical medicine be preserved. An organization that provides adequate time to sustain the human element of the doctor-patient relationship will be well-positioned to retain the truly committed physician over time.

3. Responsiveness to safety concerns

Errors and near misses' in patient care often fail to be captured by formal quality tracking mechanisms In health care organizations. When they do not lead to formal complaints or malpractice suits, which is often the case, (6) they rarely result in significant remedial systems improvements. Physicians working in environments that feel unsafe in terms of care delivery experience tremendous stress and alienation from their organization. Over time, the sense that an employer organization does not share one's standards for quality and sense of accountability to patients can lead to anger, depression, acting out behaviors, apathy, and/or a decision to leave. The successful organization will establish mechanisms for dealing with errors and adverse events that ensure that its level of responsiveness to safety issues will be aligned with the quality standards of the most desirable and committed physicians.

4. Administrative and policy issues

Policies that are inefficient, rigid, and ineffective ensure that the physicians most committed to quality and productivity will burn out. On the other hand, physicians welcome bureaucratic structures that facilitate their work and do not inhibit their autonomy. The process by which policies are determined should:

* involve physicians at all levels

* preserve as much professional autonomy as possible

* prioritize flexibility and responsiveness, given that the environment around the organization is in such a massive state of flux.

5. Variety and growth opportunities

An increasing number of physicians are seeking a way of infusing some variety into their daily work lives. "Assembly line" medicine is not what they had in mind when they went to medical school. Some will choose, rightly or wrongly, to make a transition into management as a way of addressing this desire for change. But for many, a move up the organizational hierarchy is not appealing. However, the range of options for lateral moves is limited, both by the organization and by the profession, where such changes require a major commitment of personal resources for formal specialty retraining. In many cases, the most ambitious and creative individuals find that they must leave the organization to pursue career growth opportunities. This represents a tremendous loss of potential returns to the organization.

The enlightened organization will begin to explore innovative approaches to career diversification that also provide substantial return on investment. For example, some organizations invite interested and high performing physicians to participate in ongoing activities in other business departments, such as marketing, business development, and information systems. Creating such diverse career opportunities provides physicians with experience and training in cross-business functions, while also providing an innovative reward system for high performers who might otherwise leave the organization in order to obtain new career challenges. In addition, the cross-disciplinary perspectives provided to business teams are strategically advantageous for the organization.

Other organizations provide entrepreneurial physicians with support for the development and commercialization of their intellectual property. In addition to facilitating the career growth of the individual, support of internal entrepreneurship, or "intrepreneurship," has proven to be highly lucrative for some organizations in terms of spin-off companies, patents, and royalities. (7)

Conclusion

The massive changes in the health care industry over the past decade have led to a shifting of the framework of physician stress and burnout. Physician wellness is no longer a marginal issue relevant only to the "impaired" physician. Rather, it is now clear that, given the right set of environmental conditions, we are all vulnerable to burnout.

This framework shift has important implications for health care organizations, which struggle to meet the myriad challenges they face in the areas of quality improvement, risk management, and cost containment. Organizations positioned for long-term success will recognize that physician career management is a vital thread that links all of these institutional priorities. Resources committed to this domain will yield enormous returns for all stakeholders, including the organization, the physicians, and, most importantly, the patients.

References

(1.) McCue, J.D. The Effects of Stress on Physicians and Their Medical Practice, New England Journal of Medicine, February 25, 1982, 458-463.

(2.) Pfifferling, J. Things I Wish They Taught Me in Medical School. Resident and Staff Physician, April 1990, 85-92.

(3.) Taylor, R.B. Are You Heading for Physician Burnout? Physician's Management. November 1982, 186-196.

(4.) Schidermayer, D.L., and Tesch, B.J. Primary Care Physician Burnout: Definitions. Self-Assessment, and Treatment. Wisconsin Medical Journal, April 1992, 179-182.

