the physicians foundation’s sixth addressing the growing … · 2018-12-12 · definition of...

Physicians’ Bi-Monthly Volume 4, 2018

Addressing the Growing Burden of Diabetes in

New Hampshire

By Marisa Lara, MPH, RD Manager, Diabetes, Heart Disease, Obesity and School Health, NH Division of Public Health Service, DHHS

As the number of people with diabetes increases, the demands on your time and practice will continue to escalate. In New Hampshire, 9% of all adults reported having diabetes and among adults 65 years of age and older, the prevalence is 20%.1 Beginning in September 2018, the NH Department of Health and Human Services, Di-vision of Public Health Services (DPHS) is entering into a new, 5-year cooperative agreement2 with the Centers for Disease Control and Prevention (CDC) that will assist health care pro-viders and public health profes-sionals to address the growing burden of diabetes in the state. For example, the funds will be used to:

Also in this issue...

Social Media Risk Management

Reframing Burnout

Type 3c, the Overlooked Diabetes

Burden of Diabetes, cont. on page 7

The Physicians Foundation, a nonprofit organization that seeks to advance the work of practicing physicians, recently released the findings of its 2018 survey of U.S. physicians. The new survey in-cludes responses from almost 9,000 physicians across the country and underscores the overall impact of numerous factors driving physi-cians to reassess their careers.

Here’s a Q&A with Dr. Gary Price, president of the Physicians Foun-dation, to share what these findings mean.

Q: Physician burnout has been an issue the Physicians Founda-tion has been monitoring for years in its biennial surveys. What’s changed in this year’s results?

Dr. Price: Unfortunately, physician burnout is on the rise. A stunning 78 percent of physicians say they experience feelings of burnout in their medical practices. To give you context, in our 2016 survey results this number was at 74 percent, so we see this figure climbing.

• 78% sometimes, often or always experience feelings of burnout.

It’s truly alarming that more than three-quarters of physicians are experiencing burnout, particularly because it is causing many physi-cians to reassess their careers. Forty percent of our survey respondents plan to either retire in the next one to three years or cut back on hours. Equally distressing, 46 percent say they plan to entirely change career paths within the next three years.

Physicians have been silently cop-ing with this burden. It is far past time to do something meaningful to change this negative trend.

Q. What factors are driving burn-out among physicians?

Dr. Price: Physicians responding to our survey report that the chief culprit contributing to feelings of burnout is the frustration they feel with the inefficiency of electronic health records (EHRs) followed by the burden of regulatory and insurance requirements. All of these have intruded on their time to care for their patients, without significantly improving the quality of that care.

If the healthcare industry does not confront the significant challenges caused by the inefficiency of EHRs and excessive burden of regula-tory and insurance requirements, physicians will continue to experi-ence increasing burnout symptoms – which, in turn, will exacerbate the physician shortage already felt in

The Physicians Foundation’s Sixth Biennial Survey Identifies Burnout and Social Determinants as Top Issues

Sixth Biennial Survey, cont. on page 5


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Physician burnout is a somewhat recent phenomena and certainly not a subject that I learned about in medical school. Nevertheless, it is a condition that is now all too common, experienced and written about for physicians in training and in every phase of our careers as physicians. In this article I will discuss this prevalent condition by defining it, consid-ering how it came about and then suggesting some possible rem-edies.

In many ways, the issue of phy-sician burnout touches on the trends that are affecting medi-cal care in general these days, as corporations, hospitals and even hedge funds are owning our practices and controlling how we organize our time, schedule our patients and deliver the care that we used to control. Government regulations impact this issue as well. In fact, the control of our lives as physicians is increasingly governed by the entities that are the owners of our practices and we have found these entities to be less and less interested in hearing from us about our concerns. I

am convinced that the more our “voices” are ignored the more likely we will suffer burnout.

But I am getting ahead of my-self, as I want to first discuss the definition of physician burnout. Physician burnout has been defined as a long-term stress reaction characterized by a sense of being overwhelmed by the demands of the work as a physi-cian or as a student learning the education and skills required to become a physician. This sense of being overwhelmed can include feelings of depersonalization and emotional and/or physical exhaustion. Burnout can also lead to undermining the care and compassion towards one’s patients, as compassion and empathy for others is diminished when one’s sense of self is threat-ened. Numerous studies have shown that physician efficiency and quality of delivered care de-creases as symptoms of burnout become more significant.

