AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. September 2003, Volume 5, Number 9.

Clinical Cases

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Managed Care and Physician Burnout

Focusing on patient-communication can help physicians alleviate the stress caused by the administrative tasks and regulations associated with managed care.

Commentary by David S. Brody, MD, and Pamela Brody, PhD

Dr. Richard Kent walked into the office and pulled up his schedule for the day on the computer. Another full one. Four patients had been scheduled for every hour. Contractually, he was allowed 20 minutes per visit, but Hippocrates Health Care, the organization for which he worked, operated on the assumption that 1 out of every 4 patients doesn't show for his or her appointment. Great; suppose all of his "assumed" no-shows for the day showed up. Suppose 4 didn't, but they were all scheduled for 4 pm. His day would be hectic. He found himself hoping that all the assumed no shows would indeed fail to keep their appointments. In truth, he hoped even more than that wouldn't show.

Hippocrates Health Care had been moving into the area and signing up increasing numbers of company health benefits contracts over the last 5 years. Now, few physicians in the region were not part of the system. When more and more of Dr. Kent's patients had told him they'd have to leave him and find a physician on the Hippocrates list, he and his partners signed on as Hippocrates employees. They immediately enjoyed some perks, full patient load on days when they worked, no more filing paperwork for reimbursement from 10 or even 12 separate insurance plans, no more uncollectible accounts.

But the numbing sameness of his days was getting to him. Patient records were automated, and there were computers in each examining room. On initial visits, Dr. Kent would sit at the computer and ask each patient 30 or so questions beyond what the nurse or PA had already asked and click in the proper field on the answer given by the patients. Then he would leave while the patient undressed, go ask patient 2 the same 30 questions, and return to examine the patient 1.

Physicians under contract to Hippocrates were required to practice within the boundaries of what was "customary and standard" throughout Hippocrates' nationwide service area. Dr. Kent had to document deviations from those standards of care, get approval before rendering the service, or apply retroactively for reimbursement for an extra day in the hospital or for a particular brand of drug.

What compromised Dr. Kent's sense of professional integrity more than anything was having to explain Hippocrates' business-based decisions to his patients. When Hippocrates suddenly dropped a brand name drug from its formulary, Dr. Kent would have to tell patients, some of whom had been successfully dose-calibrated and maintained on that drug for years, that they would have to change. He had to be truthful in telling them why he was changing their prescriptions; he couldn't say medical judgment was behind the decision, because it wasn't. The same was true in limitations or delays placed on diagnostic tests that, based on his own medical judgment, Dr. Kent would have ordered without delay. He worried that explaining the reasons for such bottom-line-oriented decisions was eroding his patients' trust in medicine and in him.

What a rut, Dr. Kent thought. Imagine hoping that patients don't show up. This doesn't feel like the noble profession of medicine.

Commentary

Managed care is often blamed for decreasing physician work satisfaction. Surveys indicate that many primary care physicians believe that managed care has adversely impacted relationships with their patients, as well as the quality of care they provide [1,2]. Physicians' sense of control over their practice environment has been shown repeatedly to be the key factor in determining their job satisfaction or dissatisfaction. Physicians like Dr. Kent believe that they must see more patients in order to maintain their income. They are frustrated about pharmacy formularies that limit their ability to prescribe the medications that they and sometimes their patients prefer. They may also be frustrated about utilization review decisions that prevent them from ordering tests they think their patients need or force them to shorten their patients' hospital stays, and they may feel frustrated about limitations that are placed on whom they can refer patients to or where they can send their patients for specific services.

To some degree, a sense of frustration about these incursions into their control over their practice is normal. When it results in emotional and physical exhaustion, a sense of alienation, cynicism, negativism, and detachment to the point that the physician begins to resent work and the people who are associated with it, it is a problem that is referred to as burnout.

Burnout can affect as many as 40 percent of physicians. The symptoms of burnout vary. Some physicians become angry and irritable, others continuously complain and blame any annoyance on external factors. Some become quiet, introverted, and isolated, which can be a manifestation of an underlying mood disorder. Others manifest burnout by overeating or abusing alcohol or other mood altering substances. Still others experience chronic physical symptoms or diseases.

Burnout can affect a physician's ability to perform his or her job. Physician satisfaction or lack thereof can influence patient satisfaction. Two studies found that patient adherence to prescribed medications and follow-up appointments was affected by physicians' attitudes about their work [3,4]. Dissatisfied physicians may also have more costly practice styles. Studies have found that dissatisfied physicians use more total outpatient procedures and make more referrals than physicians who are satisfied, even after adjusting for case mix and other covariates [5,6].

Obviously, not all physicians who see predominantly managed care patients experience symptoms of burnout. Individual's perceptions of and reactions to the same source of stress vary. Factors that influence one's perceptions of and reactions to workplace stressors include one's need for control and perceived ability to establish control (or self-efficacy); one's overall optimistic or pessimistic perspective, and how one attributes the cause of negative events (eg, were they caused by internal or external factors).

