Managed Care

 

Medical Directors Explain Hows and Whys of Burnout

MANAGED CARE September 2012. © MediMedia USA
Cover Story

Medical Directors Explain Hows and Whys of Burnout

These high-achievers wrestle with competing interests as they operate both in the medical and business worlds

Frank Diamond
Managing Editor

These high-achievers wrestle with competing interests as they operate both in the medical and business worlds

Frank Diamond

Managing Editor

After 13 years in neonatal intensive care, Marjorie Schulman, MD, became a clinician executive, working as a medical director. She left Aetna at the end of 2011. She loved it there, calling it an ethical company that has done more than any other in the industry to allow work-life balance. Still, there was pressure, and balance in the lives of medical directors can be difficult to come by.

On her first day at Aetna, one of Schulman’s new physician colleagues pulled her aside.

“‘Your specialty is neonatal intensive care, right?’

‘Yes,’ I answered.

‘Well, you are going to see a lot of hysteria in this industry. Everything is urgent, urgent, urgent when money is on the line. But remember, nothing in business is ever like medicine, especially the kind of medicine you practiced.’”

Hidden problem

Medical director burnout often goes unseen and undetected. Most professionals, not just medical directors, don’t want to admit to burnout; it took a while to get anyone to speak to us about the problem. The attitude was “Medical director burnout? Never heard of it! Especially at my company!” Even an interview with a physican who works for one of the large consulting companies, someone you’d assume would be forthcoming, went nowhere.

A spokeswoman for America’s Health Insurance Plans advised us that we should instead be writing about how excited medical directors are to go to work every day to face the challenges of the health reform era, about how much they love their jobs. While we have no doubt that most do, to suggest that medical director burnout doesn’t exist pulls the reach of credulity out of its socket.

“The problem is quite real — not just for medical directors, but for any physician in a management role,” says Brent James, MD, the chief quality officer and executive director of the Institute for Health Care Delivery Research at Intermountain Healthcare. “We tend to be really compulsive and over commit. The problem afflicts all ranks of management.”

Despite appreciating her career, Schulman says that she hasn’t met many medical directors who don’t burn out at some point. Still, if she had it to do over again, she’d still become a medical director.

“My hope when I entered the health insurance field was to influence population health at the place where money drives clinical behavior,” says Schulman. “I have been lucky to see that up close.”

Now’s the time to define terms. Managed care medical directors provide clinical leadership and expertise related to health insurance programs including — but not limited to — quality improvement, utilization management, network design, policy development, accreditation, credentialing, care delivery, and working in a team/collaborative relationship with other organization leaders, says Jaan Sidorov, MD, a former medical director at Geisinger Health Plan and a member of Managed Care’s editorial board. Medical directors typically report to the chief medical officer.

Burnout is not a recognized psychiatric disorder, so there is no diagnosis, says Philip R. Muskin, MD, professor of clinical psychiatry at Columbia University and a distinguished life fellow of the American Psychiatric Association.

Sad every day

“Someone with burnout might be sad, or might be sad enough to qualify for a diagnosis of depression that has a main symptom of a pervasively sad mood for most of the day, every day, or significant loss of interest in usually enjoyable activities, plus other symptoms,” says Muskin. “The person might be anxious and might be anxious enough for a diagnosis of generalized anxiety disorder that has a main symptom of worry. I would not want anyone to think he or she has a mental disorder if experiencing burnout.”

Also, while someone might call himself a “burnout specialist,” there is really “no such specialty,” says Muskin.

Robert Forster, MD, is a health care consultant who has held various positions in his career, including chief medical officer (CMO) at BlueCross BlueShield of Florida for seven years. The medical director’s role is far too restricted and inflexible, he says. “They are really not treated as a professional, if you will. You might as well put information in a computer and not have any judgment.”

“Nearly all medical directors want to be on a professional advancement track, but that is not always possible,” says Abbie Leibowitz, MD, of Health Advocate.

Abbie Leibowitz, MD, agrees. He is a former chief medical officer at Aetna and now is executive vice president and chief medical officer of a consumer advocacy company called Health Advocate. “Many medical director roles are pretty repetitive and don’t require a lot of creativity or encourage much strategic thinking,” says Leibowitz. “This is especially true of the utilization review jobs — a common entry point in many plans. Nearly all medical directors want to be on a professional advancement track, but that is not always available.”