Burnout can lead to clinical depression but it is distinct from depression if the symptoms of burnout are only related and em-bedded in the physician’s work-life and do not extend into the remainder of the physician’s or trainee’s life. But when the symp-toms of burnout extend to other or all aspects of a physician’s life, clinical depression and the risk of suicide can become promi-nent, requiring psychiatric care on an emergent basis. Substance use problems can also appear, as dysfunctional methods of dealing with overwhelming stress. Sui-

President’s PerspectivePhysician Burnout: Causes, Effects and Possible Remedies

Leonard Korn, MD

New Hamphire Medical Society7 North State Street Concord, NH 03301 603 224 1909603 226 2432 [email protected] www.nhms.org Leonard Korn, MD ................... PresidentJames G. Potter, CAE ......................... EVPMary West ....................................... Editor

Type 3c, the Overlooked Diabetes ..........32017-2018 NHMS Council ......................9Social Media Risk Management

Considerations for Staff ....................10NHMS Welcomes New Members ..........13The Challenge of Competing Binds:

Reframing Burnout in the Context of Moral Injury .................................14

Mission: Our role as an organization in creating the world we envision.The mission of the New Hampshire Medical Society is to bring together physicians to advocate for the well-being of our patients, for our profession and for the betterment of the public health.

Vision: The world we hope to create through our work together. The New Hampshire Medical Society envisions a State in which personal and public health are high priorities, all people have access to quality healthcare, and physicians experience deep satisfaction in the practice of medicine.

Do you or a colleague need help?The New Hampshire Professionals’ Health Program (NH PHP) is here to help! The NH PHP is a confidential resource that assists with identification, intervention, referral and case management of NH physicians, physician assistants, pharmacists, and veterinarians who may be at risk for or affected by substance use disorders, behavioral/mental health conditions or other issues impacting their health and well-being. NH PHP provides recovery documentation, education, support and advocacy – from evaluation through treatment and recovery. For a confidential consultation, please call Dr. Sally Garhart @ (603) 491-5036 or email [email protected].

*Opinions expressed by authors may not always reflect official NH Medical Society positions. The Society reserves the right to edit contributed articles based on length and/or appropriateness of subject matter. Please send correspondence to “Newsletter Editor,” 7 N. State St., Concord, NH 03301.

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President’s Perspective, cont. on page 6


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Type 3c, the Overlooked Diabetes

By Andrew R. Crawford, M.D. Assistant Professor of Medicine, Dartmouth-Hitchcock Medical Center, Dartmouth Geisel Medical School, Depart-ment of Medicine, Section of Endocrinology

Pancreatogenous diabetes, sometimes referred to as “type 3c” diabetes, is an under-recognized disease. A large 2012 retrospective study in Germany by Ewald et al. demonstrated that 9% of hospitalized patients had this form of diabetes, in which a dis-ease of the exocrine pancreas leads to failure of the insulin-producing pancreatic islet cells.

The underlying mechanism of damage to the pan-creatic islet cells is distinct from type 1 diabetes in that there is no immunologic assault. While patients with pancreatogenous diabetes are often misdiag-nosed as having type 2 diabetes, pancreatogenous diabetes differs significantly from type 2 diabetes in that there is an absolute deficiency in insulin pro-duction from pancreatic beta cells, typically with little peripheral insulin resistance, although some patients may present mixed features and display some insulin resistance.

A large study in New Zealand published in 2017, by Pendharkar et al. revealed that pancreatitis is the driving factor in 61% of pancreatogenous diabetes cases, but other diseases such as cystic fibrosis and pancreatic cancer, as well as surgical resection of significant portions of the pancreas, are also impor-tant risk factors. Pancreatogenous diabetes should be considered in any diabetic with risk factors such as a history of chronic alcoholism, pancreatitis, gallstones, or pancreatic surgery. A history of ste-atorrhea, fat soluble vitamin deficiencies, elevated

pancreatic enzyme markers, dramatic unexplained declines in glycemic control in previously well-con-trolled diabetes, epigastric pain, or jaundice should raise suspicion.

