In recent years, physician burnout has become increasingly recognized as a major issue in medicine. A staggering 44% of physicians describe themselves as burned out, with another 15% self-described as clinically or colloquially depressed.¹ The World Health Organization (WHO) even recognized burnout as an official medical diagnosis in its 11th edition International Classification of Diseases. The WHO’s definition of burnout is characterized by 3 dimensions²:

1. Feelings of energy depletion or exhaustion,
2. Increased mental distance or cynicism from one’s job, and
3. Reduced professional efficacy.

Addressing physician burnout is important for more reasons than the health of our fellow physicians. A study by researchers at Harvard Business School estimated that every year in the United States approximately $4.6 billion in costs are related to physician turnover and reduced clinical hours.³ This annual economic cost equates to approximately $7,600 per employed physician each year. Furthermore, physician burnout is associated with increased risk of patient safety incidents, poorer quality of care due to low professionalism, and reduced patient satisfaction.⁴

Ophthalmology generally has a lower burnout rate (34% of ophthalmologists) than other medical specialties, with only pathology, nephrology, and public health physicians reporting lower rates. One central factor is shorter work hours, because longer work hours are correlated with increased rates of burnout.¹ Among subspecialties in ophthalmology, retina is one of the most demanding, with a workload comparable to other surgical specialties. However, there are a myriad of other factors that contribute to physician burnout, including increasing bureaucracy and EMR implementation, insufficient compensation, and lack of control and autonomy.¹ Vitreoretinal surgeons Janice Law, MD, Priya Sharma, MD, and Jayanth Sridhar, MD, discuss specialty-specific issues related to burnout.

HOW HAVE INCREASED INCORPORATION OF EMR, CHANGES IN PAYMENT MODELS, AND INCREASING REGULATION ALTERED YOUR PRACTICE? HAVE THESE MADE YOUR DAY-TO-DAY EASIER OR MORE DIFFICULT?

• Dr. Law: There are, obviously, advantages and disadvantages to EMR. At this time, it takes more than 10 clicks to order an anti-VEGF injection in the clinic. Some parts are done by a technician and some parts are done by the physician. Cancelling an injection order takes even longer and requires more personnel to get involved. These small things that once were easier to do in clinic without EMR regulations and compliance audits are no longer small things and have added more time to each patient’s visit. Payment models are constantly shifting, and reimbursements are always being re-evaluated, often for the worse. In this complex and changing health system, I spend a lot of time coaching the patient how to navigate the insurances and helping patients make appeals.
• Dr. Sharma: The increasing regulations of medicine have certainly made the day-to-day more challenging. Much of the charting consists of checking off “boxes” to ensure that we are following regulations. I am incredibly lucky to be in a practice that is excellent at staying on top of current policies, payment models, and has a way to integrate changes easily. Even with this, I can see how these constant changes can contribute to incredible physician burnout, taking time away from patient care and focusing more on paperwork.
• Dr. Sridhar: EHR systems still have much room for improvement. That being said, they have made continuity of care for patients much better in terms of documentation, and overall they represent a win and not a loss for the medical field in the long term. Insurance and payment issues are only becoming more prevalent, and can make it more challenging to provide the best possible care to all patients. Day to day, it makes our jobs more complex, but ultimately our job is not only to provide medical knowledge and compassion, but also to use our experience to help patients navigate the system to the best of our abilities.

SUMMARY

One study found that burnout prevalence was higher among physicians who used EMR (27.2%) than those who did not (13.6%).⁵ They also reported that physicians reporting “poor/marginal” time for documentation have 2.8 times the odds of burnout as compared to those who report “sufficient time.” The largest contributors to burnout are too many bureaucratic tasks, like charting and paperwork; spending too many hours at work; and increased computerization of practice (EMRs).¹ The topics discussed here are the large contributors to burnout. Streamlining the documentation process may alleviate these nonclinical pressures on physicians.

