Ep. 77: The Crisis of Physician Burnout with Dr. Alfred Atanda

The American Medical Association (AMA) defines physician burnout as a long‑term stress reaction that can include emotional exhaustion, depersonalization and a feeling of decreased personal achievement. It's a condition that affects all specialties and practice settings – and the AMA has declared physician burnout a crisis. A 2023 AMA survey of physicians and non-physicians in 30 states specific to burnout indicated that half of practicing physicians reported experiencing burnout in 2023. While this is lower than the all-time high in 2021 (during the height of the COVID-19 pandemic), burnout among physicians persists. So what can be done?

On this episode, we talk about the crisis and possible solutions with Alfred Atanda, MD, a pediatric orthopedic specialist and Director of Clinician Well-being for Nemours Children’s Health, Delaware Valley.

Guest:
Alfred Atanda, MD, orthopedic specialist, Director of Clinician Well-being, Nemours Children’s Health, Delaware Valley

Carol Vassar, producer

Thanks for tuning in today! Please visit NemoursWellBeyond.org to catch all our episodes and sign up for our monthly newsletter. You can also use the voicemail feature on the website to leave a message with your episode ideas or questions — you just might be featured on an upcoming episode of the show. 

Views expressed by guests do not necessarily reflect the views of the host or management.

Subscribe, review or let your voice be heard at NemoursWellBeyond.org.

Transcript

Carol Vassar, podcast host/producer:

Welcome to Well Beyond Medicine: The Nemours Children's Health Podcast. Each week, we'll explore anything and everything related to the 80% of child health impacts that occur outside the doctor's office. I'm your host, Carol Vassar. Now that you're here, let's go.

MUSIC:

Let's go, well beyond medicine.

Carol Vassar, podcast host/producer:

The American Medical Association (the AMA) defines physician burnout as a long-term stress reaction that can include emotional exhaustion, depersonalization, and a feeling of decreased personal achievement.

It's a condition that affects all specialties and practice settings, and the AMA has declared physician burnout a crisis. A 2023 AMA survey of physicians and non-physicians in 30 states specific to burnout indicated that half of practicing physicians reported experiencing burnout in 2023. While this is lower than the all-time high of 2021 during the height of the COVID-19 pandemic, burnout among physicians persists. So what can be done? Joining me to talk about the crisis of physician burnout is Nemours orthopedic surgeon Dr. Alfred Atanda, who also serves as director of clinician well-being for Nemours in the Delaware Valley. Physician burnout is definitely on his radar, both professionally and personally, and he'll talk about it from both of those perspectives. So, what are the main factors that contribute to physician burnout? Here's Dr. Alfred Atanda.

Dr. Alfred Atanda, Nemours Children's Health:

It's very interesting because I think it's a very multifactorial problem. When you look it up, and you read a lot of the articles that come out of the Mayo Clinic, Stanford, and other large well-being centers, I think the biggest issue that people talk about is the excessive workload, the excessive administrative and cognitive burden that happens with our jobs. It's not necessarily the amount of work. Even though that sometimes it can be excessive, it's also the type of work. So a lot of times physicians find themselves needing to do things that you don't need a physician to do, quite honestly, and it can take up a lot of your time and energy, and I think there's a lot of pressure to produce. A lot of us work in a fee-for-service world where we trade our time and our energy for income. So if you do more work and see more patients, then you often can make more money.

But that comes at a cost because, a lot of times, that's the real essence of why we're there: to see patients. But the more patients you see, then the less time you can spend with each patient, and that's what erodes that ability to connect and bond with human beings. I also think we live in a very regulated and work in a very regulated environment, so issues with HIPAA, legal compliance, and risk...all of those factors we do need to take into account in order to do our job safely and to mitigate risk for the organization that we work in and for. But oftentimes, that external regulatory pressure, it just makes our jobs harder. It gives us more clicks to do, more paperwork to fill out, and more hoops to jump through. Don't even get me started on the insurance verification issues and prior authorizations.

