On this episode, Dr. Louise Underdahl discusses physician burnout, offering insight into contributing factors and potential solutions. Dr. Underdahl?

Dr. Underdahl: I have been privileged to serve at UCLA. I went to UCLA for my English literature undergraduate work, and then I was going to be a librarian, so I got a master’s in library science. Then it branched off into public administration, and that’s when I got the PhD at USC. I spent 39 years working at UCLA in various capacities.

The last position was 25 years at the UCLA Health Risk Management department, trying to improve patient satisfaction and reduce risk exposure while also improving clinical outcomes. Those are three goals that were always memorable. They’re challenges, but it kept life interesting.

After working at UCLA, I retired from risk management in 2017, but I’ve continued to work with online doctoral students since 2004. You can’t just bring your workplace experience to the classroom. You need to continue doing research.

Physician burnout has always been a topic that I’ve been intrigued by because it may be intangible. You can’t see it like a cut on somebody’s hand. But even though it’s not completely visible, the ramifications are very visible in terms of stress, the ability to feel positive about the work experience, and the choice of career, like whether to continue serving as a practitioner with patients or deciding to go into the laboratory research environment. It is a loss if we lose physicians who are helping patients stay healthy to just the research lab.

It is thought provoking, so I am intrigued by the momentum of burnout. It’s not just dwindling away. This is an area that has yet to be completely explored. It’s not, “We’ve solved the problem so we can move on to another topic.” It continues to generate dialogue, but we have yet to find the best, optimal solution that works for everyone.

There is a variety of thoughts about which approach to take, including individual, organizational and systemic. The one that I think is perhaps the most challenging is, as the literature has explained, the systemic approach. One research meta-analysis indicated that organization-directed interventions for reducing physician burnout were the most effective but also the rarest. If you have an effective solution that is rarely used, that is a challenge. It’s a contradiction in terms of it works really well, but nobody uses it. I believe systemic changes have the most potential for actually solving some of the problems.

But what we need to do—or at least, what I suggest might be worthy, because it’s always unwise to be too categorical and say what must be done—the results of our review and what you see in the literature suggest that neither the individual nor the organization-wide solutions seem to be extremely efficient and effective. But the systemic solutions have a lot of potential. I mean, it has logic and the economies of scale. If you can get the system-wide problems resolved, there is a chance that it would trickle down and start to make a difference on the individual physicians.

Systemic changes also have the benefit of not really having been implemented much, so we can’t have the people saying, “Well, we tried it, but it didn’t work.” We haven’t tried it as on a wide-scale basis.

I believe it is a source of light at the end of the tunnel. It might be something that could help our physicians. Systemic solutions say it’s a system-wide problem and it’s up to the institution, the system, to help solve a problem, as opposed to saying, “Well, it’s just that you need to get more sleep and be more efficient with your work-life balance, and if you could just use meditation a little bit better, you’d be better off.” I think that might be a bit simplistic.

Very few physicians will ever admit that they have burnout because there’s stigma. It translates into, well, if you aren’t working as well as should be, then that might spill over into some of the interactions you have with patients or colleagues and make you less efficient. Nobody wants to upfront say, “I’m flawed.”

Also, if they do recognize burnout, they might not go out and try to seek help. Sometimes organizations have wellness centers that are even located in a physical office that is way away from the center of the medical center. But that still doesn’t encourage physicians to go and seek help there because it’s just the mindset. And they’re not the only ones. All of us tend to be a bit subjective when looking at the mirror and saying, what could be done to improve things here?

Then, in addition to that general hesitation to self-diagnose, in some of the recent research and the articles/commentaries by physicians themselves on this topic, physicians have perceived that they receive less respect and have less autonomy than they would like. About 47% of physician responses have said, “I don’t get the respect I should have, and I don’t have the autonomy that I need.”

