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Physician Burnout: The Additive Effect Of Bureaucracy On The Psyche

Tue, 02/11/2014 - 9:31am
Sid Schwab, M.D.

In trying to understand my own burnout, “control” (or lack thereof) is a dominant theme. This is nothing new. In fact, I doubt I’m unearthing bones not already thoroughly analyzed. But I can give instructive personal examples.

For a while I was on the board of directors of my clinic, which was then and is even more so now one of the most successful doctor-owned and -managed in the US. During my tenure, we were deeply in the thrall of the managed care model as the guarantor of our future.

My feelings about it were, diplomatically, mixed. If I may be allowed to say it for the ten thousandth time, providing cost-effective care has always been as much a part of me as the Krebs Cycle. I’ve never needed anyone to remind me of it.

Nor — take my word for it — have I ever been a trigger-happy surgeon: many is the patient sent to me for an operation, returned to his/her referring doc with a note pinned to the shirt saying, “Please excuse Johnny from surgery today. He doesn’t need it.”

So the idea of being required to seek approval from a peach-fuzzed (or even a grey-muzzled) primary care doc (need I repeat myself?) sat, diplomatically, unsteadily in my saddle. (In fairness, some of the internists who knew me over several years filled out all the authorizations the minute they sent the patient to me. Not, however, the family docs. But I’ve been over that. In one sense of “over” anyway.) Frosting a burnt cake, we even agreed to pay primary care docs a “gatekeeper” fee. Perfect.

I never objected to scrutiny; in fact, I welcomed any legitimate comparisons of my work to that of others. But it was always my contention that being in a clinic was the ideal situation in which paperwork could be minimized. After all, we had a medical director whose job included oversight; we knew each other well; we worked in a closed shop. Hell, we’d even cashiered a couple of losers. Ought there not be a presumption of quality?

So when one of my fellow board members — a young family doc whom I actually admired for his practicality — announced at one of our meetings that he’d come up with his own form (in addition to the required ones!) he was going to send to specialists along with his patients, and showed it to us (couple of pages, lots of blanks to fill in) I hit the roof. Sailed right through it. Covered the man, the board room, and myself with plaster. Lots of it. Then, still rising, I resigned from the board. The form was never distributed, but it took enough days for my pulse to return to its usual 1.5x that I figured who needs the extra aggravation.

Every few weeks the medical staff at the hospital came up with a new committee, for which it obtained members by also coming up with regulations requiring and penalties for failing to sign on. Among the three or four on which I sat was the “Blood Utilization Committee.” People from the blood bank (really good people, I might add) presented quarterly data on the use of blood and blood products and we looked into any deviations from accepted indications.

Without fail, the data showed near perfect compliance, with the only outliers being nephrologists buffing up their dialysis patients — outside of “standard” indications, but within “special” protocols. If ever there were proof that doctors knew what they were doing in an area, this was it.

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