So there's a whole myriad of factors that are set against us because, as we were going through our training, at least for me, all I knew was that I liked working with my hands and I liked bonding and connecting with people. That's literally all I wanted to do, and I always give the analogy of when you're young, and you're in your 20s, and you're going out with your friends, and you're standing outside of a nightclub or a bar, and you hear all the music, and everybody's in line, and you're paying a cover charge, and then you get in, and it's not really what you thought it was going to be. Maybe the drinks weren't that good, or the music wasn't that good, or there was nobody in there, or it smelled really funny, or the air condition was broken, whatever it is, but at that point, you spent half your day getting ready. You may have driven an hour to get there. You spent $100 or whatever to get in for cover trouble.

So what are you going to do, turn around and just leave? Maybe it's somebody's birthday, maybe it's an anniversary, maybe it's a big, huge event, and that's like what it is in healthcare. You spent all of this time to become a physician, having one particular idea in your head of what it's going to be like, your expectations. When your reality and your expectations have a disconnect, that in and of itself can be very deflating, but even worse, you don't have anything that you can really do about it. What am I going to do, just quit? Go to business school. Go to law school. There's nothing that I can just do tomorrow that's going to help me make the same amount of money I make as a surgeon. We call that the golden shackles. You're just handcuffed to it, and it's that realization that I think that does people in. It's not that we don't want to work. It's not that we're lazy. It's more of that situation isn't what we would have expected, and there's very little that we can do about it.

Carol Vassar, podcast host/producer:

I want to pull on a thread that you mentioned in your response to that question, and that was the fee-for-service healthcare model that we have now. Would moving toward value-based healthcare, which it feels like we are finally getting there or at least moving that way, would that help with physician burnout at all?

Dr. Alfred Atanda, Nemours Children's Health:

I think tremendously because it would help change the emphasis of what a physician sets out to do each day. Right now, it's high volume. I do a lot of procedures, see a lot of patients, interpret a lot of tests. Whereas in a value-based care model setting, the idea is more about providing value and providing good care. For example, there are patients who need to see a physician in my group or my practice, and they invariably don't necessarily need to see me. They come, and they see me, and they spend half their day to get here, take their kid out of school, they wait in my waiting area, they come into my office. That's when I realized that I'm not necessarily the right doctor for them, but I still have to see them. I still have to talk to them. I still have to chart on them. I still have to document on them.

So I'm treating somebody with a problem that I necessarily can't fix. They are being seen by somebody that can't help them, and everybody usually feels pretty terrible, but we still make money. In a fee-for-service world, the incentive is to bring people in. Obviously, you want to be able to take care of them, but even if you can't, we still make money off of it. I think that pressure is something that's like a conflict for us because I don't want to charge somebody to talk to them in a way that isn't even helpful to them.

Now they have to go and come and see my partner in two weeks, and that's just a very small analogy, but I think it's that overarching theme and model of doing more, doing more with less, doing more quicker, doing it faster, what have you really erodes at the true essence of why we got into this in the first place, and I'm sure value-based care, nothing is perfect. I'm sure that it may have its own shortcomings, but I do think that it's worth exploring because we do need options for a healthcare climate and ecosystem that is better than what we're in currently.

Carol Vassar, podcast host/producer:

Now, that same survey that I mentioned earlier found that there are six physician specialties that are at highest risk for burnout, including pediatrics, but also emergency medicine, hospital medicine, family medicine, OB-GYN, internal medicine, all of which seem to hit on the kids at some point. They cite excessive stress, long hours, emotional exhaustion, which you mentioned earlier. What does this mean for the healthcare system in general and specifically for pediatrics?

Dr. Alfred Atanda, Nemours Children's Health:

It's a big problem because the specialties that you cited tend to be more primary care, and they tend to be the front door of the healthcare ecosystem. People go to the ER, their PCPs, their family practice docs, internal med docs, peds docs, and if the people who are at the front lines who are manning the gates, if you will, into the healthcare ecosystem are burnt out and are not optimized and are cynical and irritable and depersonalized and having emotional, physical, and mental exhaustion, what does that say to the people who are coming to the healthcare ecosystem to get help? You need those people to be happy. You need them to be fulfilled. You need the docs to be engaged because that will then make the experience better for the patients and also allow us to take better care of them and go that extra mile, and be thorough and be detailed.