When you take away their ability to make decisions that they feel will impact their patients, they feel powerless. And then they see the patients go downhill and they feel it’s not their doing, but they don’t know how to change that trend.

Some of the things that have been cited that cause them to feel powerless: the prior authorization process for commercial insurance can often frustrate physicians. They feel that they know what the patient needs, but they can’t take the corrective actions that they would like or, if they can, it takes a lot of delayed time.

Also, from what I saw with risk management, there were frustrations over what would be perceived as a frivolous lawsuit. Many of the physicians felt lawsuits were unjust, and they wanted to do something about the frivolity of the claims. Sometimes that’s difficult to do in the legal system, and a lot of times in the organizational context, that’s just not one of the options that would be available. So they’re frustrated by those.

The advent of the electronic health record was heralded as the panacea for problems: we could have simultaneous access to patient records by various clinicians, and that would solve many of the problems. And yes, it has delivered many, many, many advantages. However, there have been time- and labor-intensive ramifications where many physicians have expressed that they feel like a glorified clerk because they have to spend so much time tapping into the EHR. Even if they just dictate to it, it still takes time. It varies depending upon the specialty, but it can take two hours or more just to keep up with the charting.

Also, they’ll come in to talk to the patient. We all know that when you’re talking to your physician, it’s nice if they could be listening to you, but physicians are expected to deal with higher volumes of patients. That’s the business side of healthcare. We’ve got to see so many patients in order to get a return on investment and keep this place open. They’ll walk in with their notepad or something, and then they are tapping into that as they’re talking. Many times, patients feel that they’re not getting their physicians’ full attention.

Then, in terms of why physicians became a physician in the first place, again, this is increasingly a recurring theme that you see in the literature. Physicians feel that they are so sabotaged and their time is stolen by all of these requirements to document and to speed up the process, that they don’t have the time that they would like to spend just getting to know the patient.

One of the more reflective articles that came out was talking about a French philosopher, Simone Weil, and how her views were: The best gift that one human being could give to another would be to focus your attention on that other individual. You’re giving them not just your time, but your attention, you’re listening, and you’re just thinking about that one individual.

Physicians are saying they don’t have time to sit down with the patient and say, tell me about what’s happening. They don’t have the time. They talk about moral injury, the frustration, the loss of autonomy. Physicians feel that they’re not able to do their best work. That’s why they became a physician. They want to help patients, and they feel that is being denied to them by large healthcare organizations, other stakeholders like insurers, and, of course, the litigation system. All these things accumulate.

Eventually, it’s not a question of work-life balance. It’s that they can’t do patient care the way they envision it should be done and have what they believe would be a quality healthcare relationship with their patients. Those are the factors.

So, what happens? Well, I’ve seen physicians who were active and had decades of experience, and they would get very frustrated about things. That’s where I got the idea of going into pure research, because some of them felt that if this is going to be the future—what they predict would be their life in the next decade—it just wasn’t the rewarding work environment that they had envisioned. Therefore, they were going to withdraw from patient care and do research in the lab where they would have a different environment.

I can understand their rationale, but I think it’s a loss to all of us. We’re always talking about, “There’s so many old people.” Well, here I am, at least! The decades are piling up, and as I get older, I would like to feel that the doctors who are out there are experienced and actually care about patients so that they can provide care. There is no point in having a long life if you’re going to be doomed to illness. Quality of life is very important.

I think physicians are to be commended for caring about quality and wanting to establish a patient relationship. I think physicians long for the ability to walk into the patient’s room, to see them and get to know them as a human being, a whole person, rather than, “Okay, I’ve got to ask you these questions and then fill this out and walk away.” Because that doesn’t make patients content either. They feel disrespected, and the physicians feel disrespected by the system. There are opportunities for improvement here.

Thanks for listening. Stay tuned for next week’s episode. To hear more, follow PeerPOV: The Pulse on Medicine on Apple Podcasts, Spotify, or Amazon Music.

This transcript has been edited for readability.