Likes going to work

One medical director, who asked not to be identified, recently changed jobs, moving from a regional to a national plan. An 11-year veteran, she now finds herself in an unusual state: She likes going to work. Not that it was torture before. “In the very beginning it’s interesting because it’s a learning curve, but after a while it just ends up becoming tedious,” she says.

Some plans want medical directors to be involved in many extracurricular activities, such as meeting with specialty groups, serving on multiple internal committees, visiting practitioners and hospitals, “all the while being responsible for time sensitive turnaround cases without coverage from your peer physicians, which creates a huge amount of stress and job dissatisfaction.

“At the end of the day we’re still responsible for the basic widgets. That is more highly valued. And if you do external activities, that is an addition, not a substitution. So there’s less and less incentive to want to do outside activities.”

Would more money help? “It’s not really the compensation; it’s more that for the most part, your basic activities take eight hours, so I would go to an external meeting, get back at 3 p.m., and find that I was going to be working until 8 p.m. to finish my core job.”

Forster points out that medical directors’ performances are often judged by nonclinical people. “Ultimately, as they move up the ladder, there’s a non-clinician above them who has a difficult time grasping the subtleties.”

Forster is a mentor to medical directors, and most of what he teaches has to do with explaining medical information in terms that nonclinician executives can understand. “You don’t necessarily talk about the quality benefits that you can sustain by doing something in this method but about what it can bring in terms of dollars, in terms of saving the plan money, or allowing the plan to reduce premium and therefore become more competitive. Sometimes you have to talk their language.”

Familiar symptoms

Thomas J. DeLong, PhD, points out that medical directors are high performers and that they burn out the way high performers in most professions burn out. They are addicted to achievement and sometimes become self-absorbed. “They don’t understand how their behavior affects others,” says DeLong, the Philip J. Stomberg Professor of Management Practice at Harvard Business School. “I believe, based on the interviews that I’ve done, that it is an addiction — as much of an addiction as being on prescription drugs or on heroin. It’s that hard to break.”

Divided

Physicians who become businesspeople might feel divided. The positive medical part is “being with the patient and forming an intimate relationship and seeing the patient get better,” says DeLong. “But once you are a medical director, it becomes more about policy and procedures and numbers. That is degenerative. It doesn’t refill the vessel by giving a feeling of growth and renewal and some sense of peace.”

In the world of practicing physicians, corporate medical directors are viewed as the enemy, not as peers, which can be very depressing, says Schulman. “It is still the rule that practicing physicians carry stereotyped views of medical directors as paper pushers, care deniers, and little more than claims processors. Every medical director can cite dozens of incidents when network doctors or their former colleagues in practice accuse them of having gone over to the dark side.”

Arlen Collins, MD, president and chief science officer at Remedia, a company that addresses problems of overuse and misuse of medications, has worked as a medical director at US HealthCare and also — as a chief medical officer — turned around several ailing health plans. He cites competing interests. “I was on a call the other day with some folks at a major national health plan and they invoked the lawyers at least six times as an impediment when discussing what everyone on the call agreed would be a real positive move for the plan and its members. Increasingly there are regulatory compliance issues that impede progress that drive many medical directors nuts.”

He never experienced burnout, he says; his US Healthcare experience was constantly exciting and with the turnarounds, he was too busy trying to fix companies. “These plans were in such extremis that no one bothered me and I was able to do what needed to be done.”

Marla Tobin, MD, a recently retired senior medical director at Aetna, thinks that burnout is rampant in the medical director community, especially among boomers.

Marla Tobin, MD, a recently retired senior medical director at Aetna, says that “physician burnout in the medical community is rampant — especially in the boomers.” (See “Burnout Rooted in the System.”)

The medical director community sees burnout, too, “and it often involves two main issues — task work and travel. Especially with the utilization review work and completing tasks in the queue, often physicians get into a production mode and have little personal contact or job satisfaction, as their feedback loop is often negative.” In addition, she says, the peer-to-peer interaction involved in denials can get nasty.