I think that's very scary. A lot of the specialists were left off of that list because we're the ones that are two or three layers away from the front door of the healthcare ecosystem. Obviously, somebody can just schedule and come and see me on their own, but invariably, they go somewhere else before they come and see me as a specialist. I think making sure that all types of physicians are optimized, engaged, fulfilled, and have joy is critical, but it's extremely critical for those front-facing types of docs who are navigating patients into and through healthcare ecosystems.

Carol Vassar, podcast host/producer:

Let's talk about the signs and symptoms of physician burnout. What do you see in physicians who are starting to experience or are experiencing burnout? What should we look for?

Dr. Alfred Atanda, Nemours Children's Health:

Yeah, I think the true definition is the triad of emotional and mental exhaustion, depersonalization, or being detached from the patients you're taking care of, as well as this lack of self-efficacy or this notion that you don't necessarily feel that the energy and the work that you're putting in results in anything. Now, in a more informal definition, that's usually what we described again as before: cynicism, irritable behavior, workplace conflict, and those sorts of things are usually rampant throughout healthcare, whether it be amongst trainees or more experienced physicians. I remember during my training, irritable behavior that's just par for the course, especially when you're hanging out in the operating rooms with a bunch of surgeons; that's ingrained in our DNA and our fabric. That's totally acceptable that you're in an environment where people are irritated with each other, where there's conflict. If you knew the amount of times that doctors are squabbling with each other over patients, over processes, and over tasks, you'd be shocked.

It's like we're all just putting this pressure cooker, and they put the lid on us, and then it's like a battle of the gladiators. We just have to figure it out ourselves. This is after not sleeping for however many hours and having not eaten, and you may not have been able to use the restroom, and you're standing in the OR and this and that. It's a very complex environment. What really scares me is that when I first started this work in well-being, and I was reading about these symptoms, it didn't sound like anything really out of the ordinary, like irritable behavior. That's so part of our training, and I just assume that that's just the way it had to be. But now I know, obviously, that it's possible for healthcare workers and physicians to go to work and actually enjoy what they're doing. That's what's been most eye-opening for me, that the signs and symptoms of burnout, you can find that in almost anybody that you encounter.

Carol Vassar, podcast host/producer:

Interesting you should say that. It sounds almost like when you come into medical school, you go into training, you're in your years of learning the craft that this becomes normalized in some way, this irritable behavior, this squabbling, this fighting. Am I on the right track here?

Dr. Alfred Atanda, Nemours Children's Health:

No, you're 100% right. I think you bring up medical students when you look at them. They're kind of bright-eyed and bushy-tailed. When you look at their well-being early on in medical school, they're so hopeful and so optimistic, and they're so gritty and resilient, and they're taking all these tests and studying, but all of that slowly declines over time when you look at a lot of the research that's been done, and that's the culture that kind of beats that out of them. A lot of these irritable and cynical docs...they weren't like that when they were 20, 22 years old, pre-med, and embarking on a career in healthcare. It's just something that wears you down slowly along the way. It's like high blood pressure, but you don't really notice that it has an effect on you until you have a stroke or something like that, or a brain bleed, or whatever it may be.

This is the same thing. It slowly wears you down until you start feeling certain feelings and emotions. We talk about this idea of emotional intelligence.  If you're not emotionally intelligent enough and self-aware enough, you won't even realize that you're on the spectrum of being burnt out. That's really scary. You may just think that you work with incompetent people or your hospital is inefficient, or you start to blame it on all of these other external factors. But until you really look within to how you're responding to everything, it'll suck you in, and you won't even notice it. That's where a lot of the work that we're doing is trying to combat a lot of these things.

Carol Vassar, podcast host/producer:

Which reminds me of the question, and correct me if I'm wrong, but physicians are highly susceptible to suicide.