Initial screening, in addition to assessing for the above risk factors, also requires the identification of signs of pancreatic exocrine insufficiency, which typically occurs prior to irreversible damage to the insulin-secreting pancreatic islets (Gudipaty and Rickels 2015).Type 1 diabetes can be ruled out by checking a biochemical marker of autoimmune pancreatic disease such as GAD-65 (glutamic acid decarboxylase 65). Most patients with pancreatog-enous diabetes will have inappropriately low insulin c-peptide. Imaging studies such as a CT of the ab-domen should be considered to assess for pancreatic disease if the suspicion is high.

Treatment can differ greatly from strategies used to treat type 2 diabetes. Patients with pancreatogenous diabetes have a significantly earlier dependence on insulin relative to type 2 diabetics. Oral medications may have a more limited role, and GLP1 recep-tor agonists and DPPIV inhibitors are relatively contraindicated given their weak association with causing pancreatitis. Given that patients with pan-creatogenous diabetes often lack significant insulin resistance, relatively small doses of insulin may be sufficient, and patients should be carefully moni-tored for hypoglycemia given potential co-existing deficiencies in pancreatic glucagon secretion. In select patients, pancreatic transplant or total pan-createctomy with islet auto-transplantation may be options for treatment. �

References:Ewald N, Kaufmann C, Raspe A, Kloer HU, Bretzel RG, Hardt PD. Prevalence of diabetes mellitus secondary to pancreatic diseases (type 3c). Diabetes/metabolism research and reviews. 2012 May;28(4):338-42.Gudipaty, Lalitha, Rickels, Michael R. (2015). Pancreatogenic (Type 3) Diabetes. Pancreapedia: Exocrine Pancreas Knowledge Base, DOI: 10.3998/panc.2015.35Pendharkar SA, Mathew J, Petrov MS. Age-and sex-specific prevalence of diabetes associated with diseases of the exocrine pancreas: a population-based study. Digestive and Liver Disease. 2017 May 1;49(5):540-4.


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Sixth Biennial Survey, cont. from page 1

many areas of our country, and needlessly prolong the sometimes tragic consequences of burnout.

Q: Do physicians feel able to instigate changes to help alleviate these feelings of burnout?

Dr. Price: Only 10 percent of physicians who took our survey feel they have the power to im-pact the healthcare system. The perspective of physicians needs to be at the forefront of discus-sions around healthcare policy and regulation. Physicians are on the front lines of healthcare every hour of every day, and ultimately are held responsible for their pa-tient’s outcomes.

The Physicians Foundation strives to focus and amplify the voices of physicians. Their insights will be critical to improving our health-care system in a successful and sustainable way. Physicians need to feel empowered to contribute their ideas, and planners need to recognize the value of their input.

Q: A lot of people are talking about the influence of social determinants on healthcare out-comes. To what extent are factors like poverty impacting patient care?

Dr. Price: An overwhelming ma-jority (88 percent) of physicians report that some, many or all of their patients are impacted by social determinants. In fact, only one percent of physicians taking our 2018 survey report that none of their patients have such cir-cumstances.

Conditions such as poverty, un-employment, lack of education and addiction all pose a serious impediment to a patient’s health, well-being and their eventual health outcomes. These challeng-es directly impact a physician’s ability to deliver effective care.

• 88% of physicians indicate that some, many or all of their patients have a social situation (poverty, unemployment, etc.) that poses a serious impediment to their health.

Many physicians on our Board of Directors personally witness the impact of poverty among the pa-tients they serve. Social determi-nants as they relate to healthcare have been a critical focus of the Foundation for several years now. We have made concerted efforts to address this vital area with like-minded individuals and organiza-tions across the U.S.

While patients and physicians must work together to navigate the hardships that hinder proper care and drive up costs, it’s key that health policy experts and regulators actively acknowledge and engage with this issue. Sim-ply ignoring it – or pretending it is not a factor in driving up costs while undermining outcomes – is no longer tenable.

Q: Many people dealing with so-cial determinants that adversely affect their care are also patients who have been negatively im-pacted by the opioid crisis. To what extent has the opioid crisis changed the way that physicians practice medicine?

