How physician stress can hurt your practice

Doctors breaking under pressure

When the 300 physicians of Medalia HealthCare in Washington state voted to unionize on June 2, it wasn't a surprise to Todd Pearson, MD, a former pediatrician and founder of the Center for Physician Renewal in Bellevue, WA. Physicians stressed by fast-paced changes in health care, increasing requirements to see more patients while spending less on their care, and a lack of input and control in their work environment are increasingly turning to unions as a way to deal with that stress, he says.

The vote to unionize the 46 clinics that make up the largest primary care practice in the state was only one symptom experts see as proof that physicians are under more stress. The Washington State Medical Association has noted a drop in the average age of its retiring members. Increasing numbers of physicians are entering counseling and even substance abuse rehabilitation programs. The American Medical Association and Canadian Medical Association held a conference on physician health in May that included several sessions on burnout.

And in some states, the number of physicians claiming and collecting disability for stress and burnout is going up, says John Wilters, MD, MBA, medical director of the five-physician Baptist Tennessee Christian Medical Group in Madison, TN.

Wilters should know; he was a salaried physician in a five-physician medical group where the doctors had no employment contracts and little say in how they were practicing medicine."I had no energy or desire to increase the number of patients I would see in a day," he recalls of his time with the South Florida practice. "Nor would I participate in marketing the group. My boss was in the same boat, and he finally convinced others he was disabled. This was common in South Florida, and most physicians that I knew who were collecting their disability insurance were not disabled."

Wilters got so frustrated, he would often respond to a late night beep by throwing his beeper, breaking it. His anger was not only threatening his job, but his marriage.

A bottom-line effect

The impact can be immense, Pearson says, not only on the individual, as in Wilters' case, but on the practice as a whole. "It pollutes the environment of the whole practice," he says. "Retention of star performers goes down, which means a practice has to put more money into recruitment and training. If a physician is disruptive or becomes dead wood, he or she may leave or be asked to resign. Then there is money laid out for severance packages and for counseling or rehabilitation." Disability claims can also skyrocket, Pearson says.

Poor teamwork and communication brought on by stress among physicians can lead to declining patient satisfaction scores, a loss of patients, and even canceled contracts with managed care organizations. And if one physician's problem becomes so great that he or she is brought before a board of medicine, the public record of those proceedings can create negative publicity that affects the rest of the practice, Pearson says.

And if one physician experiences stress and burnout, you can be sure that others will follow, Wilters says."Burnout is like a flu virus. It can spread throughout the clinic and lead to its demise."

And, says Pearson, burnout is an increasing problem among physicians. "We have always been a slow moving industry, and now we are faced with continuous and accelerating change," Pearson says. "Add to that an increasing number of physicians as employees, and you have a growing problem."

Curing the burnout bug

One of the reasons physicians become overstressed at work is because the new environment in which they are forced to work takes a lot of control away from them, Pearson says. "If you are responsible for others, but don't have control over your situation, then you tend to burn out. But if you give them a voice in patient care issues and management, they get a sense of control."

Even if it is just a seat on a committee to discuss the new managed care requirements, Pearson says, it can help a physician react more readily to change.

Physicians are feeling role strain - they are being asked to do more things for which they were not trained and which they don't want to do, like paperwork, management of resources, or marketing. They are feeling role conflict, Pearson continues, in which they have to meet the expectations of patient, payer, peers, employers, the patients' employers, the government, and policy-makers. "I think in time, in a mature managed care environment where the physician and patient are actively involved in policy matters, those multiple expectations will eventually decrease somewhat," Pearson says. "In the mean time, it is a matter of investing our time and energy in those things we can control and are within our sphere of influence."

That is what Wilters did. He decided that by taking charge of his financial future, he would be able to reduce his stress. He entered an MBA program, became a registered securities agent, and is two years away from having his certified financial planner certificate.

Not only did that cure Wilters professional malaise by giving him a new focus, but he has brought his new skills to his practice. "Since arriving in Nashville, I have directed the marketing of our group," he says. "Fellow physicians and managers are beginning to quiz me regarding financial planning. When the market goes south, which it will, I hope to be more involved in helping others achieve their financial goals."

Wilters says creating a work environment where physicians are satisfied with their jobs is a sure immunization against the burnout bug. You should also be aware of the first signs of dissatisfaction among physicians (for a list of signs of burnout, see list, at left.). "Sort through what is fact and what is fiction. But don't discount the soft stuff."

Pearson agrees. "Be aware that burnout is prevalent and a normal response to a dysfunctional and nonsupportive work environment. Don't just regard it as the character of the individual. It isn't. That is an outdated, stigmatizing pathology model. The person isn't sick; the organization is."

Sometimes, all it takes to cure burnout is a chance for the physician to sit down and talk. Flexibility can help. See if offering job sharing or flex-time or part-time hours can help rejuvenate a physician, Pearson says. "A timeout is vital for renewal." Some of the flexibility can even have good bottom line results. For instance, a flex-time schedule may allow your office to expand office hours to evenings and weekends.

You may also want to create a well-being committee and look at the core values of your practice. "What is your purpose and direction?" he asks. "If you sit down to discuss this, people will feel they have a voice in the organization. It is a great starting place to see what you have control of and what you don't. Then it's a matter of accepting what you can't change and changing what you can."

(For a list of resources - both books and organizations - see box, p. 86.)

· John Wilters, MD, MBA, medical director, Baptist Tennessee Christian Medical Group, Madison, TN. Telephone: (615) 612-2261.

· Todd Pearson, MD, Founder, Center for Physician Renewal, Bellevue, WA. Telephone: (253) 351-8577.