Dr. Alfred Atanda, Nemours Children's Health:

Yeah, we talk about it. There are personal and professional ramifications and consequences of, on the personal side, there's alcohol abuse, mental health issues, drug abuse, substance abuse, broken relationships in the home. But the most grave consequence is physician suicide. There's about 400 to 500 physicians every year of all levels of training and all levels in their careers that take their own lives. It isn't until you may have heard of Lorna Breen, the emergency room physician who took her life right in the height of the pandemic. It isn't until those stories start emerging that people really start to take notice. It's a shame because you shouldn't have to wait until people are literally taking their own lives in order to do something about it. The flip side of that, the professional ramifications tend to hit people in their wallets. So there's increased medical errors, there's increased turnover of physicians.

People are quitting and changing jobs. There's poor patient satisfaction. There's decreased productivity and work effort. It's sad to me, but it isn't really until the professional ramifications started to be highlighted and elucidated that the greater healthcare ecosystem really took notice because it was affecting their bottom line. I think over several decades, it just seemed like there's certain docs who were, quote, unquote, "weak," or they couldn't handle it, or they weren't resilient enough, and they were complaining. So, it was more of a personal issue.

But I think now that we realize that it doesn't just affect doctors, but it affects the patients they take care of. It affects the healthcare systems. It affects the outcomes of the patients, and that's really opened up a lot of eyes and our organization, I think amongst pediatric facilities in general, is at the forefront of really understanding how to take care of those that take care of others.

Carol Vassar, podcast host/producer:

We'll get to what Nemours is doing to support its physicians in a few minutes. But I want to ask if there are additional risks for burnout based on gender, ethnicity, cultural background, or any or all of those.

Dr. Alfred Atanda, Nemours Children's Health:

Yeah, so, unfortunately, our female colleagues are at much higher risk for burnout than male colleagues. Underrepresented minorities. Being single is a risk factor for burnout because you don't, in general, have a spouse or a partner in that close support system. Folks that belong to different religious groups may feel marginalized or discriminated against, either by their own colleagues or by the patients they take care of. I think people who already have substance abuse issues are at risk, and people who also have mental health challenges such as anxiety and depression are more susceptible to experiencing burnout.

Carol Vassar, podcast host/producer:

I think the latter two of those, the two seem to go together: the burnout and the alcohol, the burnout and the mental health issues. Why is it that gender, ethnicity, or cultural background may raise the risk for burnout?

Dr. Alfred Atanda, Nemours Children's Health:

I think those groups in society tend to not always have the support that they need. I think for females, as you can imagine, they tend to bear the brunt of life just in general with childcare things around the house. They tend to be the ones that go to the appointments and maintain the appointments. All of the stressors that physicians feel, I think it's just magnified, unfortunately, by our female colleagues because this is generalizing, but the roles they tend to have in their lives tend to have a lot more burden and a lot more stress on them.

I think a lot of males, and again, I'm generalizing, men in my position, not always, but often may have a counterpart or a partner at home that can maintain a lot of things in their personal lives, so they may just have to focus on their jobs, whereas female physicians tend to obviously have to focus on their jobs, but they tend to have a bit more stress and burden in their personal lives as well. So I think females and underrepresented minorities, as we mentioned, have issues in life and society, too, that just get compounded by some of the stressors that physicians feel in general.

Carol Vassar, podcast host/producer:

One of the things we know and is well documented is that there is a physician shortage, particularly in primary care. How does that impact physicians who are currently practicing, and does it add to the burden of burnout?

Dr. Alfred Atanda, Nemours Children's Health:

Of course, because if there's less people practicing, then the people who are remaining in practice invariably have more work to do because health systems and practices usually take care of a certain number of patients in their locales, in their regions, and there's only a certain number of physicians. If you have 10 doctors doing the work, and now three of them have quit, resigned, or are less productive, you don't necessarily have to quit. But some people, like myself right now, I'm 60% clinical because I have found other ways that bring me joy, that provide value to Nemours to do my job.