Dr. Price: Our survey results re-port that 69 percent of physicians are prescribing fewer pain medi-cations in response to the opioid

crisis. To put things in perspec-tive, an opioid overdose was the cause of more than 60,000 deaths in 2017 alone – quadruple the number of deaths from an over-dose since 1999.

There are many causes of this epidemic, and physicians are seri-ously engaged in efforts to reduce it, as well as untangle the multiple root causes of this major public health concern.

Q: Anything else we should know about the 2018 Physician Survey results?

Dr. Price: Physicians overwhelm-ingly agree (79 percent) that the most satisfying part of being a physician is the relationships with patients that they build across their career. We hope policy makers, healthcare influencers, media and other stakeholders will use the findings of our survey as a valuable resource to better understand the underlying challenges facing phy-sicians and our healthcare system. This will allow all stakeholders to formulate more effective policies to advance the health and interests of patients through helping physi-cians focus on what they love and do best – care for patients.

To view the full results of the survey, visit https://physiciansfoun-dation.org/research-insights/the-physicians-foundation-2018-physi-cian-survey/. �


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cide rates of physicians and physician trainees have indeed become much more prevalent as burnout has become more widespread.

So how prevalent is physician burnout? Medscape Medical News has surveyed physicians annually and the prevalence of physician burnout has increased dramatically over the last six years. Emergency medicine, obstetrics-gynecology, family medicine and internal medicine were the specialties with well over fifty percent of physicians reporting burnout, compared to lower percentages, closer to forty per-cent, for pathology, ophthalmology and psychiatry.

Causes and Remedies of Physician Burnout

Clearly, the locus of the control of our practices is a major cause of physician burnout, and transforming the systematic control back to physicians can there-fore help alleviate burnout. That is obviously easier said than done, as the powers controlling the deliv-ery of medical care have slipped from our grasp. Organized medicine needs to regain that control, at least to some extent, to reverse this trend. There are encouraging signs as more physicians are seeking training, such as the training and leadership pro-grams sponsored by NHMS and other state medical associations and universities. I recently attended the Maine Medical Association Annual Meeting in Bar Harbor and was pleased to attend a panel discussion on “Physician Leadership in the C-Suite.” Physi-cians are leading many of the hospitals and hospital systems in Maine, and this seems to be an increas-ing trend throughout the country. I hope that this trend of physician leadership leads to improvements in physician practices, so that this epidemic of burn-out subsides.

When discussing burnout with physicians, the burdens of EMRs and prior authorizations are, of course, at the forefront. We have stopped looking at our patients, as more and more attention needs to be paid to our computers just to get our work done. Physicians are often finishing up their EMRs at home and on weekends - unpaid time - just to get the work done. Surveys of physicians suggest that well over half our time if not considerably more is spent on “paperwork,” and less and less time with our patients. Furthermore, EMRs are redundant and it is so hard to separate “the wheat from the chaff.” Recently, I requested records from a family

President’s Perspective, cont. from page 2

Wendy Cohen, MDBoard Certified Psychiatrist

Curbing the Epidemic of Physician Burnout

Saturday, November 10th 3:00 - 4:00 pm

Today’s health care environment—with its packed work days, demanding pace, time pressures, and emotional intensity—can put physicians and their teams at high risk for burnout. Dr. Wendy Cohen explores issues related to physician burnout and identifies steps to mitigate its impact on you and your practice.

Just one of 14 CME credits…Join us for #NHMS18 at the Wentworth by the Sea Hotel and Spa

November 9-11, 2018http://www.nhms.org/2018conference

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President’s Perspective, cont. on page 7


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• Help healthcare providers to identify patients with prediabetes and refer them to National Diabetes Prevention Programs.3

• Help healthcare providers identify patients in need of diabetes self-management education and support and refer them to accredited/recog-nized programs.4

• Increase collaboration between pharmacists and providers to improve medication management for patients with diabetes.5

Funds will be dedicated to continuing educa-tion for clinicians and public health professionals as well as project implementation similar to the American College of Preventive Medicine’s Dia-betes Prevention Program Demonstration Project funded by CDC in 2017.6 For more information on this cooperative agreement, contact Marisa Lara at [email protected]. �

1 BRFSS Analysis by New Hampshire Division of Public Health Services, Bureau of Health Statistics and Informatics

2 Improving the Health of Americans through Prevention and Management of Diabetes and Heart Disease and Stroke https://www.cdc.gov/rfa-dp18-1815/index.html