(5.) Hirsch, C. Strategic Career Management for the 21st Century. in press, Chicago. IL: American Medical Association.

(6.) Weiier, P.C., Hiatt. H.H., Newhouse, J.P., Johnson, W.G., Brennan. T.A., and Leape. L.L. A Measure of Malpractice: Medical Injury, Malpractice Litigation, and Patient Compensation, Cambridge. MA: Harvard University Press, 1993.

(7.) History of ThermoElecron (ThermoElectron Corporation-Waltham. MA). http://www.thermo.com/history.html.

RELATED ARTICLE: SUGGESTED RESOURCES

Brousseau, KR, Driver, M.J., Eneroth, K., and Larsson, R. Career Pandemonium: Realigning Organizations and Individuals. Academy of Management Executive, Vol. 10, No. 4, 1996.

CareerView Assessments, found under "Assessments" on the MD CareerNet website (http://www.mdcareer.net).

Lichtenstein, R.L. Job Satisfaction and Retention of Physicians in Organized Settings: A Literature Review. Medical Care Review, 41(3): 139-179.

Pines, A. and Aronson, E. Career Burnout: Causes and Cures. New York: The Free Press, 1988.

Raelin, J. The Salaried Professional: How to Make the Most of Your Career. New York: Praeger Publishers, 1984.

Schein, E.H. Career Dynamics: Matching Individual and Organizational Needs. Reading, Massachusetts; Addison-Wesley, 1978.

A PROFESSION IN CRISIS

Findings reveal that physicians currently represent a profession in crisis. Managed care has dramatically altered the landscape of the health care industry resulting in:

* A surplus of 100000-150,000 physicians in the U.S. (1) Many of these individuals are struggling to find non-clinical career alternatives.

* A greater than 60 percent increase in the incidence of physician disability claims (2) for some insurance companies between 1 990-1 997, with some claims costing an insurer between $5 to 10 million over the lifetime of the claim. This trend is driven, in large part, by the increased workplace stress and professional dissatisfaction of physicians. Associated costs are fueled by the notorious challenge of finding viable career options for disabled physicians, resulting in prolonged claim durations.

* Intense pressure for earnings. The nearly half of physicians who are no longer self-employed have median annual incomes that are 35 percent lower (3) than their self-employed colleagues, in addition, under many capitation contracts, 15 to 50 percent of payments to physicians are withheld until the end of the year. (4) All of this is superimposed on an average medical school debt of $75,000. (5)

* A fourfold rate of increase in the incidence of physician suicide in the past two years in certain areas of the country with unusually high levels of managed care penetration. (6)

* 30 to 50 percent of surveyed physicians reporting that they would not choose to pursue a medical career if they had it to do over again. (7)

REFERENCES

(1.) "Shifting the Supply of Our Health Care Workforce: A Guide to Redirecting Federal Subsidy of Medical Education," Pew Health Professions Commission, October 1995.

(2.) Ainge, D. Increased Physician Disability Claims Causing Crisis, MGM Journal, September/October 1997.

(3.) Mitka, M. Doctors Pay Shrinks for First Time in '94, American Medical News, January 22/29, 1996.

(4.) Greene, J. Feeling the Squeeze, Modern Physician, February 1998, 48-50.

(5.) "Managing Medical School Indebtedness from Educational Loans," AAMC Fact Sheet, August 18, 1997.

(6.) Personal discussion with anonymous source within a state physician health program.

(7.) Schroeder. S. The Troubled Profession: Is Medicine's Glass Half Full or Half Empty? Annals of Internal Medicine, April 1, 1992,116(7): 583-592.

Gigi Hirsch, MD, is CEO of MD CareerNet, a unique, full-service career management and placement company in Boston, Massachusetts. She uses her expertise in physician career design and development to help both health care organizations and individuals face the challenges of the changing industry. She can be reached through MD CareerNet's website (http://www.mdcareer.net) or via email at [e-mail].