But there are 14 other surgeons in our practice, two of which specifically do sports medicine and surgery. I have to understand that by shifting my focus, the patients don't go anywhere. They're still there. They still need us. So I think that shortage is a huge problem, and it's kind of a vicious cycle because the shortage is because people were overworked and overburdened and doing the wrong kind of work and all of the things we talked about, and that leads to decreased productivity and people leaving, and then the remaining people are just more stressed, and then they're more likely to leave, and they're more likely to have decreased effort. So it's huge. I don't have a crystal ball to solve all of healthcare's issues, but I do know that that's a substantial problem.

Carol Vassar, podcast host/producer:

I want to ask you, have you ever personally experienced burnout, and how have you dealt with it?

Dr. Alfred Atanda, Nemours Children's Health:

Yeah, the answer is yes. For me, two things that I don't do very well with. Number one is being rushed, and number two not being in control. Working in a large academic healthcare system, there's always pressure on you to see as many patients as you can and do as many surgeries as you can. I quickly realized, just like that analogy of waiting outside the club, when I got into this, I quickly realized that I was going to find myself being rushed a lot because that's just the way it is. I don't have 35 minutes to talk with every patient, bond with them, and ask them where they want to go to college and what sports they play. Sometimes you have 5 minutes or 10 minutes. As I got on with my career, I realized that it wasn't the best fit for me to necessarily always be seeing patients and being as clinically oriented as possible all of the time because I had other aspirations, goals, and dreams. I have my pearl, and I have what motivates me and what I desire.

I was fortunate enough to be at Nemours at a time where they were really looking into rehabilitating and revamping the well-being efforts. I think I was blessed in the fact that my previous chairman, Dr. Mackenzie, who recently retired, was able to work with me to figure out ways that I can maintain my salary, to figure out ways that I can keep providing value to Nemours, but most importantly, do things that brought me joy. I think I was truly fortunate, but not all physicians have that ability. They don't all have that luxury to tailor their practices in a way that meets what they need. There's 15 orthopedic surgeons, so there's a lot of redundancy. There's a lot of other people to pick up the slack for me. But if I'm in a practice with three people, I may not be able to do that.

We know that if you can spend 20% of your time on average doing something that's particularly meaningful to you, we do know that that's protective against burnout. The solution for me wasn't necessarily to just only work three days a week clinical and then stay home the other two days a week. I love working. I'm a very hard-working guy. My clinic today doesn't start till 1:00. I've been here in the office since 7:30 because I love getting things done, but it's on my own time. I have control over how I spend my time this whole morning, and I'm sharing part of that time with you all.

I think giving people that flexibility and that autonomy and control to do the things they love, just ensuring obviously that it's in alignment with the greater Nemours vision, then they can still be valuable to the organization and to the patients that they take care of. That's a true sweet spot, and that's what I was able to do. It took many years. It took a lot of time. It took a lot of thought and intention working with life coaches and a therapist to figure out the best plan. But that's what I try to encourage others on how to not necessarily leave but to reinvent yourself in a way and find ways that you can be more in balance and alignment with what it is that you're all about.

Carol Vassar, podcast host/producer:

Certainly, exercise can help. Maybe playing a musical instrument or singing outside reading, just putting it all to the side and saying, "I need me time." Let's talk solutions. This is, as you said, a very complicated issue. No crystal ball is going to tell us how to solve it all, but what are some approaches that you have looked at and found that alleviate burnout? And also, what is Nemours doing to support physicians who may be at risk?

Dr. Alfred Atanda, Nemours Children's Health:

When you look at a lot of the work that's been done at Stanford and the Mayo Clinic, the Stanford WellMD it's called, is a three-pronged approach, and they look at three things: culture of well-being, personal resilience in something called efficiency of practice. So, a culture of well-being is going to be talent development, leadership development, building communication skills, and building a culture and environment where well-being is prioritized. That's a longitudinal process. Personal resilience is going to be exactly what you talked about. It's going to be yoga, mindfulness, stress, relaxation techniques, exercising, spending time with family. Last but not least, it's this notion of efficiency of practice. So, not just working to improve the work that we do, but most importantly, improving how we do the work that we do, and I think that's been key.

