The Solution to Burnout

Is anyone else tired of hearing the solution to burnout is more focus on clinician well-being? This sounds like victim-blaming to me, and why is the focus only on clinicians? I know many service representatives, administrators, and students who say they’re burned out too. Is what we are doing now working? When will our crisis of burnout in health care lead to real change?

Estimates of health care worker burnout are as high as 70%,1 and at least one in five health care workers have left the profession since February 2020.2 With this extreme shortage of health care workers, those left are working harder than ever. I know a nurse in her last month of pregnancy taking extra overnight shifts to lessen the burden on her colleagues. I’ve seen practice directors paged 24/7 because they are covering an untenable number of clinics. I’ve never seen health care team members work closer, work longer, and be pushed to this level of exhaustion. When burnout is at an all-time high and staffing levels are at an all-time low, as expected, there are concerns about declining quality of care.3 Is what we are doing now working?

A literature search for “causes of health care worker burnout” resulted in a shocking preponderance of articles focusing on individuals and their personal coping skills and practices. These studies are missing the root cause. Researchers, please focus on the real cause of burnout: the health care system. Providing wellness coaches, resources for mental health support, and creating a culture of wellness are all helpful, and let’s be real here, the main reason we need all these resources is because of a dysfunctional health care system. The health care system has been causing burnout long before the advent of COVID-19,4 and we’ve watched COVID-19 make everything so much worse. We were on a collision course of burnout before COVID-19, and many times I heard, “COVID will finally be the crisis we need to effect a change.” Did that change come? Is what we are doing now working?

Here are the issues as I see them:

• Understaffed clinics and hospitals.
• Too much time spent in electronic health records (EHRs).
• Too much time handling insurance issues such as prior authorizations, specific quality measures, referrals, training mandates, etc.
• Too little reimbursement from Medicaid.
• Too little support and leadership from Medicare to transition to value-based payments.
• Too much emphasis on sick care instead of preventive care.
• Overwhelming moment-to-moment complexity of administrative issues from dealing with so many payors.
• High health care professions student loan debt.
• Inequities in care based on patients’ insurance coverage.

Let’s spend a moment considering the last one. In the United States, we have a standard of care for the appropriate treatment of patients. All too often, only my wealthier patients get that standard of care, because many patients cannot afford the recommended treatments, or get blocked by their insurance providers. What that means for me as a physician is the feeling that patient-by-patient, I am colluding with a system that is harming my most vulnerable patients. We want to provide the same standard of care for everyone, but in the US health care system, I have seen many of my disadvantaged patients blocked by system factors. Frankly, that makes me feel terrible. Is what we are doing now working?

So, what is the solution? Take away all the payor complexities that are wasting our time, are so expensive, are leading to burnout, are threatening quality of care, and are often an obstruction to the type of care that everyone deserves. The only way I see to remove the barriers is to change to a single-payor health care system.

In the beginning of the pandemic, I remember hoping for national standards for safety and treatment protocols, federal support in acquiring personal protective equipment for local health systems, and as hospitals and clinics were hemorrhaging money and laying off workers, more help to sustain us. I felt tremendous support from the American people, but felt little support from insurance companies, from Medicare, from Medicaid, or from the US Department of Health and Human Services. Every health care system had to define their own protocols, compete with each other for equipment, and fight for their very financial survival. I thought to myself, surely this is the crisis that will change everything. I wish I knew who to credit when about a year ago I had a conversation with another doctor who said, “Oh I think the crisis in health care is yet to come. It’ll be later in the pandemic when health care workers leave in droves.” What a prescient thought.

The idea of change is scary, but I ask again, is what we are doing working? In the US health care system, how are Black, Indigenous, and people of color treated? How are the poor treated compared with the rich? How is your care based on where you were born or the zip code where you live, your sexual orientation, gender identity, or what language you speak? How happy are clinicians, staff, and administrators in health care? Is this the world we are training our learners for? Is what we are doing now working?

What I’m doing now isn’t working, and I’m going to fight for something different. While writing this column, I joined Physicians for a National Health Plan.5 Nurses can join National Nurses United,6 an organization that supports Medicare for all. I don’t know what the right solution is, but I know that if we demand a change, those in power will have to propose viable solutions.

In 2019, the American Medical Association’s (AMA) Medical Student Section fought to get the AMA to formally support a single-payor system, and it was defeated by a narrow margin of 47% for and 53% opposed.7 Student doctors came very close to changing the policy of the AMA, and I hope they try again.

As teachers in family medicine, I know health care reform can become political, and I know many of you may not support my stance above, so how about this? For those who agree that what we are doing now isn’t working, I ask that we engage our health care teams, one another, and our learners on what change could and should look like. Instead of shying away from change, let’s tackle the tough discussions around reform. I don’t know about all of you, but I’m full of idealism and hope for a better future, and I’m ready to act! What we’re doing is not working, so let’s change it, together!