Shallow work and physician burnout
“I cannot see patients full-time,” a physician friend lamented to me the other day. “It’s just too hard.” He’s now working 3 days a week.
“I’m at the breaking point,” a fellow oncologist shared recently during a group discussion about another new “project” handed down from our leadership. “I’m going to quit any moment.” The frustration was obvious in her voice.
The recent paper “A Crisis in Health Care: a Call to Action on Physician Burnout,” published by the Harvard School of Public Health and others, reports that almost 80% of surveyed physicians experience feelings of burnout. In his essay titled “Why Doctors Hate Their Computers” in the November 12 2018 edition of the New Yorker, Dr. Atul Gawande cited statistics that the specialists with the highest burnout rates were the ones having to deal with the computers the most. Overall, we physicians of all specialties are quitting.
In my own experience, the heavy clinical responsibilities, the endless in-basket results, the countless hours dealing with insurance companies, and, worst of all, the numbing hours of required documentation mean that, after a 10–12 hour workday, I often work for a few more hours every night, after the kids are in bed, to finish up clinic notes, triage results, or respond to patients’ online messages. I have often considered reducing my status to part-time.
In 2016 the Georgetown professor Cal Newport published the bestseller Deep Work: Rules for Focused Success in a Distracted World. Deep work is the ability to focus without distraction on a cognitively demanding work. The author criticizes the modern workplace where deep work, which produces true value to the individual and her organization, has to compete against and often loses out to a cacophony of so-called urgent but shallow demands, emails, text messages, phone calls, and meetings. Instead of performing the deep work that requires the hard-earned skills of the modern knowledge worker, she is forced to spend most of a typical work day simply pushing information around.
Newport’s diagnosis of the malaise affecting the modern company can also be applied to the modern medical clinic. The most valuable assets of a medical organization are its highly-trained physicians, nurses, technicians, etc… Yet an astounding quantity of hours in a physician’s day is devoted to shallow work — the kind of work that perhaps requires an associate or a bachelor’s degree — not the deep work that is essential to diagnose the patient’s problem, devise a treatment plan, and make modifications based on toxicities and efficacy; the deep work that requires years of medical training; the deep work that saves lives.
An amount of shallow work is of course inevitable in any job. One has to respond to certain emails, comply to certain rules, and attend certain not-so-useful meetings. Yet when the amount of shallow work completely overshadows the amount of deep work, when physicians have to work around horrendously designed EMR interface, deal with insurance companies that deny life-saving drugs, document things simply for the sake of billing and legality, are required to implement another project that introduces more clicks, more data entry, more shallow work — this is when we arrive at our breaking point.
I still remember the first time I visited the outpatient clinic of the Cancer Hospital of Ho Chi Minh City, Vietnam. Hundreds of patients had arrived before the sun came up, taking up all the available seats, sitting on the floor, standing outside in the parking lot. Many of them had taken 6- or 7-hour bus rides from the countryside. There were only a handful of medical oncologists, each seeing 50 to 100 patients per day. The physicians were burned out but they kept working in that condition, day in and day out.
In America, the organizational responses to physician burnout often include wellness retreats, lectures from “thought leaders,” yoga sessions, and, in some cases, hiring scribes. Yet we continue to feel burned out and many of us respond by reducing the number of patients that each one of us sees a day. But my new patients can wait up to one month to see me. The American Society of Clinical Oncology estimates that by 2025 the United States will have a shortage of 2300 medical oncologists. Globally, the shortage of cancer doctors is even more pronounced. According to a paper published in the Journal of Global Oncology in 2018, in one-third of 93 surveyed countries, a cancer doctor has to take care of more than 1000 cancer patients.
Many of us physicians are burned out but we want to see more patients. Wherever we might be on this earth, we entered this profession not to be just 0.75 or 0.50 FTE or to quit outright. We all chose medicine because of the patients in front of us in the clinic and in the operating room. We are challenged by the complexities of the human body, excited by the wonders of modern science, and humbled by the spirit of our patients. We want to save more lives, not fewer. There are never enough doctors, not enough in Vietnam, and not enough in America.
We are not afraid of, and in fact crave, more deep work. But who among us will step up, re-design the system, and cut out the shallow work in our day so that we can completely concentrate on saving lives?
Shallow work and physician burnout
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