3 https://www.cdc.gov/diabetes/prevention/lifestyle-program/deliverers/index.html

4 https://www.dhhs.nh.gov/dphs/cdpc/diabetes/documents/dsme-map.pdf

5 https://www.cdc.gov/dhdsp/pubs/toolkits/pharmacy.htm6 https://www.acpm.org/page/dppdemoproject

Burden of Diabetes, cont. from page 1President’s Perspective, cont. from page 6

physician and received a pile of records that was two inches thick. Every note was seven pages in length at least and the notes were mostly the same. All of these voluminous paperwork requirements need to change if we are going to reduce the burdens on physicians and allow them to spend more quality time with their patients.

I believe that all physicians enter into the profes-sion of medicine with a goal of helping individuals (patients) overcome the problems of health and illness. These are, of course, honorable aspirations and form the core of our identity as physicians, as healers. Patients, of course, put their trust in us as physicians to care for them with compassion and competency to fulfill that responsibility and trust. However, when that trust is threatened by the changes in the patterns governing our prac-tice, our whole identity as physicians is threatened, thus leading to the burnout all too common in our profession. I am hopeful that physicians will lead the process of change so that we can better serve our patients and ourselves and stem the tide of this phenomenon of burnout.

In closing, I want to highlight a presentation “Curb-ing the Epidemic of Physician Burnout” that will occur at the NHMS Annual Scientific Conference at Wentworth by the Sea in New Castle, New Hamp-shire, November 9-11. Wendy Cohen, MD, Evalua-tion Director of the Massachusetts Physician Health Services, will share her expertise and experience with this issue that is so important to us all. �

Vacant positions on the Board of Medicine and

Medical Review Subcommittee

The Board of Medicine has one (1) vacant public member position on the Board.

The Medical Review Subcommittee (MRSC) to the Board of Medicine, pursuant to RSA 329:17, V-a, is looking for one (1) public member to serve on the MRSC. Details at:

https://www.oplc.nh.gov/medicine/board-vacancies.htm


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2017-2018 NHMS Council President Leonard Korn, MD

President-Elect Tessa J. Lafortune-Greenberg, MD

Immediate Past President Deborah A. Harrigan, MD

Penultimate Past President John R. Butterly, MD

Vice President John L. Klunk, MD

Secretary Eric A. Kropp, MD

Treasurer Stuart J. Glassman, MD

Speaker Richard P. LaFleur, MD

Vice Speaker Daniel M. Philbin, MD

AMA Delegate William J. Kassler, MD, MPH

AMA Alternate Delegate P. Travis Harker, MD, MPH

Chair, Board of Trustees Charles M. Blitzer, MD

Trustee Richard B. Friedman, MD

Trustee P. Travis Harker, MD, MPH

Medical Student Soham C. Rege

Physician Assistant Linda L. Martino, PA-C

Osteopathic Association Rep. Maria T. Boylan, DO

Young Physician Reps. Kenton Allen, MD

Young Physician Reps. Anthony M. Dinizio, MD

Members-at-Large Diane L. Arsenault, MD

Members-at-Large Albert L. Hsu, MD

Members-at-Large Seddon R. Savage, MD

Members-at-Large Doris H. Lotz, MD, MPH

Members-at-Large Linda Kornfeld, MD

Board of Medicine Representative Nick P. Perencevich, MD

Lay Person Lucy Hodder, JD

Physician Representatives Dept. of Health & Human Services Benjamin P. Chan, MD

Specialty Society Representatives:

• NH Chapter of American College of Cardiology Daniel M. Philbin, MD

• NH Chapter of American College of Physicians Richard P. Lafleur, MD

• NH Academy of Family Physicians (2) Gary A. Sobelson, MD

Molly E. Rossignol, DO

• NH Chapter of Emergency Physicians Thomas J. Lydon, MD

• NH Society of Eye Physicians & Surgeons Lauren Branchini, MD

• NH Pediatric Society Skip M. Small, MD

• NH Radiology Society Terry J. Vaccaro, MD

• NH Psychiatric Society Jeffrey C. Fetter, MD

• NH Society of Anesthesiologists Steve J. Hattamer, MD

• NH Society of Pathologists Eric Y. Loo, MD

• NH ACOG Oge H. Young, MD

• NH Orthopaedic Society Glen D. Crawford, MD

Invited Guest: MGMA Representative Dave Hutton

WANTEDInternal Medicine, Orthopedic, Neurologic, General or Family Practice Physicians interested in providing part-time or full-time staff medical consultant services for the Social Security Disability program, through the state Disability Determination Services office in Concord, NH. Staff work involves reviewing disability claims on-site and requires no patient contact. SSA Training is provided.