My particular specialty in my forte is around efficiency of practice. I think of myself as a tech nerd, and I work a lot with Bernie Rice, our chief information officer, and his team to figure out how Nemours digital health solutions can just make jobs easier, people's jobs easier. How do we reduce clicks in Epic? How do we streamline documentation and using AI to make our jobs easier? And I don't think any one thing. I think you need all three components. No matter how much yoga and mindfulness that you do, if you come to a work environment that's inefficient, complex, redundant, and malignant, that's not helpful. Same thing with a culture of well-being. I always tell people that mostly what I need to get through a day has nothing to do with orthopedic surgery. It has to do with communication. It has to do with being a good leader. It has to do with being emotionally intelligent, being self-aware, being empathetic.

When I get a parent that's out in the waiting room, and they're irate because of X, Y, or Z, there's no amount of knee anatomy that's going to get me through that. You know what I mean? And I think those, quote, unquote, "soft skills" are really what's missing from medical training. So, for us at Nemours, we've really focused on this three-pronged approach. There's about 15 of us enterprise-wide that do different facets of that three-legged model. I think what we focused on initially a lot was the culture of wellbeing and personal resilience, and we have a peer support program. We have well-being coalitions. We have rounding and Schwartz rounds where we go around the hospital and interact with folks where they're at in their work environments. But also, that efficiency of practice piece has helped me significantly figure out how we can utilize technology to make everybody's jobs easier.

So I think Nemours is doing a fantastic job of having this 360-degree view of how we're going to just make people's jobs more enjoyable, easier, and more fulfilling to them. I think a lot of organizations are lagging behind us. I think a lot of places are focusing on those more personal resilience efforts, which is natural to do that they're having happy hours, they're having different outings, and they're giving folks gym memberships, and that's all required, but "it takes a village," quote, unquote, to raise a healthy, optimized, satisfied, fulfilled physician. It's not going to be a quick fix overnight, but I think the process and the strategy that Nemours put into place is fantastic, and I'm really glad to be a part of it.

Carol Vassar, podcast host/producer:

Anything I haven't asked you about physician burnout that you'd like to share?

Dr. Alfred Atanda, Nemours Children's Health:

Burnout is an occupational hazard. Just like I go to the operating room, I could be stabbed with a scalpel, hit with a hammer, cut with a saw, or a construction person on a construction site. We give them a hard hat, goggles, ear protection, boots, and jeans. Nobody blames me when I get cut in the operating room with a scalpel or if a person on a construction site has an I-beam fall on their head and crush them. That's not their fault. They understand that it's the system that needs to have measures in place to protect the people that are doing the work.

I think the exact same thing rings true in healthcare. I think historically, we look at people that are struggling, and we blame them. We tell them that they need to be more resilient or they need to be grittier. They need to be tougher. They just can't handle it in surgery. They should change specialties. But we now know that burnout is a systemic institutional problem that, unfortunately, manifests in real people. So we have to think of systemic solutions, and we can't put the onus on the individual person going through their journey trying to take care of people to make themselves more equipped to deal with a chaotic, redundant, complex environment. We need to fix that so people can literally just show up and do their jobs.

Carol Vassar, podcast host/producer:

Dr. Alfred Atanda serves as director of clinician wellbeing for Nemours Children's Health in the Delaware Valley.

MUSIC:

Well beyond medicine.

Carol Vassar, podcast host/producer:

Are you a clinician experiencing burnout? What are you doing to take care of yourself and continue with your career, or have you decided to leave the medical field altogether? We'd love to hear from you. Leave us a voicemail at nemourswellbeyond.org. That's nemourswellbeyond.org, where you may also listen to any or all of our previous podcast episodes. Subscribe to the podcast and leave a review. Our production team for this episode includes Che Parker, Cheryl Munn, Susan Masucci, Lauren Teta, and we welcome to the team our new editor, Steve Savino. I'm Carol Vassar. Thanks for listening. Until next time, remember, we can change children's health for good well beyond medicine.

MUSIC:

Let's go well beyond medicine.