We all remember that moment: our first day of medical school. In my case, I felt like that short white coat and the accompanying ceremony, filled with pomp and promises, was the reward for all the hard work I’d put in throughout high school and college. There was hope and excitement. It was all new, and I was ready for the challenge! I couldn’t wait to use my new stethoscope, cure my first disease, and take the first steps transitioning from Mr. Knight to Dr. Knight. What an honor; it almost brought me to tears. That was 20 years ago.
Things have changed—not just for me, but for most of us. American physicians are reeling. So many of our peers are unhappy, anxious, and scared for the future of the careers they fought so hard for. Recently, The Daily Beast labeled our vocation “the most miserable profession.” Why?
It’s hard to measure physician misery, something we’ll call burnout for the remainder of this series. An unwritten rule in the culture of medicine is that it’s taboo or thought of as weak to talk about our own problems. It’s a paradox: the doctors who suffer the most often speak-up the least.
Still, a recent Medscape “Physician Lifestyle Report” showed us that half of all plastic surgeons are burned out, and the numbers are rising. What’s worse, the same report signaled that between 10-12 percent of dermatologists and plastic surgeons rank as “severely burned out,” meaning that they’re contemplating quitting altogether. 
A more recent Mayo Clinic Proceedings from December 2015 verified that more than half of US physicians are burning out, an almost 20 percent increase over four years. Even more daunting, the same report noted an 80 percent increase in suicidal ideation among doctors over the same time period. According to the Washington Post in 2014, nearly 400 doctors commit suicide annually. 
Two plastic surgeons in my community took their own lives within the last year.
In this two-part series, we’re going to identify the signs of physician burnout and define the factors that lie behind this silent epidemic. I know this article is disheartening, but I hope it is illustrative. 
In the fall, we’ll look at some tough choices we all need to make to tackle burnout and fight for our careers, our families, and our health.
I. “I’M OVERWHELMED! WHAT HAPPENED TO MY LIFE?”
This may surprise you: Dermatology and plastic surgery are unique in that most of us remain in independent small practices. We shoulder the heavy burden of federal bureaucracy more than our peers in other specialties. Our practices groan under the regulatory tsunami created by the ACA, HIPAA, MIPPA (PQRS), HITECH, and many other innocuous sounding acts. 
The first edition of “The Federal Register,” a compilation of every regulation issued by each federal executive agency, was published in 1936. It was sixteen pages long. 
Last year’s Register set a record at almost 82,000 pages. Among these pages, according to the Competitive Enterprise Institute, are 3,378 final rules and regulations, 545 of which have a direct impact on small businesses. These rules serve to encumber business owners, frighten hard-working doctors, and wrap our careers in red tape. 
For those of us who accept insurance and perform higher-complexity procedures like Mohs surgery, there is significant anxiety over newer acronyms like VBMs and MIPS. These are not abstract concepts. They will be here in a few years, and no one knows what that will mean for our careers. 
Most us were forced to adopt EHR. Signing notes and pathology reports used to take five minutes. In talking to physicians, most say it now takes hours every night after clinic to perform the same task, routinely requiring them to stay at their offices until late in the evening, missing dinner and time with their families. Yet, the majority of doctors I speak with claim that EHR actually hampers patient care. In tandem, doctors find that staffing their clinic is much more difficult in the EHR era. Fleming, Culler et al reported in 2011 that “end users” of EHR (physicians and clinical staff) need an average of 134 hours per employee to prepare for use of their system, at an implementation cost of $162,000 for an average five-doctor group.
Meaningful Use and PQRS measures swarm around us like flies, irksome and serving no purpose. It’s become obvious to me that these requirements impede patient safety. I’ve labored over our SOPs for years. Now, my important guidelines get diluted by long, complicated, redundant electronic tasks that make us jump through arbitrary hoops placed there by bureaucrats. Stretched paper thin, how long until your staff misses something important?
Recently in Washington, DC, I sat down with a legislative aide for a local congressman and I was detailing how bureaucracy and regulation were driving independent doctors out of practice. Cutting me off mid-sentence, he said, “You know Dr. Knight, the insurance industry has been in my office every week for the past decade. The hospital groups and the trial lawyers, too. Where were you?” I was stunned. The answer, of course, is that I was caring for my patients. It’s hard to lobby Congress when you’re keeping 12-15 hour days at your medical practice.
Most doctors I speak with feel defenseless against the bureaucratic forces bearing down upon them. We spend our days going from exam room to exam room to OR, isolated from the rest of the world. Our families don’t eat unless we’re at the grindstone. Doctors have no opportunity to hobnob with our legislators over lunch or rounds of golf.
A few months ago, our estate attorney sent me a newspaper clipping from the Washington Post. She wrote at the top, “This sounds about right, I’m sorry.” It was an op-ed by Charles Krauthammer. Many of you probably know that Charles had a diving board accident during his first year at Harvard Medical School that left him paralyzed. He finished, took his psychiatry residency at MGH, but abruptly left medicine a few years later stating that he had, “chosen the wrong vocation.” 
He wrote that upon attending his fortieth medical school reunion, he noted “an undercurrent of deep disappointment, almost demoralization, with what medical practice had become.” His classmates felt, “an incessant interference with their work, a deep erosion of their autonomy and authority, a transformation from physician to provider.” 
We come in early and rarely get home before 7pm thanks to our new EHR programs. We go to bed exhausted and wake up tired and anxious, not ready to face the day ahead. We break even or make less every year, despite working harder, thanks in large part to unfunded government mandates that accomplish nothing.
It’s a recipe for burnout.
II. “I’M AFRAID OF MY PATIENTS”
I had dinner the other night with my neighbor, a well-liked plastic surgeon with more than 25 years experience and great skill.
I was surprised to hear him say how difficult it had become to find patients to perform surgery on. “Most patients,” he said, “come to me as a fourth or fifth opinion, beat me up over price, or skewer me over my online reviews.” One patient with obvious body dysmorphic disorder bashed him on the internet after he declined to perform surgery on her. She wrote something like, “this arrogant **** is too full of himself, I hope he breaks his fingers.”
Another colleague of mine, an orthopedic surgeon, was devastated when a patient alerted him to this one-star gem, “I didn’t know the D in MD stood for ******* ” (I’ll leave this to your imagination).
You can’t make everyone happy all the time. It’s a fact of life. Only 10 years ago, we could have shrugged off a rare unreasonable patient and moved on. Those days are gone. Now, anyone with an axe to grind (even non-patients and competitors) can broadcast negative reviews, often anonymously or under pseudonyms, across multiple domains without fear of retribution.
Many doctors I speak with allude to the same theme—a disconnection from their patients for fear of public rebuke or simple schoolyard mockery. One physician described this as existing in a “niceness bubble,” afraid to say anything that could be upsetting or controversial in any way. 
There’s a reason that we took that white coat ceremony seriously, the same reason that we still call retired physicians “Doctor.” For us, our careers and identities are interwoven. If someone complains about your restaurant’s tasteless hamburger on Yelp it’s a far cry from being called quack, jerk, or worse online for all to see. It hurts!
Of course, there’s always the tangible risk that your phones will stop ringing because of a negative online review. Most doctors admit that this affects their medical decision making at the bedside. Are we more likely to give that patient the antibiotics they’re demanding but don’t need? Operate on a terrible surgical candidate because they’re upset they “came all this way to see you for nothing?” Smile through a 30-minute dissertation regarding 35 chief complaints—all of them somatic—in the middle of a packed clinic?

 

 


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