Survey results: doctors say morale is hurting.

Doctors are exhausted. They're burned out. The stress of their work is causing marital and family discord. And nearly 60 percent of physicians who participated in a recent survey have considered leaving the practice of medicine behind.

Those are just a few of the findings of the first American College of Physician Executives' Physician Morale Survey

Some physicians in the survey are resigned to the idea that low morale is here to stay.

"I think that it is safe to say that no physician is optimistic about the future of medicine at this point," one participant wrote.

Others seemed downright hopeless.

"One thing that rarely gets mentioned is that, unlike other industries that are cyclical, the practice of medicine continually gets worse and worse, more intolerable, more onerous, with absolutely no hope or reason for any optimism either in the near or remote future."

There was a little good news.

When asked to rate their own morale on a scale of 1 to 10--with 1 as very low morale and 10 as very high--a majority of 54 percent of the doctors rated their own morale as a 6 or higher, while 46 percent were 5 or lower.

But when asked to rate the morale of the physicians they work with, the numbers took a dive with 59 percent rating morale at 5 or less, and just 40 percent rating it 6 or higher.

The survey was conducted July 15th through August 1st, 2006, and drew responses from 1,205 physicians across the U.S. Judging from more than 330 comments written by those who participated, morale is very shaky.

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"As a physician coach, I am approached regularly by physicians who are deeply disappointed in how their medical careers have turned out. Many want to leave medicine, all want to work under better conditions, and several want to create clinical or non-clinical businesses of their own, to have some feeling of control again," one doctor wrote.

"At least five clients in the last year left medicine because of the stress of unwarranted lawsuits that left them feeling disillusioned, fearful and even hostile towards patients."

Another survey participant echoed that.

"Medical malpractice issues are the greatest source of anxiety and morale problems. I have seen physicians who have become paralyzed by med mal issues. I considered giving up practice after going through a court trial for a case that had no merit."

No exact cause

The turbulent medical malpractice climate was actually one of the lowest ranked reasons for doctor discouragement. The number one reason was low reimbursement rates from insurers and government health care plans.

"I am of the opinion that unless there is a significant shift in the practice of medicine and the reimbursement of medicine, the surge of Baby Boomers will collapse the medical system in the very near future. We are in the early stages of a very real medical crisis, and I only see a very tragic outcome," one survey participate stated.

After low reimbursement, the other causes of diminishing morale included:

* Loss of autonomy

* Bureaucratic red tape

* Patient overload 

* Loss of respect

* Medical malpractice environment

Many doctors wrote, however, that it's a combination of all these factors that is affecting their morale.

"Low morale is due to all the factors mentioned.... Bottom line is that we are working harder for less (less money, less respect, less autonomy, etc.) and it is wearing us down."

And a neurosurgeon who's planning his escape wrote:

"I have been chief of surgery at an active hospital (4 years) and CEO/president of a large neurosurgery group practice (currently). There are many issues that make medicine a difficult profession. Among them are the difficult medical-legal climate, lowering reimbursement and increasing uncompensated care, as well as the concept of medicine as a 'right' and not a shared project/responsibility.

"I have worked very hard all my life and am as burned out as it gets. I shortened my retirement horizon by 10 years from 62 to 52. I am lucky I can. I like neurosurgery, but not like this."

Although it may seem like a drastic measure to combat the morale problems, the idea of getting out of medicine altogether is an option many have considered. Almost 60 percent said they'd thought about it, and nearly 70 percent said they knew of at least one doctor who stopped practicing medicine due to low morale.

"Physicians age 45 and over have gone through a very demoralizing career," one physician wrote. "My peak earning capacity occurred in the 8th year of my 23-year career so far. We have physicians around age 60 who are having to leave practice or find some outside source of income because their overhead is so high in comparison to their ability to generate an adequate income practicing medicine."

Even one resident was ready to call it quits.

"Having just graduated residency, I saw firsthand the serious issue we as residents had with our morale. At my particular institution, the rigorous workload, long hours, lack of respect from both patients and hospital staff, meager pay and our exorbitant debt brought on a horrible morale.

"We all became angry people. Angry at our patients for being sick, angry at our colleagues for calling us for consults and admission, angry at our administrators for squeezing every last ounce of work out of our bodies. I intend to change careers to a non-clinical position as soon as possible."

A few said they'd advise others to avoid a career in medicine.

"The health care environment is driving good physicians out of the industry. I have actually discouraged my son from going into medicine. I never thought I'd see this day."

And one said the survey was biased and focused too much on the negative.

