Cardiologists and the Burnout scenario

Burnout among physicians of all specialties—including cardiologists—is an area of growing concern among the medical profession Surveys among practitioners from family practice to internal medicine, surgery, and the emergency room, show low levels of morale, fears of overwork, rising caseloads, and increased bureaucracy, leading to burnout. There are growing numbers leaving the profession, suffering mental and physical health issues…and most worrying of all, practitioners taking their own lives. Physician burnout was a topic high on the agenda at ESC 2018, including a session specifically dedicated to the subject and led by Dr Anthony DeMaria from Division of Cardiovascular Medicine at the University of California, San Diego. ‘The burned-out physician’, he noted, ‘is angry, irritable, impatient, has increased absenteeism, decreased productivity and decreased quality of care’. In a US-based survey of 15 000 physicians across 29 specialties, some 42% reported evidence of burnout.1 When the results were split by specialty, cardiology was somewhere in the middle with 43% of physicians affected, whereas the most affected were critical care specialists and neurologists (both 48%) and the least affected were plastic surgeons (23%). One of the more alarming findings was the age group of physicians experiencing the greatest incidence of burnout—50% of physicians reported were those in the 45–54 years old age group. ‘These are relatively young physicians’, said Dr DeMaria. ‘One might have expected burnout to be more prevalent in older physicians who have become more frustrated with increased bureaucracy, but this is not the case. Doctors are reporting that they are spending more and more time dealing with computers and documents, and less time interacting with their patients and practising medicine’. He also noted that burnout is prominent among medical students too. In terms of contributing factors, 56% of physicians who reported burnout cited excess bureaucracy with other causes being long working hours (39%), lack of respect from colleagues (26%), increasing computerization of practice (24%), insufficient compensation (24%), and a lack of control/autonomy (21%). Dr DeMaria continued: ‘Mounting rules and regulations coming from government, payers and hospital organizations are frustrating. The transition to electronic health records is a classic example of the need for increased documentation, which is certainly a problem in the US, and I have reason to believe that it’s the same in Europe’. Key to addressing the problem for cardiologists suffering burnout, according to Dr DeMaria, is to look at the causes of the problem. ‘Assuming that the challenges and sources of stress are not financial, which presumably is readily fixed with more money, then the main issue is workload’, he suggested. ‘Cardiologists are frequently called on to handle after-hours emergencies and often impact lifestyle. What would help enormously is a reduction in the call for documentation, especially as it is often not particularly important’. Giving cardiologists greater autonomy is also key, in terms of drug or procedure selection. ‘Interactions with colleagues and medical staff are also affected’, continued Dr DeMaria. ‘Even in the earliest stages of burnout, it begins to have an effect on how cardiologists deal with their day-to-day practice’. The US-based survey showed that 13% of cardiologists experienced depression as well as burnout and among those who reported depression, a third said they were more easily exasperated by patients (33%) or less engaged with them (32%) as a result of their depression. However, he also added: ‘Cardiology is the ‘most unhappy’ speciality but also the least likely to seek professional help’. He said another trend is of physicians leaving patient care for non-clinical jobs with drug or insurance companies, a pattern that he warns has major implications for projected physician shortages. ‘To cope with burnout, some turn to exercise, talking with family and sleep but others turn to food and alcohol, smoking or take prescription drugs. Physicians often turn to potential coping mechanisms that are very destructive’, he said. Physicians are also the highest group that commits suicide—nearly double that of other professions, with 400 a year in the US. ‘They have the knowledge and the means to do it but are also the least reluctant to come forward to seek help’. Burnout is attracting more attention from the medical profession and healthcare enterprise and he also applauded the ESC for recognizing the issue among cardiologists and for raising the profile of the issue. In one of the most powerful aspects of the presentation on physician burnout at the ESC Congress in Munich, cardiologist Patrick Verhorst from Enschede in the Netherlands discussed experiences of burnout from a real-life perspective with colleague Peter Paul van Geel from Groningen. Cardiologist Dr van Geel spoke about his experience of burnout which manifested while he was at a congress in London in February where he found himself in the street having what he equates to a panic/anxiety attack. He was brought home from the UK by his family after what seemed an emotional breakdown—and at a time he lost a close relative—but he did initially return to his department despite not eating or sleeping properly. ‘The head of department was very supportive and said to me to take some rest and get well again and see how it goes’, he continued. Looking back, he recalls how a week before going to London he was doing a routine transoesophageal echocardiogram and looked at the probe and remembered thinking, ‘how does this work?’ I had a complete block, but I did not tell those around me’, said Dr van Geel. He said his colleagues had continued to be supportive, that he spoke to a psychiatrist and had a check-up with his family doctor and then after some weeks began having terrible anxieties and side effects from medication. However, now he feels able to begin the return to work, initially for a few hours a week. During the session, Dr Malcolm Bell, vice chairman of the Department of Cardiovascular Medicine at Mayo Clinic in Rochester, USA, Focused on specific steps towards acknowledging and addressing physician burnout and the approach his organization is taking. He stressed the role of leadership of developing interventions, providing resources to deal with the problem and promoting flexibility and work life integration. He said: ‘It is important for us to know that these phenomena we are seeing are higher among physicians than other members of society. This is something we have to face up to, with work life balance, as it can have personal and professional repercussions that will affect the individual and patient care’. Reflecting on the annual suicide rate among doctors in the US he said that there has to be multiple levels of intervention, and policy reform—particularly in the US—to develop meaningful use of electronic health records and help avoid extra layers of bureaucracy. ‘We must recognize physician burnout as a moral imperative and we must act on it’, said Dr Bell. The Mayo Clinic Programme for Support and Solution has a number of steps to tackle the physician burnout issue which include: Acknowledge and assess the problem; Harness the power of leadership and associate it with physician wellbeing; Improve efficiency of practice and optimize careers (decrease the clerical burden and explore practice redesign); Develop and implement targeted interventions; Cultivate community at work; Promote flexibility and work life integrations (explore reduced work hours); Promote resilience and self-care (with wellbeing and resiliency resources and benefits of exercise, sleep habits, diet and prevention; Facilitate and fund organizational science. Conflict of interest: none declared. 1. Medscape National Physician Burnout and Depression Report 2018. www.medscape. com/slideshow/2018-lifestyle-burnout-depression-6009235 (12 July 2018).