ORPhysicians interested in performing consultative examinations in their office for the Social Security Disability program, through the state Disability Determination Services office. Compensation is provided per exam. All administrative aspects are performed by the DDS and no billing is required. Free dictation service and a secure web portal is provided for report submission. Any interested physician must be licensed by the state of NH and in good standing. Please email inquiries to: [email protected]

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The use of social media has expanded at astounding rates. An ECRI report on social media from 2014 stated that there are now 6 billion hours of YouTube videos uploaded monthly, 757 million daily Facebook users, and 500 million tweets a day. Your staff reflects this trend; surveys from 2011 found that approxi-mately 80% of both doctors and nurses use some type of social media for personal or profession-al use. A comprehensive policy is a great way to get your arms around this new and expanding area. Interestingly, an article from AIS Health found that only one-third of healthcare organiza-tions had social media guidelines.

Perhaps there were so few so-cial media policies because in 2010 the National Labor Rela-tions Board (NLRB) found that some social media policies, and disciplinary action taken against employees, violated federal labor laws. The findings from the NLRB added a layer of complexi-ty to how employees were treated after an unfavorable social media

post. In order to clarify their stance on social media, the NLRB created a sample policy for em-ployers to use.

However, the NLRB sample policy was not designed with healthcare organizations in mind. Specifically the NLRB sample did not address the HIPAA law. Legal experts felt that the NLRB policy was not specific enough for the healthcare world. To that end, AIS Health posted a sample HIPAA and NLRB-compliant social media policy developed by Boston Medical Center (BMC). This sample policy, while brief, was comprehensive and easy to understand, plus scalable for any size practice. State laws on patient privacy should be consid-ered when creating a social media policy, because state laws can be more restrictive than federal HIPAA laws.

In addition to a social media policy, continuous education was recommended for staff on social media use. In regards to BMC’s social media policy, Nickie Brax-ton, BMC’s Privacy Officer, stat-ed, “It’s not just about what you can do and can’t do, but why…it’s trying to let people understand the reasoning behind the rules.”

The two-page BMC sample policy covers key components of a social media policy:

1. General Behavior on Media Sites

2. Professionalism on Social Me-dia Sites

3. Representing the Institution on Social Media Sites

Five Tips to Guide Your Hospi-tal’s Social Media Policy:

1. Keep it short

2. Keep it simple

3. Keep it encouraging

4. Keep it educational

5. Keep it transparent

ReferencesECRI: Embracing Social Media in Healthcare: Minimizing Risks and Protecting the Brand, July 2014.National Labor Relations Board Social Media Fact Sheet: https://www.nlrb.gov/news-outreach/fact-sheets/nlrb-and-social-mediaHealth Leaders Media: Five Tips to Guide Your Hospital’s Social Media Policy, May 2010. https://www.healthleadersmedia.com/innovation/five-tips-guide-your-hospitals-social-media-policyAISHealth: Policy on Use of Social Media, May 18, 2015. Medical Mutual’s “Practice Tips” are offered as reference information only and are not in-tended to establish practice standards or serve as legal advice. MMIC recommends you ob-tain a legal opinion from a qualified attorney for any specific application to your practice.