"Too often we look at the negative. I hear docs say that they wouldn't want their children to be physicians. Rubbish. I have four children and they can do whatever they want, but if they become physicians, they will have more flexibility and lifestyle choices than just about any other profession that they could choose."

Morale maladies

Low morale manifests itself in various ways in different people. The doctors in the survey listed fatigue as the number one problem, coming in at 77 percent. Emotional burnout, 66 percent, was a close second.

Marital and family discord and depression were experienced by about 32 percent of the respondents and 4 percent have had suicidal thoughts.

One respondent was desperate.

"I am an emergency physician and have contemplated suicide," the physician wrote. "I am close to filing bankruptcy, selling my house, telling my daughter I cannot afford her college tuition! I am working every day, sometimes double shifts multiple days of the month just to keep up with the bills."

To combat the low morale, physicians in the survey:

* Talked to fellow physicians about the morale problems (53 percent)

* Searched for a job outside of health care (35 percent)

* Lobbied local, state or federal government(s) for health care changes (27 percent)

* Sought personal counseling (26 percent)

* Sought substance abuse treatment (1 percent)

Among the other ideas that the doctors suggested were:

* Take a vacation or sabbatical 

* Take antidepressants 

* Get proper exercise and rest

* Pray

And one had a unique way to cope.

"I find it necessary about once every month or two to stay in bed for 24 to 48 hours. I do this on short notice when I get the feeling I might punch somebody. (Afterwards) I feel fully reconstituted."

An analysis of the survey results compared to demographic information collected in the survey also found that doctors less than 50 years old have slightly lower morale than those over 50.

The younger set also suffers higher rates of marital discord and emotional burnout. And they are more likely than older doctors to consider leaving the practice of medicine.

That probably comes as a surprise to some who think older doctors are likely to be the most dissatisfied. One correspondent wrote:

"Physician morale issues are perhaps more common in older physicians, who tend to be working with an 'autonomy' model and haven't adapted to the changing health care environment, don't like to interface with computers, and struggle to keep up with increasing patient workloads.... Poor morale is perhaps a 'generational thing.'"

Another isn't surprised that young doctors are demoralized.

"I think that young physicians expectations are not being met and that some of their expectations are unrealistic. There has been a degradation in professionalism and dedication that manifests itself in decreased morale and satisfaction. Some do not even like their patients or feel their patients are too demanding. No one wants to take call and the needs of the physician are put above the needs of patients."

Females also were found to have slightly lower morale than males and were more likely to walk away from medicine.

A few other demographic highlights:

* Doctors working in academic medicine experienced the highest rates of fatigue.

* Physicians employed by insurance companies reported the lowest rates of fatigue.

* Doctors in group practices, hospitals and academic medicine had slightly lower morale than those working in government, insurance or industry.

Are doctors partly to blame?

Some survey respondents said it's not the health care system that's dragging doctors down. Physicians themselves are to blame.

Comic strip character "Pogo said years ago, 'We met the enemy and the enemy is us.' If we ever learn to collaborate for the sake of the patients we supposedly took an oath to care for and get beyond our self-interests we might regain our leadership position," one physician wrote.

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Gregg Broffman, MD, medical director at Lifetime Health Medical Group in Buffalo, N.Y. and president/CEO of TransitionConcepts, Ltd--a partnership of health care professionals dedicated to facilitating change and transition management--said physicians need to face reality.

"It is long past time for physicians to look in the mirror and have a real heart-to-heart conversation with ourselves. Clinging to the notion of autonomy, ship captains, power, authority, etc. is a losing strategy. As German philosopher Friedrich Nietzsche once said, 'Many are stubborn in pursuit of the path they have chosen, few in pursuit of the goal.'"

Broffman, who has studied burnout extensively and reviewed the survey results, said the loss of this power is akin to dealing with a death. "A good dose of grief counseling would go along way to improving physician morale!" he said.

"If we accept the notion that the vast majority of us chose medicine for altruistic reasons, to help people, then we must realize that to do that in today's world, the path to that goal must be different than we expected it to be and that in all likelihood the path will change continuously for the rest of our professional lives.

"Once we embrace new ways, we can potentially regain our right to lead the change. Once we embrace the grieving process, understand it and work our way through it, we will see a dramatic improvement in health care and our morale."

Another survey participant wrote that "physicians classically see themselves as helpless, some hopeless, victims who have lost their autonomy and quality of life to managed care and significantly reduced reimbursement. They are almost all addicted to money now (and) pathologically greedy."

One doctor said, "Physicians have abrogated our responsibility to be engaged in the overall health care system. We have been too busy protecting narrow interests without a realistic perspective on the landscape in which we spend our lives. The result is poor quality of care and population health status below all other industrialized nations. And at an outrageous cost. Our work is cut out for us."

