45% of Doctors Suffer From Burnout!…and More!

Paul Griner, M.D. is a professor of medicine emeritus at the University of Rochester School of Medicine and Dentistry and was a consultant at the Massachusetts General Hospital, as well as a senior lecturer at Harvard Medical School. He is concerned about a recent national study indicating that more than 45% of physicians are experiencing at least one symptom of burnout. Commenting to OTW on this topic, Dr. Griner says, “Burnout—namely, irritability, depression, and detachment—is important not only because doctors are miserable, but because it can lead to misdiagnoses. “The Archives of Internal Medicine study, published in August, surveyed 7, 288 physicians, and is a reminder about how damaging burnout can be. Burnout-symptoms such as irritability, depression and detachment is important not only because doctors are unhappy but because it can lead to mistakes in diagnosis or treatment. A number of factors contribute to burnout. First, the pace of life in medicine—new medical knowledge and technology and changes in how medicine is organized and delivered—is advancing more quickly than we can keep up with. Also, having to constantly justify services to insurance companies and others is draining, as is the need for excessive documentation. And then there is the pressure to see more and more patients in the same amount of time. As payments go down doctors must do their best to accommodate these pressures in order to maintain a stable income.”

“Preventing burnout should start early, and teachers in medical school and residency have to give students the tools to cope with and reduce the stress that cause it. By and large the faculty of medical schools and residencies are beginning to understand more intimately the extent of the damage that burnout—even during the training years—can cause. Some schools are developing programs wherein they sit down with students and teach them to cope with stress. For example, Rita Charon, M.D., Ph.D. at Columbia University has a program for medical students that is terrific. They develop stories about their patients that allow them to express their opinions and feelings about what going on with the patient and family.”

“One thing that the field is beginning to do is to reorganize primary care practices to allow more time for complex patients. This way, we can move from the traditional model of the doctor as the sole provider to a more team based care approach. Physician assistants and nurse practitioners can be more involved in the treatment of routine problems so that the doctor is free to be with patients who need more time. Having said that, it is critical that the doctor has a clear understanding of the competencies of these medical professionals...their advantages and their limits.”

“Tips for doctors: First, take care of yourself. Get sufficient sleep and exercise regularly. Spend time on your work relationships. These bonds can enhance your positive feelings about your work life. Spend fun time with your family…not doing so puts you at greater risk of burnout. Find someone in your life who is a great example of balance and try to emulate him or her. This can be done, and if you work at achieving this balance, your stress level will decline precipitously.”

Changing Referral Patterns Hurt Trauma Centers?

Clifford Jones, M.D. is an orthopedic surgeon at Orthopaedic Associates of Michigan in Grand Rapids. He is also an adjunct professor at the Van Andel Research Institute and Research Director at Spectrum Health. He has been thinking a lot lately about referral patterns and what this means for orthopedic traumatology. Dr. Jones tells OTW, “Anxiety exists about creation of hospital systems, changing referral patterns, and numbers of trained orthopaedic traumatologists. We have been training large numbers of orthopaedic trauma surgeons without knowledge of open positions for jobs at Specialized Level One Trauma Centers in the long term. A glut of orthopaedic trauma surgeons could populate or accelerate the formation of newer less specialized ‘trauma centers’ without emphasis on ancillary or adjunct services such as general trauma surgery, neurosurgery, emergency departments, and intensive care units. Objective analysis of the training and job prospects should be performed at the highest levels. Furthermore, the creation of competing hospital systems with the potential of ‘bundled payments’ can disrupt regular and normal referral patterns to existing Level One Trauma Centers. Therefore, patients are referred or treated based upon hospital controls of the quantity of the payment instead of the quality of the patient care.”

“Patients are going to smaller, less experienced, potentially understaffed systems, which are now siphoning off the usual referrals, meaning that many teaching institutions are having problems obtaining sufficient patient volumes to teach residents and fellows. Combine this with restrictions in resident work hours and you have a real problem on the education end…and it ends up being potentially more costly in the end for patients and insurers because of suboptimal care, delayed care, and/or revision surgeries. We should conduct more outcome studies to see what leads to the best results and efficiency of care down the road—rather than just looking at fracture healing based on X-rays, days in the hospital, and complications. If you don’t have the patient numbers then it is inefficient to hire someone to do outcome studies which may in the end encourage people to establish certain centers for certain things—which may be problematic. In Indiana they have three hospital systems for the whole state. So where you go first is ‘it.’ In Grand Rapids, Michigan, the largest and busiest trauma center is having change in referral patterns from usual referral hospitals to less experienced, less staffed hospitals within that system instead of outside the system to the trauma center. Many have demonstrated that centralizing trauma care to specialized centers with increased staffing and specialists lowers overall costs, improves care, and lessens complications. Things are getting a bit out of hand. It will be interesting to see if the hospital systems are going to be profitable and patients will be treated with similar outcomes proving other prior studies and systems wrong.”

