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The American Journal of Managed Care December 2018
Feasibility of Expanded Emergency Department Screening for Behavioral Health Problems
Mamata Kene, MD, MPH; Christopher Miller Rosales, MS; Sabrina Wood, MS; Adina S. Rauchwerger, MPH; David R. Vinson, MD; and Stacy A. Sterling, DrPH, MSW
From the Editorial Board: Jonas de Souza, MD, MBA
Jonas de Souza, MD, MBA
Risk Adjusting Medicare Advantage Star Ratings for Socioeconomic Status
Margaret E. O’Kane, MHA, President, National Committee for Quality Assurance
Reducing Disparities Requires Multiple Strategies
Melony E. Sorbero, PhD, MS, MPH; Susan M. Paddock, PhD; and Cheryl L. Damberg, PhD
Cost Variation and Savings Opportunities in the Oncology Care Model
James Baumgardner, PhD; Ahva Shahabi, PhD; Christopher Zacker, RPh, PhD; and Darius Lakdawalla, PhD
Patient Attribution: Why the Method Matters
Rozalina G. McCoy, MD, MS; Kari S. Bunkers, MD; Priya Ramar, MPH; Sarah K. Meier, PhD; Lorelle L. Benetti, BA; Robert E. Nesse, MD; and James M. Naessens, ScD, MPH
Patient Experience During a Large Primary Care Practice Transformation Initiative
Kaylyn E. Swankoski, MA; Deborah N. Peikes, PhD, MPA; Nikkilyn Morrison, MPPA; John J. Holland, BS; Nancy Duda, PhD; Nancy A. Clusen, MS; Timothy J. Day, MSPH; and Randall S. Brown, PhD
Relationships Between Provider-Led Health Plans and Quality, Utilization, and Satisfaction
Natasha Parekh, MD, MS; Inmaculada Hernandez, PharmD, PhD; Thomas R. Radomski, MD, MS; and William H. Shrank, MD, MSHS
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Primary Care Burnout and Populist Discontent
James O. Breen, MD
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John A. Romley, PhD; Andrew Delgado, PharmD; Jinjoo Shim, MS; and Katharine Batt, MD
Medicare Advantage Control of Postacute Costs: Perspectives From Stakeholders
Emily A. Gadbois, PhD; Denise A. Tyler, PhD; Renee R. Shield, PhD; John P. McHugh, PhD; Ulrika Winblad, PhD; Amal Trivedi, MD; and Vincent Mor, PhD
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Primary Care Burnout and Populist Discontent

James O. Breen, MD
Physician burnout has parallels to rising societal populism. Failure to address the disconnect between clinicians and the healthcare system will exacerbate the primary care crisis.

Physician burnout receives much attention in healthcare circles because it poses serious threats to clinicians, staff, and patients. The forces leading to detachment and depersonalization among primary care physicians are similar to the factors responsible for populist movements more broadly—the perception of a rigged system favoring a managerial elite, disregarding the values and welfare of those who must play by the rules. The disconnect between systems initiatives and the burdens and uncertainty they create for primary care clinicians contributes to physicians’ loss of confidence, expressed as resistance to organized medical specialty and regulatory structures, as well as migrations of medical students and practicing physicians away from the prevailing primary care service model. A failure among healthcare leaders to recognize the link between the root causes of burnout and populism will result in further exacerbation of an already existent primary care crisis.

Am J Manag Care. 2018;24(12):e371-e373
Physician burnout is a prominent topic in the medical literature and within health systems that must contend with its effects on patient care and among their medical staffs. In addition to its destructive effects on the lives of clinicians and their patients, the combination of depersonalization, exhaustion, and auto-devaluation caused by burnout also heightens physicians’ sense of detachment from the systems of care in which they practice. Although administrators have historically considered the causes of burnout to be individual physician factors, current thinking acknowledges the contributions of system issues to burnout, including the flux and uncertainty of the ever-changing modern healthcare environment.1

Surveys of healthcare leaders show that although an overwhelming majority recognize physician burnout as a serious problem in healthcare at large, they are less likely to acknowledge it in their own organizations.2 This perception of burnout as an external problem is coupled with a lack of systematic evaluation and response by many healthcare organizations—some of which have tinkered at the margins of addressing burnout with strategies to mitigate its effects through mindfulness training, documentation with scribes, and redistributing clerical work to nonphysicians.2 Many experts attribute the rise of burnout to stress engendered by a growing workload and inefficiencies in care2; however, many clinicians mourn a loss of purpose, owing to the decoupling of their clinical work from the goals of the institutions where they practice. In short, organizational initiatives are becoming increasingly divorced from the values of the physicians upon whom they depend to deliver care.

Physician burnout has much in common with the factors that contribute to populist movements in the United States and other Western countries. A polemic word, “populism” can be used disparagingly to demonize political opponents or as a laudatory descriptor of common folk reclaiming the general will from a rigged system. Whether characterized pejoratively or heroically, populist movements share common attributes. They are based on sharp distinctions between “everyday people” and “elites.” The perception of corruption, opacity, and technocratic complexity leads adherents to challenge a rigged system tilted in favor of those who make the rules at the expense of everyone else. This alienation thus undermines the legitimacy of established institutions of governance and order.3

Current events reflect growing popular discontent globally, as once-respected institutions show cracks in the façade. Stories about rising nationalism in Europe and the United States, Bitcoin’s challenge to currency policy, and cries of “fake news” highlight the lack of confidence of the governed in the established leadership’s new world order.

In many respects, the dialectical language used by physicians to describe their burnout has much in common with the disruptive change-force descriptions invoked by populist rhetoric. This expression of burgeoning dissatisfaction in medicine is particularly visible within primary care—if one pauses a moment to see it. One hears it in frank conversations with stressed colleagues and residents, in heated reader responses to online journal comment boards, and in clinicians’ skeptical questions to business consultants promoting the health system’s new vertically integrated corporation to the enlisted.

The conditions behind disillusionment in primary care have parallels with the sentiments at the heart of man-on-the-street populism. For one, the healthcare “new world order” designed by the US medical establishment—governmental payers and regulatory agencies and state medical boards, in cooperation with medical specialty and academic organizations and legislators—rests upon a top-down campaign to improve efficiency and quality metrics while reducing costs and medical errors. And although improved and safer care at lower cost is hardly controversial, clinicians’ perceived lack of inclusion toward a common understanding of these terms’ application to medicine, and their impact on individual patients and practitioners, undermines the plans of the architects of healthcare systems. Disparate visions of what constitutes “quality” care, how best to measure and achieve it, and at a lower cost to whom, are at the heart of the disconnect between those on the front lines of medical care delivery and those in the command centers of the healthcare industry.

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