Leibowitz contends that peer-to-peer review, where denials for coverage are examined and sometimes challenged, runs much more smoothly if the treating doctor or a specialty expert discusses the case with the medical director. “At Health Advocate we arrange these frequently to help our members. It is not common that the discussion between a treating physician and the plan’s medical director gets confrontational, but as I am sure one can appreciate, that can happen.”

Though the focus in this article is on medical director burnout, medical directors need to be able to spot it in their subordinates as well. Then it’s time to have a talk, says DeLong.

“One thing I do is to say to a subordinate [showing signs of burnout], ‘Number one, what’s the desired outcome? Number two, how will you know when you’ve achieved success? Number three, if you were to throw a celebration in five years, what would you celebrate? How many people are you helping along the way other than just yourself?’”

Can be managed

DeLong says that there is hope, though it might be hard-earned. “I have seen 35-year-olds, 45-year-olds, and 55-year-olds make dramatic changes in managing this need for achievement and this overdrive. But you must manage it every day. This is not a problem that you fix and then do not think about.”

More to burn out over

Medical directors once again find themselves in the position of gatekeeper, as techniques used and nearly abandoned in the 1990s in the managed care backlash make a comeback. Abbie Leibowitz, MD, says they include limited networks, step therapy, and prior authorization.

“That is an added burden and source of stress for medical directors,” says Leibowitz, a former chief medical officer at Aetna and currently executive vice president and chief medical officer at a consumer advocacy company called Health Advocate. “They are on the front lines of setting these [systems] in place and then managing through the confrontations and issues that inevitably result.”

Increase in claims

The American Medical Association’s 2012 National Insurer Report Card (http://tinyurl.com/Claims-Study) shows a 23 percent increase in the number claims that require prior authorization — something that we featured in last month’s Compensation Monitor department (http://tinyurl.com/Prior-auth).

A study by Athenahealth, a vendor that sells EHR and care coordination technology and services, shows that while the number of prior-authorization requests has gone up in recent years, the percentage of denials has gone down.

More haggling, more stress

Source: Athenahealth

How to spot it

Philip R. Muskin, MD, defines burnout as a special type of job stress. “It might be described as a state of physical, emotional, or mental exhaustion combined with doubts about the person’s competence and/or the value of the person’s work,” says Muskin, professor of clinical psychiatry at Columbia University and a distinguished life fellow of the American Psychiatric Association.

Dragging

Signs include feeling cynical or critical while at work, feeling that you have to drag yourself to work, becoming irritable or impatient with others, and becoming disillusioned with the job.

The main symptoms of burnout, says Marjorie Schulman, MD, a former medical director, are negativity and cynicism, often directed at the bureaucracy of one’s own company. “In the case of medical directors who perform medical management, it is also easy to become very jaded and angry at the network physicians who are supposed to be one’s peers. This is often because physicians can be extraordinarily rude and dismissive to medical directors when they are contacted.”

Intense depression could be a sign that burnout either caused, or is caused by, the psychiatric disorder, says Philip R. Muskin, MD.

“Some people may notice a drop in their productivity or experience little satisfaction from realistic achievements,” says Muskin. “Changes in sleep or appetite or new and/or unexplained physical symptoms such as headaches, backaches, or general aches and pains might occur. When the person notices he or she is using alcohol, food, prescription drugs, or illicit drugs to feel better or to create a sensation of not feeling at all, that is a serious warning sign that something is wrong and that intervention is necessary.”

A classic sign of burnout is overreaction — to almost everything. “When something happens, you take it very personally,” says Thomas J. DeLong, PhD, the Philip J. Stomberg professor of management practice at Harvard Business School. “There’s a spillover effect in your private life where you find yourself being more curt and more judgmental, and you listen less. You find fault in others faster. You can’t self-monitor.”

Successful people are usually smart and welcome an overloaded agenda, says DeLong. “You define yourself on what you’ve accomplished, not on what kind of person you are. You define yourself based on how many things you cross off your to-do list.”

Certain professions are predisposed to have such people in them, says DeLong; surgeons, professional athletes, and investment bankers for instance. The person knows something isn’t right.

