Primary Care Burnout and Populist Discontent

The American Journal of Managed Care, December 2018, Volume 24, Issue 12

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.

ABSTRACT

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-e373Physician 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.

Even as primary care is heralded as the essential backbone of a highly functioning healthcare system,4 the burdens imposed on practices by the new regime threaten to render it an increasingly joyless pursuit. For many practitioners, the purported ends of improved metrics and decreased per capita healthcare expenses are not worth the substantial costs and dubious means to attain them. This is exemplified by the proliferation of policy-driven measurements, such as those required by CMS’s Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), used to determine reimbursement rates for practices based on performance metrics. Rising overhead and unpredictable reimbursements resulting from new payment models threaten to harm practitioners already struggling in the dominant production- and procedure-oriented payment model.5 Increasing health system participation in accountable care organizations (ACOs), which rely on primary care quality and savings metrics, adds complexity and uncertainty to the practices of primary care physicians (PCPs) who are not convinced of the merits or effectiveness of ACOs.6 For their part, medical specialty boards’ fee hikes and the complexity of Maintenance of Certification (MOC) processes—which critics dismiss as lacking demonstrable benefits to patients7—have led to a backlash from diplomates dissatisfied with MOC as a condition of licensure and insurance contracting.

In a healthcare matrix that increasingly depends on measurable outcomes to justify its existence, the report card of American primary care does not offer much cause for optimism for its future. The increased consolidation of primary care practices by health systems8—in response to the cost and complexity of regulations such as MACRA—threatens to adversely affect small practices disproportionately, accelerating the trend toward large corporate practices that are associated with increased cost and debatable effects on quality.5 Stepped-up MOC requirements among specialty boards, including those in primary care specialties, have led to a mutiny that spawned an alternative board called the National Board of Physicians and Surgeons, as well as the successful lobbying of anti-MOC legislation in 10 states (with legislation pending in another 6).9 Perhaps it is no coincidence that the combination of these threats to professional autonomy occurs at a time when surging physician burnout rates are affecting disproportionate numbers of PCPs.10 Gazing into the horizon of the physician workforce offers little reason for hope in a resurgence of primary care, as the number of US medical school seniors choosing primary care specialties such as family medicine remains anemically low, as it has been for decades.11

One phenomenon illustrating the growth of medical populism is the expansion of the direct primary care (DPC) movement, in which PCPs eschew contracts with commercial insurers and CMS, in repudiation of overhead and administrative burdens resulting from the triangulation of third-party contracts. The number of DPC practices is small—estimated at around 930 nationally12—yet a groundswell of interest in the model exists among practicing physicians, residents, and medical students. Although this band of physician-reformers is dismissed by some as small and piecemeal, it has animated many others seeking an alternative to consider DPC practice. Furthermore, DPC advocates have organized to support legislation protecting the DPC model from regulation as a health insurance plan in at least 21 states.12 Other efforts aim to change Internal Revenue Service rules to count recurring DPC membership fees as “qualified medical expenses” in health savings accounts (HSAs)—a move that could boost DPC’s attractiveness among those seeking a reprieve from expensive Affordable Care Act—compliant individual policies by pairing HSAs with high-deductible health plans.13

Within the House of Medicine, conditions fueling physician burnout have much in common with sources of populism in political, social, and civic life. Although the phenomenon of burnout garners much attention in the lay and medical press, the US healthcare industry has failed to connect the dots between burnout and the discontent that pervades US primary care and occurs largely unnoticed in the glossy pages of healthcare journals. The increasing administrative and economic complexity of healthcare financing may give false security to industry leaders of the system’s obligatory dependence on their command-and-control leadership. As in other spheres of society, the magnitude of grassroots disaffection among PCPs—and their willingness to abandon the system—is easily underestimated by those drafting the future financial and delivery models of healthcare. Rather than interventions for burnout focusing on stress relief, culture shifts, and rearranging administrative deck chairs, managers and thought leaders of the medical establishment in policy and education would do well to recognize the link between burnout and the growing loss of confidence in the direction of our current healthcare system by clinicians in primary care. In addition to the well-documented scourges of depression, divorce, addiction, and suicidality that result from burnout,14 further disruptions that might derive from the unpleasantness of remaining within the system could be physicians’ adoption of direct pay models, early retirement from clinical care, and the development of practice niches outside the scope of insurance contracts. For influencers of healthcare policy who publicly express their concern about physician burnout, anything less than honest engagement with those on the front lines of clinical practice is akin to fanning the flames of medical populism.Author Affiliations: FSU/Lee Health Family Medicine Residency Program, Department of Family Medicine, Florida State University College of Medicine, Fort Myers, FL.

Source of Funding: None.

Author Disclosures: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content; and administrative, technical, or logistic support.

Address Correspondence to: James O. Breen, MD, FSU/Lee Health Family Medicine Residency Program, 2780 Cleveland Ave, Ste 709, Fort Myers, FL 33901. Email: James.Breen@Leehealth.org.REFERENCES

1. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146. doi: 10.1016/j.mayocp.2016.10.004.

2. Swensen S, Shanafelt T, Mohta NS. Leadership survey: why physician burnout is endemic, and how health care must respond. NEJM Catalyst website. catalyst.nejm.org/physician-burnout-endemic-healthcare-respond. Published December 8, 2016. Accessed March 29, 2018.

3. Argandoña A. Why populism is rising and how to combat it. Forbes website. forbes.com/sites/iese/2017/01/24/why-populism-is-rising-and-how-to-combat-it. Published January 24, 2017. Accessed March 29, 2018.

4. Starfield B. Toward international primary care reform. CMAJ. 2009;180(11):1091-1092. doi: 10.1503/cmaj.090542.

5. Casalino LP. The Medicare Access and CHIP Reauthorization Act and the corporate transformation of American medicine. Health Aff (Millwood). 2017;36(5):865-869. doi: 10.1377/hlthaff.2016.1536.

6. Schur CL, Sutton JP. Physicians in Medicare ACOs offer mixed views of model for health care cost and quality. Health Aff (Millwood). 2017;36(4):649-654. doi: 10.1377/hlthaff.2016.1427.

7. Teirstein PS. Boarded to death—why Maintenance of Certification is bad for doctors and patients. N Engl J Med. 2015;372(2):106-108. doi: 10.1056/NEJMp1407422.

8. Scott KW, Orav EJ, Cutler DM, Jha AK. Changes in hospital—physician affiliations in U.S. hospitals and their effect on quality of care. Ann Intern Med. 2017;166(1):1-8. doi: 10.7326/M16-0125.

9. Advocacy center. National Board of Physicians and Surgeons website. nbpas.org/advocacy-center. Updated April 2018. Accessed October 31, 2018.

10. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014 [erratum in Mayo Clin Proc. 2016;91(2):276. doi: 10.1016/j.mayocp.2016.01.001]. Mayo Clin Proc. 2015;90(12):1600-1613. doi: 10.1016/j.mayocp.2015.08.023.

11. Kozakowski SM, Travis A, Marcinek JP, Bentley A, Fetter GT Jr. Entry of medical school graduates into family medicine residencies: 2016-2017. Fam Med. 2017;49(9):686-692.

12. DPC mapper. DPC Frontier website. dpcfrontier.com/mapper. Updated October 31, 2018. Accessed March 21, 2018.

13. Primary Care Enhancement Act of 2017, HR 365, 115th Cong, 1st Sess (2017).

14. Lacy BE, Chan JL. Physician burnout: the hidden health care crisis. Clin Gastroenterol Hepatol. 2018;16(3):311-317. doi: 10.1016/j.cgh.2017.06.043.