THE FIELD HAS TRANSFORMED OVER THE PAST 10 TO 15 YEARS TO INCLUDE MORE INJECTIONS AND HIGHER PATIENT VOLUME. HOW HAVE THE INCREASING DEMANDS OF PATIENT CARE AFFECTED YOUR ENJOYMENT OF YOUR CAREER?

• Dr. Law: I entered medicine wanting to make an impact on patients’ lives. While I truly enjoy what I do every day — protecting and preserving sight through daily surgeries and injections — the higher volume patient load leaves me craving the patient-physician interactions and relationships I used to have. My most fulfilled days are when I can leave clinic knowing that every single patient was well heard and cared for. Higher volume of injections has also affected my career and personal life because of the demands of timing the injections. At least in my practice, there’s no such thing as taking vacation or time off. If I cancel a clinic to travel for personal or professional reasons, my patients still need sensitively timed injections. The greatest impact is at my remote satellites or the VA where I’m the only one who travels there or patients don’t have a way to get their timed treatment. To take any days off means carving out even more time to make up these clinics. This leads me to seek creative ways to get time back: letting go of responsibilities, hiring a personal assistant, and delegating more.
• Dr. Sharma: With the advent of anti-VEGF therapy, the number of patients has increased and the amount of time that can be spent with each patient has proportionately decreased. However, despite this, the enjoyment of my career has increased significantly, because we are now able to make such an incredible impact on our patients’ lives. I try to remind myself that we are actually able to preserve and sometimes improve the vision of patients who would have otherwise gone blind. That certainly always makes it worth it at the end.
• Dr. Sridhar: This is the big struggle. We have so many patients who need care and not enough time to care for them. In the last couple of months, my clinical volumes have increased by about 10 percent per clinic and that extra load takes a toll. I lose job satisfaction if my visit times get shorter beyond a point. I really enjoy the patient relationships that develop when you have a couple of minutes to sit down and really spend time with a patient.

SUMMARY

With the success of anti-VEGF therapies, the trend of increased patient volume with shorter patient interaction time will likely continue.⁶ At the same time, physicians consider patient relationships the most satisfying aspect of their practices, with 15% of physicians reporting this lack of patient interaction time contributing to job dissatisfaction.⁷ It is imperative for retina specialists to examine ways to maximize clinic efficiency while still being able to carve out time to create a bond with patients.

DO THE DEMANDS OF WORKING IN ACADEMIA OR PRIVATE PRACTICE ALTER YOUR SUSCEPTIBILITY TO BURNOUT?

• Dr. Law: Burnout is prevalent in every practice setting, and within all subspecialties of ophthalmology. Most physicians who choose an academic practice setting want to be involved in something in addition to a clinical and surgical practice, like advancing the university’s research or education mission. For me, I have another role as an educator and administrator in my department. It’s the demands of the administrative responsibilities of this full-time role and other exciting leadership and service opportunities that force me to learn to delegate to be effective so I don’t burn out. Despite the challenges, this part of my job (mentoring, teaching, and curriculum and program design) is the most rewarding part of being in academia.
• Dr. Sharma: I think that all physicians are uniquely susceptible to burnout. While there are different demands in academic vs private settings, the similarities are that both settings can be highly stressful, with emphasis on either academic or clinical productivity.
• Dr. Sridhar: In my observation, each physician’s experience is different, and the lines between roles in private practice and academia are becoming blurred. Private practice jobs historically demanded more clinical time with more clinics per week and higher volumes, but they offered higher levels of autonomy and efficiency with less time available for meetings, presentations, and manuscript preparation. Academic positions offered the benefits of less clinical “grinding” yet had greater teaching and research requirements. Everyone’s personality is different, and understanding yourself and your priorities is probably the first and biggest step to a happy career in retina. Now, with the lines blurring between academics and private practice positions, it is more important than ever to evaluate each job prospect on a case-by-case basis.

SUMMARY

According to a study of 556 academic physicians, 68% reported that patient care was the most meaningful aspect of work, with smaller percentages reporting research (19%), education (9%), or administration (3%).⁷ The amount of time spent working on the most meaningful activity was strongly related to the risk of burnout. Academic and private practice careers can substantially differ in regards to daily tasks. It is vital for physicians to analyze their true career aspirations and determine whether the extra rigors of a career in academia vs private practice are worth it to them.

