A Conceptual Framework for Understanding Physician Burnout

Raj Karnani, MD

Last year, a colleague in my LinkedIn network posed the question of what physician engagement might look like at a day-to-day level outside of what one would typically find in an annual physician engagement survey. I commented with my thoughts, and I was pleasantly surprised by the positive reactions I received from other commenters and colleagues. As a result, I thought I would expand on these thoughts as physician burnout has recently come to the forefront of medicine. The framework I explain below is adapted from Stephen Covey’s book, The 8th Habit: From Effectiveness to Greatness, the follow-up book to the all-time business classic by Dr. Covey, The 7 Habits of Highly Effective People.

In the workplace, all people have essential needs that must be met to maximize effectiveness. These needs are especially true in the Knowledge Age we are currently in, where workers are hired for their intellectual capital (i.e., knowledge workers). Contrast this with the Industrial Age, we as a society transitioned from a few decades ago, where workers were hired primarily for their physical output in an assembly-line manner without much thought given to their other needs (highly unfortunate). Knowledge workers are best represented by the whole-person paradigm, meaning that they have multiple dimensions that cannot be separated from one another. These dimensions, which are adapted to the modern workplace, include the following:

  1. Physical (the body) – does the knowledge worker have the tools s/he needs to do the job, and is s/he paid fairly?
  2. Social/Emotional (the heart) – is the knowledge worker treated with kindness, and does s/he have high-quality relationships with coworkers and management?
  3. Mental (the mind) – is the knowledge worker’s talent being used creatively and to the fullest, and are there opportunities for professional growth and development?
  4. Spiritual (the spirit) – is the knowledge worker doing meaningful work and serving people’s essential needs in principled ways with their contribution?

Physicians are knowledge workers. Knowledge workers decide how much of themselves they will give to their work depending on how they are treated and their opportunities to use all four parts of their nature. If any of the four parts of their nature are not met, then knowledge workers will give much less of themselves. This disconnect manifests with cynicism, fatigue, and lack of compassion—the more dimensions of a physician’s nature that are not addressed, the greater the negative symptoms.

You can think of a knowledge worker’s response along a continuum that looks like this:

  • Creative excitement                      (Best)
  • Heartfelt commitment
  • Cheerful cooperation
  • Willing compliance
  • Malicious obedience
  • Rebel or quit                                 (Worst)

Now, let’s adapt this continuum to the life of a typical physician. How would you respond to each scenario?

1. You have a new position with an established medical group. You are not treated fairly, and they refuse to pay the incentive bonus agreed to at the interview. Moreover, it takes twice as long to write notes in their new EMR as it did before.

  • Creative excitement                     
  • Heartfelt commitment
  • Cheerful cooperation
  • Willing compliance
  • Malicious obedience
  • Rebel or quit    

2. You see many sick neurologic patients who need an MRI to make accurate diagnoses, but the insurance companies make you go through a difficult preauthorization process. In the end, you do what the insurance company tells you to do to get the patient what they need, even though it is truly unnecessary.

  • Creative excitement                     
  • Heartfelt commitment
  • Cheerful cooperation
  • Willing compliance
  • Malicious obedience
  • Rebel or quit

3. You ask your physician boss to discuss concerns you have about the call schedule and patient workflows in the outpatient clinic, and he treats you unkindly and refuses your request.

  • Creative excitement                     
  • Heartfelt commitment
  • Cheerful cooperation
  • Willing compliance
  • Malicious obedience
  • Rebel or quit

4. You are a member of a talented medical group and enjoy your patient care work. However, you have noticed your practice manager is billing health insurance companies for services your team has not provided to help everyone meet their RVU targets.

  • Creative excitement                     
  • Heartfelt commitment
  • Cheerful cooperation
  • Willing compliance
  • Malicious obedience
  • Rebel or quit

5. You work for a busy hospitalist group that makes it difficult for you to spend quality time with your family. You want to change jobs, but an onerous non-compete clause in your contract means you would have to relocate your family to a new city.

  • Creative excitement                     
  • Heartfelt commitment
  • Cheerful cooperation
  • Willing compliance
  • Malicious obedience
  • Rebel or quit

How many checkmarks do you have in the top three categories? How about the bottom three categories? I bet that most or all of your checkmarks are in the bottom three categories. Is it any surprise that physicians feel frustrated and burned out?

Physician burnout, then, is the result of healthcare organizations being operated in a controlling, industrial age model rather than with a whole-person model that unleashes physician potential. In an industrial age model, the main assets are machines or capital (think new hospital wing or sophisticated MRI machine), and people are replaceable. The focus is on getting the numbers (think RVUs) and using the carrot-and-stick philosophy to motivate physicians. This controlling model insults and alienates physicians, depersonalizes work, creates low trust between physicians and hospital management, and eventually leads to codependency and lack of responsibility. Ultimately, patients are the ones who suffer. In a modern knowledge age worker model, the main organizational assets are the physicians’ knowledge, skills, and talents, and people are four-dimensional, whole beings (and so are patients, by the way!). The focus is on unleashing human potential, where the goal is to find one’s voice or calling.

So what’s the solution? Change the paradigm. But that’s not easy to do in the incredibly complex system of U.S. healthcare. It might be better to start by thinking about the solutions medicine has come up with so far and why they don’t work. How about yoga and mindfulness thinking? This helps, but it only addresses one part, the heart. How about resilience training? Again, this helps, but it addresses only the body. How about a big party on Doctor Appreciation Day? You see the point. All these solutions assume that physicians are the problem. They are most certainly not! The honest answer addresses the misalignment between the four parts of a physician’s nature and the organization’s management paradigm. I’ll discuss this topic in a future article.

References:

Covey, S.R. (1989). The 7 Habits of Highly Effective People. New York, NY: Fireside Publishing.

Covey. S.R. (2004). The 8th Habit: From Effectiveness to Greatness. New York, NY: Free Press Publishing.

Covey, S.R. (2006). The 8th Habit Personal Workbook. New York, NY: Free Press Publishing.

Dr. Raj Karnani is an academic physician and a healthcare analytics translator. His analytics expertise provides a foundation for healthcare organizations to appreciate and utilize advanced analytics (i.e., predictive modeling, machine learning, artificial intelligence), thus providing a more robust platform for planning and actions in population health management, value-based care, and clinical research.

Furthermore, with knowledge, experience, and training in medicine, clinical data science, medical education, and healthcare management, he bridges the gap that frequently occurs on analytics teams between IT professionals, who seek clinical experience, and key business stakeholders, who seek data science expertise, to enable them to work more effectively as a unit.

To this role, Dr. Karnani brings more than a decade of progressively expanding management and development accomplishments with documented successes improving both business and clinical outcomes. His corporate and organizational background includes CommonSpirit Health, IQVIA, and Michigan State University, and he can help your organization be more competitive with the right analytics. Dr. Karnani can be reached via email and through LinkedIn.

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