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Dr. Brian McDonough is a Clinical Professor of Medicine at Temple University School of Medicine in Philadelphia and the Chairman of the Graduate Medical Education Committee at St. Francis Hospital. He’s also an Emmy award-winning health news reporter and family medicine expert.

Do you wake up excited to go to work? I know—that is probably dramatic because it’s hard to get excited about anything before that first cup of coffee. So, let me ask it another way. Do you get the “Sunday night scaries” before you begin a typical work week? Don’t get me wrong. Negative feelings and anxiety are not always bad. Without stress, pressure, and long hours, we can’t truly appreciate the joy that can come from hard work.

However, there is a tipping point. Physicians are not a lazy group, and most (if not all) have been conditioned to work extreme hours. But, there is a price. The stress, pressure, and long hours can impact your personal life and your personal happiness. My own experience has taught me that physicians have an incredible pain tolerance. You can’t get into medical school without extreme sacrifice. The four years of medical school are difficult and demanding and require seemingly endless hours of self-sacrifice and denial. As for residency and fellowship—need I say more? 

So, why are physicians feeling burned out? Clearly, physicians of past generations worked long hours and dealt with life and death issues. Are today’s physicians soft? I will argue that they are not fulfilled.

I recently had the opportunity to travel to Scottsdale, Arizona for the Annual American Association for Physician Leadership Meeting. I had been asked to facilitate a discussion focused on “Physician Engagement and Retention.” The response was so great that we needed to switch from the assigned room to the main conference room. I would like to say that the attendance was due to the fact that I was facilitating the discussion. I might have believed it for a few minutes, but the discussion that followed told me something else. It was the topic.

“Physician Engagement and Retention” rapidly turned into “Physician Burnout and Need to Escape.” The discussion was not just illustrative of the issues, but it was a great opportunity to look at what a group of physicians from all over the country thought.

We developed a top ten list, and it included the usual suspects like salary, call coverage, CME benefits, control of schedule, and vacation time. But there were two issues that rose to the top and dominated the conversation. Close your eyes for a moment and guess what they are. (If this was a PowerPoint, it would be easier to force you to guess!) The biggest barriers to physician happiness also happen to be the two major contributors to physician burnout:

• The computerization of medicine
• Lack of independence

When I first heard about electronic health records I thought, “It is about time!”

For many years, I was banking online, and my work in television and the overall media had become “semi-virtual.” However, when I went to the office, I was doing what I did decades before—writing notes in paper charts and walking to radiology accompanied by the house staff to look at x-rays. Labs would arrive by paper, and many days I would shuffle through papers to look for my patient’s results. Computerization could bring everything to my screen at my desk.

But progress has been slow and continues to be painful. Little did I know that our future electronic health records would be developed to market to CEOs and CFOs and primarily be built for coding. I also didn’t know that engineers with very little physician oversight would be developing workflows. The engineers and builders meant well, but “you don’t know what you don’t know.” I also did not realize that government agencies and third-party payers would insert quality measures with hard stops.

Personally, I still hold out hope that we are in the Model-T stage of development and things will improve. My hope lies in the fact that the people who are making decisions about future computerization will learn from the past.

So, what is the biggest issue with computers? What is the low-hanging fruit leading to burnout? What can we change right away?

It is the fact that doctors have become scribes and need to race through a gauntlet of tasks that often have little to do with care of the patient in front of them. Many doctors rarely look at the patient in front of them because their eyes are fixed on the computer. The progress note, which was once a quick way to summarize a visit, has become a medico-legal-billing-coding document that allows outside agencies to monitor for quality measures. Physicians find themselves finishing charts at home during so-called “pajama time.” The most rewarding part of patient care—interaction with the patient—has been largely replaced by keyboard clicks. The resulting burnout is impacting physicians of all ages. Many of the oldest are retiring early, and many the youngest are looking for a way out.

A lack of independence is the other key issue. Physicians of past generations worked long hours—possibly longer. However, most were independent. Initially, their independence started to evaporate as government and third-party payers began inserting rules to control costs. As payment started shifting, physicians slowly realized they could make a better living in an employment model. Hospitals soon learned that they needed to “own” practices to compete with other hospitals, and the race was on. For physicians, this has come at a price: independence. A major source of burnout is the fact that people who essentially sacrificed their younger years to provide care for others find themselves jumping through hoops that are not of their own making. The hoops often have little to do with improving their patient’s health.

If you are a physician or someone familiar with our healthcare system, you know that I have only scratched the surface—the tip of the proverbial iceberg. Despite the problems, there is hope. I truly believe that most of the decision makers are trying to do the right thing. Many of the present-day barriers were constructed by well-intentioned people who thought they understood the doctor-patient relationship but could not be expected to understand. Their mistake: not including or allowing the experts in the decision-making process. This is already changing, and perhaps most importantly, we still have a strong foundation to build upon.

Thankfully, the physician-patient relationship remains sacred, and the personal care you provide your patients greatly depends on your decisions. The computer is still a tool that you can use to document your decisions and write your orders. As a result of greater physician involvement and close work with non-physicians, several of the leading electronic record companies are starting to make the products they develop more physician friendly. As physicians, we need to take time to work with government policymakers and third-party payers to incorporate quality measures that truly make a difference in patient care. Physicians don’t mind “extra clicks” on the computer if care is improved, but they despise “extra clicks” to generate profits that are not returned to patient care. The sky is the limit as technology improves, but frontline providers need to have a voice in the improvements to make them more relevant.

As for the employed physician model, the lack of satisfaction comes from not having a voice. Physicians and physician leaders need seats at the decision-making table. Most people, whether physicians or not, want their voices heard.

It is a bit ironic, but as I write this blog, changes are already happening. The irony is that the shortage of physicians is becoming a national problem. As a result of the shortage, healthcare decision makers are starting to realize they need to make changes. Some of the best and brightest are changing the physician employment model, and several major health systems are demanding that the leading electronic health record companies make their products more physician friendly. The best way to reduce burnout is to increase workplace satisfaction. Physicians want to improve the health of their patients, and they are asking to take away the barriers and be allowed to control their own destiny.