Subir Roy: Why is burnout high among doctors?

Indians consider their health care system to be unduly costly and riven by unethical practices. Doctors, who play a key role in this set-up, are seen as one of its main beneficiaries. But a recent survey has revealed a high degree of burnout and dissatisfaction among them. How is it that those who are seen to be doing well for themselves remain unhappy?

The survey (conducted by Dr Deepak Langade and others, published in Cureus) has found that, under the three components that go into determining the level of burnout, 45 per cent feel emotionally exhausted, as high as 66 per cent feel depersonalised vis-à-vis patients, and only 26 per cent feel satisfied with their calling. These results are similar to those of earlier studies in India and other countries, the exception being Europe where the burnout rate is lower. As in other countries, burnout levels in India are higher among female doctors. Burnout levels rise with age and experience. Academics have lower burnout levels but also low job satisfaction. One problem with the study is most of the respondents are from one state, Maharashtra.  

I checked out these results with a senior manager of a corporate hospital and an active private practitioner who also helps run a successful non-profit hospital that funds its own expansion. In private hospitals, work imperatives for doctors depend on whether they are part time consulting specialists who bring in their own patients and get a percentage of their revenue spend or are regular employees earning a salary. The former will be more revenue driven. The trend in the country is to move away from this system, with around 70 per cent of doctors in private hospitals now salaried employees.

With patients increasingly opting for hospital brands rather than a particular specialist, a salaried doctor’s performance and bonus depend on how good a cog his is in the system. (One hospital can focus single mindedly on revenue whereas another can say, let’s certainly make money but also have a good brand name.) Hospitals are increasingly trying to minimise a patient’s stay and maximising revenue per day. A doctor’s ability to handle complex cases and how much of revenue can be traced to him influence the bonus he gets. The good news is that today’s young doctors are more like corporate executives who do a good nine-to-five job and also take out some time for the family. This should lower chances of burnout.

Burnout is most likely for a resident graduate who never got a postgraduate seat and always remained a resident. A major cause of burnout is becoming obsolescent in knowledge and skill. These explain why disaffection grows with age. Doctors in teaching hospitals tend to keep greater track of what is appearing in leading medical journals and this may explain the lower burnout among them. But most simply depend on what a medical representative tells them.   

With medical science becoming more and more technology driven and a well-equipped modern speciality hospital needing huge capital investment, the best way to remain a good doctor is to be attached to a good (read well-funded and -equipped) hospital. As for independent specialists, they face severe professional downside once they fall out of a referral “chain”. 

A burnout is a welfare loss for society (one more doctor becoming good for nothing). Welfare is also not maximised when patients end up spending more than what they need to. Patient spending is driven by private health care’s business model making it imperative to maximise patient spend. Can you have a business model which maximises investor returns while maximising patient satisfaction and its corollary, minimising patient spend? 

All doctors are agreed that patients and their relatives too often rush to suspecting negligence on an adverse outcome. This has made doctors unduly cautious, prompting them to recommend unnecessary diagnostic tests. It is absurd to recommend a brain CT scan for a headache but there will be one case in a thousand in which the riddle could have been cracked early only by a CT scan. That apart, today in India, doctors almost mechanically reach for pen and paper to list a whole set of diagnostic tests without trying to use clinical skills for initial diagnosis. While decline of clinical skills is now a global phenomenon, in developed countries load on health care systems is being increasingly managed by the nurse practitioner, the first point of contact, going by established protocols for given symptoms. The nurse practitioner is non-existent in India because of lobbying against the idea by the private practitioners’ trade union, Indian Medical Association. Decision makers, from ministers to senior judges, are emotionally very dependent on their doctors and go by their perception of what is good for society. 

One way to minimise patient cost can be through a slab system of tax. Let the tax rate go up progressively as bed charges or operation theater charges go up. Another is for a hospital to have internal protocols based on physical parameters and patient/relatives interviews, which try to transparently judge if a patient has received value for money or not.  

Protocols apart, what really matters is having faith in your doctor who is conscientious and honest. One of my informants tells me that in their estimation, around 15-20 per cent of Indian doctors can be so described. If you can’t requisition morality then you can at least try to have the right institutional set-up. There is a clue in Europe having a lower rate of burnout. It also has the best public health services in the world. If the latter deliver then certain social norms are set and private health care behaves itself because of the nature of competition. This is partially true in Kerala and Tamil Nadu; with the old Andhra region and Karnataka one step behind. 

My informant, who helps a non-profit, has another idea. Entrepreneurs in health care can try to aim for a bit less than maximum returns, be social entrepreneurs just a wee bit. If doctors see owners settle for a bit less, then they will also do so. Burnout happens when a doctor loses meaning in life. Bank balance helps but the best sleeping pill is knowing there is a sense of gratitude among your patients.  
 

subirkroy@gmail.com