Social Media Risk Management Considerations for Staff


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NHMS Welcomes New MembersMark A. Abel, MD

Daniel P. Auger

Oliver J. P. Bamzak, MD

Matthew E. Batliner

Charles J. Bettag, MD

Michael A. Bevilacqua, MD

Jacques H. Blanchet, MD

Eric B. Bland, MD

Maxwell R. Blazon

Kathy S. Bolgatz, MD

Jonquille Bouchard, DO

Eileen R. Brandes, MD

Lucas D. Breen, MD

William L. Brown, MD

Hillary D. Bui

Rabia G. Buridi, MD

Emily A. Burns, MD

Steven A. Calamita, MD

Audrey H. Calderwood, MD

Victoria A. Caruso

Yasolatha Chalicheemala, MD

Christopher B. Chapman, MD

Douglas O. Connolly, MD

Libby R. Copeland-Halperin, MD

Breanna A. Davis

Evan C. Devanny

Mark L. Dick, MD

Jude L. Divers, MD

Nathalia O. Docar, MD

Jacob Doncher, MD

James D. Doss, MD

Ryan D. Doyle, DO

Devin W. Druen, MD

Hannah L. Duane, MD

Bilal Elchaarani, MD

Seyde Felek, DO

Olivia A. Fournier, MD

Xavier P. Fowler, MD

Catherine F. Frye

Sage E. Gale

Allison H. Gathany, MD

John M. Gemery, MD

Erica K. Gotow, MD

Matthew D. Gott

Katherine R. Grey, MD

Sherry A. Guardiano, DO

Carsten R. Hamann, MD

Robert B. Hamilton

Elizabeth A. Harvey, MD

Sara N. Heard

Julia M. Hickey

Joel B. Huleatt, MD

Mary L. R. Joseph, MD

Humnah Khudayar, MD

Courtney N. Knill, MD

Amanda Kore, DO

Elaine P. Kuhn, MD

Aditya Kulkami, MD

Luke A. Lamar, MD

Tad P. Lanagan, DO

Melissa M. Ley, MD

Regina G. Lief, MD

Joshua H. Litchman, MD

Sean S. Lombard

Brittany F. Lovascio, MD

Jennifer J. Lucas, MD

Douglas R. Mailly, MD

Stephen Marko, MD

Isabella W. Martin, MD

Bridget Marvinsmith, MD

Samantha A. Matthews, MD

Daniel G. McCall, MD

Emily J. McCarty, MD

Nathan A. McDonald, MD

Anna P. McLean

Michael M. McLeod, Jr., DO

Andres F. Mindiola Romero, MD

Parlo Mishyn, DO

Sarthak B. Misra, MD

Julio D. Montejo, MD

Sameneh Motanagh

Chuck E. Navanze, MD

Thatcher R. Newkirk, MD

Christopher D. Ortrngren, MD

Apama Raju Padmaraju, MD

Frank C. Papik, MD

Ryan W. Pate, MD

Kriner Patel, MD

Lisa A. Patterson, MD

Samantha Rebien Pawlowski, MD

Ryan Peterson, MD

Jeremy B. Petrous, DO

Luke J. Plumier, MD

Laura Ragoonanan, MD

Marie-Elizabeth Ramas, MD

Cody M. Ramirez, MD

Elizabeth M. Ran, MD

Raja A. REhman, MD

Meghan E. Reynolds, MD

Alexandra Robertson, MD

Colby P. Rondeau

Timothy B. Rooney, MD

Marie-Helene Sajous, MD

Parth S. Shah, MD

Allancesue J. Smith, MD

Alexander A. Soto-edwards, MD

Inbar S. Spofford, MD

Tray Nicholas Stai, MD

Derek R. Start, DO

Saira C. Tekelenburg, MD

Victoria G. Teveris, MD

Andrew J. Thomson, MD

Robert A. Tokhunts, MD

Sindri A. Viraorsson, MD

Nicholas J. Welsh, MD

Madeline P. Whitaker

Sandra L. Wong, MD, MS

Sherry L. Wu, MD

Sean S. Zadeh, MD

Kimberly C. Zanor, MD

Vi Zhang, MD

Rebecca A. Zuurbier, MD


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The Challenge of Competing Binds:Reframing Burnout in the Context of Moral InjuryBy James Potter, NHMS EVP with Wendy Dean, MD, and Simon Talbot, MD

Physician burnout – exhaustion, cynicism, and a sense of lack of ac-complishment – has risen as a major pain point for physicians as they have increasingly become employ-ees of health systems. But the con-cept of “burnout” does not resonate with most physicians. That particu-lar term implies an individual fail-ing of resilience or durability that has never really comported with my career experience in working in the medical community. In general, I find doctors are a tough, gritty lot who have developed substantial reserves of resilience during intense education and training, with many of these traits likely hard-wired into their amygdalae.