Less fun

“The fun is less,” says Muskin. “Don’t sweat the small stuff? Suddenly the small stuff looms much larger. There’s a change in your behavior — inability to control your irritation with somebody. If you never had road rage, now you have road rage. You notice changes in yourself but not changes for the better. You notice that the creative stuff that got you where you are isn’t functioning the way it should be.”

What to do about it

Richard Rosen, MD, believes in the restorative power of sabbaticals. Rosen is retired and does some consulting work for the National Committee for Quality Assurance. In 1975, he began working for Rhode Island Group Health, which in the mid-1980s was bought by Harvard Pilgrim Health Care and became Harvard Pilgrim Health Care of New England.

Change of pace

“We created a sabbatical system at Harvard Pilgrim Health Care of New England,” says Rosen. “Several physicians took advantage of the opportunity to have a change of pace and to take advantage of educational and travel opportunities.”

Harvard Pilgrim Health Care of New England closed its doors in 1999, but the Harvard Vanguard Medical Group that contracts with today’s Harvard Pilgrim Health Care still offers sabbaticals for physicians, says Rosen. “I know that many large groups have sabbatical plans, especially those that are part of academic university hospital medical centers. This allows for academic expansion, research, and development of publications. For many of us, it helps to prevent burnout.”

Rosen recalls a trip to Russia with a group from Jewish Hospital of Louisville to be part of a medical exchange team for the Good Will Games in St. Petersburg. “We spent 10 days between Moscow and St. Petersburg, touring a bit and meeting with medical staffs at various facilities,” says Rosen.

Energized

The next ten days “my wife and I went to Scandinavia, where I had a day tour of the Karolinska Institute, and we traveled all over Finland and Lapland, Sweden, and Norway in a bit of adventure and vacation. When we returned home, I spent the next three weeks doing intensive medical quality reviews for NCQA.”

Thomas J. DeLong, PhD, the Philip J. Stomberg professor of management practice at Harvard Business School, says the change of pace need not be as extreme as a sabbatical. “Here’s what helps: Stop and reflect. Make sacred time — an hour or two hours or three hours during the week where there are no PDAs, no telephones. Where you are having conversations with the most meaningful people in your life.

“That is not happening for most people, but if they were to do that, it would make a huge difference.

“Make sacred time — an hour or two hours or three hours during the week where there are no PDAs, no telephones. Where you are having conversations with the most meaningful people in your life.”

“Take 10 minutes every day and write down five things that you are grateful for. It slows you down so that you can reflect. That is the first stage in individual change.”

DeLong describes this as stopping the hamster wheel. “The trap is that one of the ways that high-achieving personalities try to solve the problem is to get busier and busier. That is a way to distract. It sets them up for some real problems later.”

Take a break

Philip R. Muskin, MD, agrees that taking time for yourself is crucial. “No lunch at the desk,” says Muskin, professor of clinical psychiatry at Columbia University and a distinguished life fellow of the American Psychiatric Association. “Take a walk, go to the gym, listen to music. Learn a deep breathing or relaxation exercise to do during the day a few times.”

Burnout rooted in the system

Burnout comes with the territory not only for medical directors, but for physicians as well, according to a study that made headlines last month. Published in the Archives of Internal Medicine, “Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population,” states that nearly half of doctors suffer from burnout. Burnout is not a recognized psychological disorder but, as the study’s main author Tait D. Shanafelt, MD, points out, its ICD-10 code describes it as “Problems related to life-management difficulty.” (It’s an experience not a disorder.) Burnout among nearly 7,000 doctors is measured using the Maslach Burnout Inventory, a 22-item questionnaire. Authors describe it as “a syndrome characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment.”

Burnout rates

The study looks at various specialties, finding substantial differences in burnout rates. “Emergency medicine, general internal medicine, neurology, and family medicine had the highest rates of burnout, whereas pathology, dermatology, general pediatrics, and preventive medicine (including occupational health and environmental medicine) had the lowest rates.”

One of the concluding points: “The fact that almost 1 in 2 U.S. physicians has symptoms of burnout implies that the origins of this problem are rooted in the environment and care delivery system rather in the personal characteristics of a few susceptible individuals.”

That’s something many medical directors can probably agree with.

Burnout by specialty

Source: “Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population,” Archives of Internal Medicine, Aug. 20, 2012

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