Satisfaction with life outside of work can have a protective effect. Social supports, hobbies, and other outside interests, as well as religious or spiritual beliefs can help buffer work stress. Physicians whose identity and sense of self-esteem are largely dependent on their work may be at greater risk of burnout when confronted with issues related to loss of control.

Coping successfully with a sense of loss of control involves both behavioral and cognitive strategies. These strategies may be aimed at modifying the problem itself or modifying the physician's emotional reaction to the problem. Dr. Kent might try to modify the problems he is confronting by negotiating a schedule that includes fewer patients or fewer hours in return for assuming other responsibilities or earning less income. He might develop strategies for minimizing his frustration over formulary limitations by using a computer system that contains updated lists of the formularies for all of the managed care companies he has contracts with. He might work with other physicians in his practice to pursue changes in the health care systems that have frustrated him and impaired the quality of care that is provided to his patients.

Dr. Kent may learn to work more efficiently by identifying appropriate goals for the visit, prioritizing these goals, and focusing on the most important issues. Changes in his chart and practice and additional resources may also help him feel more comfortable seeing patients at 15 to 20 minute intervals. He might also develop communication skills that will help him minimize the conflict that he has been experiencing with his patients. Levinson and colleagues have identified 3 key skills to resolving conflict with patients: (1) understanding their worries and concerns, (2) empathy, and (3) encouraging patients to play an active role in decisions about their care and negotiating differences of opinion when necessary [7]. When addressing an angry patient who has just learned that his anti-hypertensive medication is no longer covered by his insurance plan, Dr. Kent might begin by empathizing with the patient's feelings and asking if he has any specific concerns about switching to another medicine. When there is more than 1 type of medication he could reasonably switch the patient to, Dr. Kent might involve the patient in the decision-making process.

Coping strategies can be effective even when the causes of the problems themselves are difficult to change. For example, one can alter one's expectations about the situation so that it is more consistent with the reality. Most of us came into medicine with an idealized impression of what it means to be a doctor and were shocked by the reality of the current practice environment. Many accept this reality and strive to make the best of it, but some continue to see the difference between their expectations and reality as a persistent source of frustration and distress. While practicing medicine may not be exactly as expected, its essential elements remain unchanged. The ability to focus on the more positive aspects of the doctor-patient interaction may help reduce the distress associated with more problematic external factors.

The recent stock market crash has taught all of us the value of diversification. This lesson is also relevant to the difficulties we are encountering in the practice of medicine. The practice of medicine must not become the only important aspect of our lives. Spending time with family and friends and regularly engaging in activities that provide relaxation and pleasure and enhance our sense of self are necessary to balance the stressors that are inherent to our profession. In order to be good at what we do and enjoy it, we need to take care of ourselves by eating right, getting sufficient rest, exercising routinely, and by paying more attention to our internal signals of stress. We need to learn to understand the sources of our stress and the thoughts and feelings they evoke, and we need to practice stress-reducing strategies that can modify the stressful situation itself or the emotional impact of that situation.



References

  1. Feldman DS, Novack DH, Gracely E. Effects of managed care on physician-patient relationships, quality of care, and the ethical practice of medicine. Arch Intern Med. 1998;158:1626-1632.
  2. Baker LC, Cantor JC. Physician satisfaction under managed care. Health Aff. 1993;12(suppl):258-270.
  3. DiMatteo MR, Sherbourne CD, Hays RD, et al. Physicians' characteristics influence patients' adherence to medical treatment: results from the Medical Outcomes Study. Health Psychol. 1993;12:93-102.
  4. Linn LS, Brook RH, Clark VA, et al. Physician and patient satisfaction as factors related to the organization of internal medicine group practices. Med Care. 1985;23:1171-1178.
  5. Eisenberg JM. Doctors' Decisions and the Cost of Medical Care. The Reasons for Doctors' Practice Patterns and Ways to Change Them. Ann Arbor, MI: Health Administration Press; 1986.
  6. Freeborn DK, Johnson RE, Mullooly JP. Physicians' Use of Ambulatory Care Resources in a Prepaid Group Practice HMO. Final report for Health Care Financing Administration grant 18-P-9799319-02. Portland, OR: Kaiser Permanente Medical Care Program, Health Services Research Center; 1984.
  7. Levinson W, Gorawara-Bhat R, Dueck R, et al. Resolving disagreements in the patient-physician relationship. JAMA. 1999;282:1477-1483.

David S. Brody, MD, is a professor of medicine in the Department of Medicine at Drexel University School of Medicine in Philadelphia, PA.

Pamela Brody, PhD, is an adjunct faculty member at the Philadelphia College of Osteopathic Medicine and at Friends Hospital.

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.