Wrestling with this subject, I recently read and would recom-mend to you a recent article by Drs. Dean and Talbot that suggests the diagnosis for physician distress may be inaccurate. Perhaps there is a better concept to explain this disturbing trend.

Rather than burnout, physicians may in fact be encountering what is more akin to the term moral in-jury. Moral injury is a concept first used to describe the experience of soldiers who committed acts they found reprehensible in the context of war, and is defined as “perpe-trating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Physi-cian moral injury does not result from killing another, but from the inability to help patients in the context of healing.

The distinction between these concepts is important. The stress of an overloaded schedule, caused by continually trying to be in two

places at once, can be ‘treated’ with education about coping, improved scheduling, and judicious offload-ing of responsibilities to others. On the other hand, moral injury is inflicted by a system complicit in creating double binds that no end of individual effort or caring can fix, nor is it amendable to simple solutions. However, in my policy experience, having the right lan-guage to describe this subject can help reframe conversations with policy and decision makers to cre-ate meaningful changes.

Providing care to patients in the current environment requires that physicians take into consideration a myriad of interests outside of patients’ direct medical needs. Any given treatment plan must consider what the patient’s insurance will cover, what the healthcare system demands, and any employment requirements for the physician. Allegiance to multiple competing drivers results in double-, triple-, or quadruple binds for the physician such that there is often no course of action that can satisfy all parties.

Doctors train for at least a decade to understand how best to care for their patients. But when they get into practice, they face administra-tive and economic constraints as to what they can provide. They don’t have control of those decisions, but they bear witness to the repercus-sions – to the pain and disability resulting. Being responsible for those decisions, delivering the news to the patient, and watching the fallout is the recipe for moral in-jury. The lower self-esteem, feelings of resentment, apathy, and erosion of the doctor-patient relationship are the hallmarks of moral injury in healthcare.

There is a laundry list of other contributors to the distress phy-sicians feel: lack of control over

work, erosion of the connection to leadership, other physicians and the focus on clinical care, poorly aligned metrics, continually in-creasing administrative burdens, and the erosion of patient trust in response to their increasing aware-ness of competing allegiances.

The challenge for most physicians in practice is that they have been so dutiful in trying to meet their patients’ needs that they have failed to attend to their own. Below are some suggestions for maintaining perspective in the current health-care environment.

Physician, know thyself. No mat-ter your practice environment, you will face many of the challenges listed below. The better that you understand these mounting obliga-tions, the more able you will be to choose a dispassionately considered response to them, rather than an instinctive, emotional reaction:

• Administrative burdens (pri-marily EHR demands)

• Insurance constraints, prior authorizations

• Marketing pressures and billing implications

• Employer quotas

• MOC disconnects

• All of the above, at once

Follow the money and metrics. Physicians are not trained to fully understand and manipulate the economic drivers in health care. Many high up decisions are driven by bottom lines and understand-ing how you are tied to that is important in addressing the work environment. Our new NH Phy-sician Leadership Development Program (https://paulcollege.unh.edu/physicianleadershipnh) focuses on helping physician leaders better comprehend these drivers.

Reframing Burnout, cont. on page 15


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Understand policy and how government works. Physicians who are deeply knowledgeable about both policy and medicine must inform national conversa-tions about the direction of healthcare. And those physicians must speak as advocates of patient care, not business principles.

Start conversations and keep in touch. Drs. Dean and Talbot’s article, Physicians aren’t ‘burning out.’ They’re suffer-ing from moral injury. (STAT News - https://www.statnews.com/2018/07/26) can help spark continuing discussions about the personal costs to physicians of the current healthcare environment (www.moralinjury.healthcare).

At minimum, it means our efforts to address these is-sues will require advocacy strategies confronting the environmental challenges noted above, as well as build-ing greater physician leadership in health systems and helping maintain life-work balance.

Wendy Dean, MD, is a psychiatrist and senior medical officer at the Henry M. Jackson Foundation for the Advancement of Military Medicine. Simon Talbot, MD, is a reconstructive plastic surgeon at Brigham and Women’s Hospital and associ-ate professor of surgery at Harvard Medical School. �

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