Heat Illnesses Heating Up

Benjamin Noonan, M.D., M.S. is an orthopedic surgeon at Sanford Health in Fargo, North Dakota. His recent work on the evaluation and management of heat- and cold-induced injuries in athletes is garnering some attention. Dr. Noonan tells OTW, “With all of the focus on heat illnesses, I thought that this topic merited further investigation. The main issue is the ‘pull’ between safety and getting adequate early practice time for athletes. Take football…there are often two practices a day during the summer months. The coaches need to get their training hours in…coupled with the fact that the athletes may not be showing up in perfect condition. Doctors must be aware of the risk factors, know how to evaluate the ambient conditions and be willing to push for increased rest or reduced intensity if warranted.”

“There are two types of risk factors for heat illness. The first is extrinsic where we consider the ambient conditions and protective equipment. A practical way to assess this is by the use of a ‘wet bulb globe temperature’—a composite temperature of that takes into account temperature and relative humidity (assuming standard wind and sunshine). It’s not just one or the other that matters…it’s the interplay between the two. Protective equipment can inhibit the cooling mechanisms by preventing airflow near the skin, which is crucial for sweat evaporation. Then there are the intrinsic risk factors such as the person being overweight, out of shape, medications, dehydration, and family history of heat illness.”

“If you are worried about heat illness in an athlete, know this: it is very common for a player suffering from heat illness to complain that they are not feeling ‘right.’ They may appear lethargic and confused. The number one priority (after assessing the ABC’s) in this type of situation is to initiate cooling, followed by obtaining a rectal core temperature as it is the most reliable way to determine the athletes core temperature. Heat stroke is officially 104 degrees; if someone has a temperature that high they need immediate cooling via ice bath if possible, serial measurement of core temperatures, and transfer to a medical facility.”

“Most of the evidence out there is unfortunately not from randomized controlled trials…it’s mostly position statements and expert opinions issued by national organizations. In working with athletic trainers at The University of Michigan while completing my fellowship, I learned that there is an increasingly strong tendency not to hesitate if you suspect a problem, i.e., to cool the athlete off by using ice baths without any delay.”

Private Patients: 14 Days; Uninsured Patients 121 Days

Michael G. Baraga, M.D. is assistant professor of orthopedics at UHealth Sports Medicine at the University of Miami Miller School of Medicine. He has done a study looking at anterior cruciate ligament (ACL) injury and access to care in South Florida. He tells OTW, “In this area we have a higher proportion of Medicaid and uninsured patients than many other states; and my practice is based in both a university medical center and a county ‘safety net’ hospital. My colleagues and I noticed a disparity in the presentation of patients coming to see us for a similar injury. Not only did the privately insured patients seem to present earlier, but those with Medicaid or those who were uninsured had different paths to diagnosis. The latter group had to wend their way through multiple ERs and see many practitioners, including other orthopedic surgeons before they reached our clinics. We decided to interview patients with the same injury and find out the path to diagnosis and subsequent treatment and what different factors led to this. Whether they sought care or not, whether they thought that it wasn’t serious and did not seek care, whether they could leave work to seek care, whether they could afford it, etc. We also wanted to look at whether the system had anything to do with this disparity in time to diagnosis, such as delays in obtaining an appointment or referral, because we know that the resources of county safety net hospitals may be limited.”

“We did find significant differences based on insurance status in the total time it took patients from when they were injured to when we diagnosed them with an ACL tear. We chose a diagnosis of ACL tear by our team as the time "end point" since we would be initiating treatment and not referring the patient to someone else. It didn’t matter what type of treatment they chose afterwards (i.e., whether they had surgery or not). Private patients were diagnosed at a median of 14 days from injury; for Medicaid patients it was 56 days; for those with no insurance it was 121 days. We then took into account whether they delayed seeking care, whether it was by their own choice or for what we called ‘system’ issues, such as waiting for a referral or appointment. We adjusted for those who delayed seeking care by subtracting that from the time it took from injury to diagnosis. With this adjustment, it took a median of 8 days for privately insured patients to be diagnosed, 43 days for Medicaid patients, and 83 days for the uninsured. Interestingly, though the differences in time to diagnosis and adjusted time to diagnosis were statistically significant, there was no difference in the time patients delayed seeking care across insurance groups.”

“We also looked at the number of doctor visits; those with Medicaid and the uninsured had more medical visits before being diagnosed in our clinics. They were also more likely to go to the ER as a first visit (this was statistically significant). Some patients would make it to a specialist’s office and then be referred to either of our two centers because of their insurance. But even after being seen initially in the county sports medicine clinic, it would sometimes take an extended period of time to obtain an MRI and get an appointment to come back. While providing insurance to those without it is important, as our study and other have shown, this may not result in complete access to care. Fewer practitioners are seeing new Medicaid patients, therefore we can expect an increase in patients at our county and university hospitals with an increase in participants in the program. We cannot then forget that we must ensure our safety net hospitals have the resources to take care of patients and ensure adequate access to care.”

“One of the limitations of our study is that it is a regional study. We would like to take this research from a regional to a national level. As this goes to publication I will be contacting different institutions in similar locations across the U.S. to see if we can do the same type of study at different centers.”