"Physicians don't appreciate how good they have it," another doctor wrote. "The highest paid occupation, on average, doing very important work that is highly valued by patients and society, very interesting some or most of the time. They long for the good old days, that weren't very good for quality."

"By and large I am concerned about the work ethic and general ethics of many physicians today. All want very large $$$ but some don't really want to work for it."

And one other stated that, "medicine will continue it's downward spiral until it is 'picked clean' by the insurance industry, government and other professions and industries until we are reduced again to being barbers (no disrespect meant toward the barbering profession.) Physicians lack cohesiveness and leadership."

High morale

In addition, there were some comments from doctors who are very happy and fulfilled with their jobs and don't think low morale is a problem.

"Morale in the VA (Veteran's Administration) is dramatically better than in private practice or at a university. While you won't get rich, you can actually work in one of the 'cognitive' areas of medicine and do the right thing for a population of patients! Clearly, (the) U.S. should move to a single payer system for the sake of doctors and patients."

A similar attitude came from a military doctor.

"Generally the physician morale in the military is pretty good. The physicians deployed to the Afghan/Iraqi areas of operations generally return energized to take care of our esteemed and distinguished beneficiary patients. We have select patient population of great Americans who take pride in what they do. This carries over to the physician population of the armed services, to include military, civilian and contract providers."

Doctors' advice

Despite the doom and gloom that many survey respondents expressed, some of the physicians were quick to diagnose the problems and offer some remedies.

"When I feel beaten, stressed, or burnt out, I remind myself that this is still the career choice for me," one doctor wrote. "I love the practice of medicine, and my patients, and the challenges. But I truly appreciate my family (husband and son, as well as siblings) and friends, and time away from the office.... I am slowly allowing myself to spend more time at leisure ... and scheduling time off."

Another said setting limits is important.

"One of the major sources of stress seems to be more the pace and amount of work and balancing that with your life outside of work. With the technology available today, you can essentially have the ability to always be connected to your work responsibilities.

"I know of more physicians now finishing their documentation and checking their e-mails at home after they have completed a long day of seeing patients. We need to make a conscious effort to 'end the day' at some point and put as much effort into our personal lives and time."

And one gave reason for hope.

"It is very easy to get discouraged because of all the possible problems that have been listed in the survey; however, if we just sit back and think about why we are in the profession of medicine to begin with, it is not very difficult to put those depressing, discouraging feelings aside and feel good about what we do as physicians.

"I feel that every industry, work place, organization, job sector and so on has gone through tremendous changes over the years. We just know more about the profession of medicine, because we are right in the middle of it. Just think of the people who have lost jobs or have been demoted because of collapse of the computer/software/IT industry, or loss of jobs overseas, or automation in the work place or any other reason.

"The antidote to depression and a discouraging attitude is exercise, stress management practices and good diet. While we may remember 100 patients who did not thank us or appreciate our help, few who do appreciate will compensate for the negatives any time."

Bill Steiger is editor of The Physician Executive.

RELATED ARTICLE: Note to Readers

Low Physician Morale Not to be Taken Lightly

For years, we've been hearing about deteriorating morale among physicians. And results of a new survey on physician morale show that doctors truly are experiencing extreme stress that often leads to fatigue, burnout and depression.

Perhaps most alarmingly, low morale can also contribute to medical mistakes, as despondent physicians overlook safety measures or simply can't concentrate fully on patient care.

In the following pages of this special report on discouraged doctors, The Physician Executive explores the many factors that contribute to physician stress, burnout and low morale.

Experts who study these tough issues also provide some solutions to the problems, offering various ways to improve morale.

Bill Steiger, editor

RELATED ARTICLE: Physicians Sound Off About Low Morale

Here's a look at some more comments posted by some of the doctors who completed the ACPE Physician Morale Survey

Lacking creativity

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"Physicians got to their medical careers by being curious, creative, passionate, and thinking for themselves. Today's environment in the health care industry does not reward those key attributes of happiness and well-being. Top it off with the malpractice environment, and it's no wonder morale needs a boost!"

Retiring soon

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"As the managing partner of an 8-pediatrician group, my main problems are almost always human resources, both from general staff and clinical staff. Second is reimbursement and third is the overwhelming amount of paperwork. I have been in practice for 29 years, so I have a great vantage point of reference. I used to be able to take care of twice as many patients as I can see now. I, and my associates, are crushed by the weight of the increasingly onerous requirements of the insurance companies. All I ever really wanted to do was care for my patients as best as possible. I feel that is becoming more difficult with each passing day. I am fortunate in that I can retire in a few years, or at least cut back. I feel badly for my younger associates who have to deal with these problems for the next 30 years."