HOW DO YOU PERSONALLY AVOID OR DEAL WITH BURNOUT?

• Dr. Law: First, knowledge and insight about burnout are powerful. I’ve been through several seasons of burnout and I can now more readily recognize when symptoms are resurfacing, such as emotional exhaustion or irritability at work and home. I’ve learned a lot from working with professional life coaches to reset my mental framework and learn life hacks for thriving at home and in my career. When sensing burnout, I review my prewritten priorities and goals for both professional and personal life, and this acts as a compass to set me back on track. Tips include finding a good mentor and accountability partner for you to share your goals and taking steps to remove tasks that don’t align with your goals. I also schedule protected “meetings with me” in my calendar, and I consider these meetings to be as important as if I were meeting with the chair of my department. During these meetings I work on projects that are for me, as opposed to tasks for others, and I use the time to reflect, rest, or catch up with work. At home, I’ve learned to actively pursue other things I love, like crafts, painting, and baking. I’m a better physician, mother, wife, mentor, and mentee when I first take care of myself and I am in a heathy place spiritually, mentally, and physically.
• Dr. Sharma: I’ve found that the best way to avoid burnout is to lead a healthy, balanced life. I try to exercise every morning, which helps me clear my mind and energizes me for the rest of the day. I also prioritize my time with my family and friends — often, as physicians, we are working or tackling a long list of tasks at the end of the day. Being engaged and available for family and friends is critical to maintaining a healthy balance in life — this may mean putting your phone away during dinner or taking 30 minutes a day to talk to your spouse without distractions. I believe that a happy and healthy physician is the best physician, so taking care of yourself is better for both you and your patients.
• Dr. Sridhar: I manage burnout poorly sometimes. I think my own keys to staying mentally healthy are maintaining good sleep when possible, and catching up whenever I can, and exercising at least 4 times a week and stretching daily. I also think it is valuable to write down a list of your core values at least 3 times a month and then introspect and really see how much of your week you spend working on the things you actually value. Often, you will find your time is being consumed by things that matter very little at the expense of the important things, and unconsciously this could lead to internal stress and burnout.

SUMMARY

Maintaining a balanced life between your work, health, and family/friends is the ultimate way to reduce burnout. The two most common ways physicians cope with burnout are exercise (48%) and talking with family and friends (43%).¹ Training focused on coping strategies, interpersonal skills to increase social support, management of negative emotions, improving communication skills, incorporating discussion of high-stress situations, and the use of relaxation techniques should all be considered as therapeutic tools to create a holistic intervention to burnout.⁸ The best way to avoid burnout is to be proactive. Find time to live a healthy lifestyle, enjoy your hobbies, and spend your days the way that makes you happiest. RP

REFERENCES

1. Kane L. National physician burnout, depression, & suicide report 2019. January 16, 2019. medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056 .
2. World Health Organization. ICD-11 for mortality and morbidity statistics: QD85 burn-out. icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/129180281 .
3. Han S, Shanafelt T, Sinsky C, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. 2019;170(11):784-790.
4. Panagioti M, Geraghty K, Johnson J, et al. Association between physician burnout and patient safety, professionalism, and patient satisfaction. JAMA Intern Med. 2018;178(10):1317-1330.
5. Gardner R, Cooper E, Haskell J, et al. Physician stress and burnout: the impact of health information technology. J Am Med Inform Assoc. 2019;26(2):106-114.
6. Brand CS. Management of retinal vascular diseases: a patient-centric approach. Eye (Lond). 2012;26 Suppl 2:S1-S16.
7. Shanafelt TD, West CP, Sloan JA, Novotny PJ, Poland GA. Career fit and burnout among academic faculty. Arch Intern Med. 2009;169(10):990-995.
8. Wiederhold BK, Cispressor P, Pizzioli D, Wiederhold M, Riva G. Intervention for physician burnout: a systematic review. Open Med (Wars). 2018;13:253-263.