Redesigning Clinical Workflows to Return Joy to Patient Care
Insufficient Reward Driving Burnout
Insufficient Reward Driving Burnout

Have you thought much about insufficient reward driving burnout? I didn’t think so. Most people think burnout is primarily emotional exhaustion, brought on by work overload.

Emotional exhaustion is the first of three manifestations of burnout. The other two are depersonalization (cynicism) and a low sense of efficacy, as though what you are doing is not really making a difference. The latter two are significant issues, carrying their own negative impact on the person experiencing burnout and the people they come into contact with.

The other drivers of burnout include: lack of control (discussed in last week’s posting), insufficient reward (the topic for this week), breakdown of community, absence of fairness, and conflicting values. I’ll get to the last three in the coming weeks.

Insufficient Reward is a bigger deal than you may think

You may think insufficient reward is not a big deal for doctors. Hopefully you will understand why it is as you read on.

Most doctors make enough money that financial reward is not a big issue. But this is changing as the cost of medical school escalates and new grads accumulate hundreds of thousands of dollars of educational debt. Starting off that deep in the hole drives graduating med students to more lucrative specialties, and saddles them with an need to work very hard to pay off the debt.

By their early thirties, most non-physician professionals with similar training and responsibility have equity in a home, are funding retirement plans and children’s education funds, and have disposable income. Compared to these peers, physicians finally starting a practice acutely feel the financial impacts as insufficient reward.

The deeper issues with insufficient reward driving burnout have to do with intangible rewards, things such as professional recognition from patients, positive working relationships with other physicians and nurses, and respect from health system leaders.

Physicians are still well thought of by patients, but that trust and professional recognition is waning. The latest Gallup Poll on honesty and ethical standards by profession ranks doctors fourth behind nurses, military officers, and grade school teachers, but above pharmacists, police officers, and judges. (Nursing home operators ranked 10th, and there is no specific ranking for health insurance or hospital administrators. Business executives ranked 18th, right below lawyers.)

Positive working relationships with fellow clinicians is an intangible reward that drew many of us to health care. The changes to the volume and intensity of work, along with the way the EHR has interfered with normal interactions between doctors and nurses has made it more difficult to enjoy the benefits of the valuable camaraderie that comes from collaborating to care for those in need. (More on this next week when I discuss Breakdown of Community.)

Respect is key

Respect from health system leaders is the most complex aspect of insufficient reward driving burnout. Both doctors and executives have experienced steadily growing challenges to doing their jobs effectively over the past twenty years, with the intensity relentlessly accelerating. Most physicians feel that they should be equal peers with hospital CEOs, considering the length of training and impact on people’s lives involved in caring for patients. While a small percentage of CEOs are committed to working with physicians as peers, many do not behave as though this is a priority.

It’s not hard to understand why. Health care executives, especially those with no clinical background, have a different world view. Their job is to ensure their hospitals stay in business and run well. This depends on managing revenues and expenses (as Sister Irene Krause, President of the Daughters of Charity National Health Care System first exhorted, “No margin, no mission!“)

Two of the ways that physicians can feel disrespected by executives are when executives make decisions that impact patient care without consulting the physicians, and when executives express concern that physicians are not “pulling their weight”. I have witnessed a number of hospitals that chose to lay off staff to manage their financial margin, in some cases laying off significant numbers of nurses, with minimal physician input and very poor communication afterwards. Doctors are justifiably angry that these actions make it harder to provide proper care for their patients. Had they been involved in the decision and communication process from the start, the decision may not have been different, but the relationships between physicians and executives would have been far better.

Are hospitals losing money on physicians?

The other way physicians feel disrespected is when executives complain that the hospital is losing money on its physicians. In many hospitals this can be to the tune of $50 – 100K per physician. This demonstrates a deep lack of understanding of some key dynamics in health care delivery and finance.

  • First, physicians did well on their own until payers, including CMS, changed a number of reimbursement rules, and now  practice administrators impose further restrictions based on over-interpretation of other regulations.
  • Second, most physicians contribute $1.5 – 2M to their hospital’s net revenue. These downstream revenues (many of which physicians generated in their offices prior to joining the hospital) are not considered in the loss calculation.
  • Third, if we are concerned about who is getting subsidized, ask the executive who expresses the concern how much revenue they have directly generated for the hospital. Unless they are seeing patients, the answer is “zero”. Using the same logic applied to calculating loss per physician, the loss per executive will be significant multiples as any loss per physician in the hospital system.

Insufficient reward may not have much impact on emotional exhaustion for physicians. It has a big impact on depersonalization/cynicism and sense of inefficacy.

We have excellent opportunities to address the root causes of insufficient reward.

Have you found some that work for you and your work situation?

What will you do mitigate the impact of insufficient reward?

I welcome you to share share your thoughts by submitting a comment.

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