Feeling blessed

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"The only time I considered leaving medicine was on the one occasion when I was being sued. Most physicians I know love medicine so much they put up with all the increased aggravation and stress, and still feel blessed that they are practicing medicine. I would not discourage my children from entering medicine if they chose to do so."

Losing authority

"I left a position of medical director of a group practice, that was part of a national corporation. As a middle manager, I had all the responsibility but none of the freedom. Matters as trivial as where to store charts and whether I could leave 15 minutes early were determined by offsite supervisors. None of the staff reported to me, but to offsite supervisors. Professionals need the freedom to determine how they will accomplish goals. This company treated physicians as the lowest level technicians, expected (us) to perform the duties as directed, no questions asked."

Taking away the fun

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"As near as I can understand, physician morale is at an all time low. The physicians that I talk to over coffee or lunch talk about how the government, Medicare/Medicaid, lawyers and agencies such as JCAHO make the practice of medicine so difficult; helping the patient isn't fun anymore, nor is keeping the trial attorney at bay."

Expecting honor

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"While the present conditions are impacting physician morale, there is a large component of overblown expectations, especially in the generations before me. In reality we are doing better than our parents ever did. We have more options in life. We enjoy the subject matter and the people. In addition, we have been hearing that "it isn't like it used to be" and "the golden goose is dead" since we applied to medical school. Don't get me wrong--young physicians can still be an organizational challenge. But it isn't an existential crisis, where they feel the world is threatening everything they thought they were and their place in it."

Lacking respect

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"As emergency physicians, my colleagues and I are continuously overwhelmed because we have to take care of admitted patients bordering in the emergency department in addition to constant stream of new patients. Our hospital administration does not respect the emergency department. Instead of treating the emergency department like the front door of the hospital and an opportunity to generate revenue, our hospital administration considers our emergency department to be nothing more than an endless supply of bed filler for when capacity is not maximum. Even though we are the first physicians to see all the sick patients and the last to transfer "admitted" patients, we are often criticized, berated, and disrespected by the medical staff and administration. No one ever commends our department for the difficult work we do under horrific conditions of overcrowding and suboptimal facilities. Our department is a hospital outcast, with the actual emergency department facility maintained in a 100-year-old building one block away from the main hospital. Our patient to physician ratio during the middle of the day can be as high as 30 to 1 and physician to nurse ratio as high as 15 to 1. I can go on and on but I think you get the idea."

Please choose the single biggest factor that you believe lowers the
morale of physicians working in U.S. health care.

                                 Response %  Response Total

Patient overload                 12.1%        145
Loss of autonomy                 21.2%        254
Loss of respect                  11.8%        142
Low reimbursement rates          21.9%        263
Medical malpractice environment  10.5%        126
Bureaucratic red tape            16.8%        201
Other                             5.8%         69
Total Respondents                            1200

Please indicate if you have personally experienced any of the problems
below as a result of your work as a physician. (Please check all that
apply.)

                        Response %  Response Total

Marital/family discord  34.2%        347
Emotional burnout       66.7%        676
Depression              32.2%        327
Substance abuse          2.9%         29
Fatigue                 77.4%        785
Suicidal thoughts        4.4%         45
Other                    9.4%         95
Total Respondents                   1014

[c] ACPE 2006 Physician Morale Survey

Have you ever considered leaving the practice of medicine as a result of
morale problems.

                   Response %  Response Total

Yes                59.7%        715
No                 40.3%        483
Total Respondents              1198

What steps if any have you taken to combat problems associated with low
morale. (Please check all that apply.)

                                  Response %  Response Total

Sought personal counseling        26.3%        276
Sought substance abuse treatment   1%           11
Talked to fellow physicians       54%          566
Searched for a job outside of     35.8%        376
health care
Lobbied local, state or federal   27.3%        286
govt. for health care changes
Other                             31.2%        327
Total Respondents                             1049

[c] ACPE 2006 Physician Morale Survey

Please indicate if the physicians you supervise or work with have
experienced any of the problems listed below as a result of their work
as physicians (Please check all that apply.)

                        Response %  Response Total

Marital/family discord  69.7%        770
Emotional burnout       86.5%        956
Depression              64.3%        711
Substance abuse         35.2%        389
Fatigue                 77.1%        852
Suicial thoughts        13.4%        148
Other                    8.9%         98
Total Respondents                   1105

Do you know of any physicians who have left the practice of medicine as
a result of morale problems?

                   Response %  Response Total

Yes                69.9%        835
No                 30.1%        359
Total Respondents              1194