The World Health Organization added “burnout” as an International Classification of Diseases code in 2019 and recognized it as an occupational hazard. Further defined, burnout is a psychological syndrome triggered by chronic interpersonal stressors at work, which may lead to overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness.(1) These symptoms are not just associated with a toxic occupation, however, burnout can result from relentless stress caused by any aspect of one’s social, behavioral, and physical health.
The U.S. healthcare system has the highest costs but the worst outcomes compared to other developed countries. According to a report from the Commonwealth Fund comparing OECD nations, the United States has the lowest life expectancy, highest rate of avoidable deaths, highest rate of infant and maternal mortality, and the highest percentage of adults suffering from chronic conditions.(2)
Patients with chronic healthcare needs endure prolonged stress. The stress of disease management, interactions with the chaotic healthcare system, health inequity, and dissatisfaction with outcomes are factors that can lead to patient burnout. In a 2023 Gallup poll, 64% of the respondents rated their overall confidence in the American health system as “some” or “very little.”(3)
An ineffective healthcare system leads to patient stress, and ultimately patients suffer exhaustion, cynicism, and disengagement — symptoms of burnout. Disengaged patients, with depleted motivation to advocate for their health, have poor outcomes. Healthcare-associated burnout is a reality and it is perpetuating the poor health of the nation.
Last year, TIME magazine published “Long Waits, Short Appointments, Huge Bills: U.S. Health Care is Causing Patient Burnout.”(4) The article highlighted issues such as primary care accessibility and navigating health insurance coverage as causes of inadequate patient experience and disillusionment. However, even after establishing access to care, patients experience another major stress posed by the healthcare system: “unwarranted variations in healthcare care delivery.”
Variation in Healthcare Delivery
Not every person who receives healthcare gets a consistent experience or the same outcome — it has less to do with the patient’s needs or health conditions, and more to do with availability and effectiveness of care ultimately delivered. Decades of research have demonstrated that utilization and quality of care is highly variable across regions and not driven by population characteristics, thus considered unwarranted.(5)
The late John Wennberg, founder and director emeritus of the Dartmouth Institute for Health Policy and Clinical Practice, dedicated his research to understanding the impact of unwarranted variation in healthcare delivery. He described three main drivers of variation: 1) care that is not evidenced-based; 2) care that is dependent on supply and availability; and 3) care that is not guided by patient preferences, values, and understanding.(6)
1. Care that is not evidenced-based. Evidence-based guidelines have supported the intensification of diabetic therapy at regular intervals for uncontrolled patients, however in one study, therapeutic inertia by clinicians is present in up to 50% of patients.(7)
A patient suffering from the complications of uncontrolled diabetes is a poignant example of an individual under chronic and exhaustive stress. Similarly, ineffective treatment approach applies to other chronic conditions like congestive heart failure; the Heart Failure Adherence and Retention Trial (HART) revealed that only 63% of physicians prescribed evidence-based medications that were adherent to clinical practice guidelines.(8)
The translation of clinical knowledge to delivery is essential and requires continuous training of healthcare professionals and elimination of system-oriented barriers that prevent patient-facing delivery of evidence-based science. Patients receiving subpar treatment will feel defeated by their disease, lose trust in their care team, and display poor compliance.
2. Care that is dependent on supply and availability. Healthcare that is dependent on supply is illustrated by the rate of diabetes-specific ED visits, which increased by 51% between 2008 and 2017.(9) There is natural reliance on the supply and profitability of acute care, while investment in and access to primary care remains a challenge.
The hospital is an unfavorable setting for the management of preventable chronic conditions and burnout is inevitable for patients trapped in the revolving door of the hospital. The United States benefits from the best medical technology and innovation in the world, but the availability of these resources and fee-for-service tendency creates overutilization of low-value diagnostics and interventions.
The U.S. Preventive Services Task Force has proclaimed there is insufficient data to assess the balance of benefits and harms of screening mammography in women 75 or older. In a retrospective study of Medicare beneficiaries, women 75 to 84, who were subject to screening mammography, approximately 47% of breast cancer cases were potentially over-diagnosed.(10)
Over-diagnosis describes the discovery of low-risk, clinically silent cancer that will not have significant impact on a patient’s life span. Over-diagnosis can promote patient stress and anxiety and lead to unnecessary follow up tests and procedures. Complications of over-diagnosis can leave an individual vulnerable to burnout from the abundance of accessible, yet ineffective and even harmful care.
3. Care that is not guided by patient preferences, values, and understanding. Care delivery that fails to account for a patient’s understanding and preferences causes loss of patient autonomy, poor patient satisfaction, and misguided utilization of care. When patients do not feel in control of their health or do not feel empowered to make the most informed decisions for themselves, disillusionment and burnout are inevitable.
Transparent, timely, and patient-centered conversations about desires for aggressive or emergent interventions, for example, have shown that patients with serious illness have higher likelihood of electing hospice and avoiding interventions like chemotherapy toward the end of life.(11) When patients receive enhanced coaching and support for treatment decisions, they tend to have reduced overall care costs, lower rate of hospitalizations, and fewer elective surgeries.(12)
Patients who partner with their providers and advocate for their needs will inherently have better outcomes, feel more satisfied, and have more trust in their care process.
Battling Patient Burnout
The prevalence of burnout in the patient community is palpable. The U.S. healthcare system is disappointing the population on many fronts compared to other developed countries and the failure points are intertwined with the drivers of unwarranted care delivery. The hope of improvement will rely on scaling evidence-based medicine, curbing overutilization of low value resources, and upholding patient choice and autonomy.
References
Maslach C, Leiter MP. Understanding the Burnout Experience: Recent Research and Its Implications for Psychiatry. World Psychiatry. 2016 Jun;15(2):103–111. https://doi.org/10.1002/wps.20311
U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes. The Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022#:~:text=Despite%20high%20U.S.%20spending%2C%20Americans,dropped%20even%20further%20in%202021 .
Confidence in Institutions. Gallup. https://news.gallup.com/poll/1597/confidence-institutions.aspx .
Ducharme J. Long Waits, Short Appointments, Huge Bills: U.S. Health Care Is Causing Patient Burnout. TIME. February 27, 2023. https://time.com/6257775/patient-burnout-health-care .
Sutherland K, Levesque JF. Unwarranted Clinical Variation in Health Care: Definitions and Proposal of an Analytic Framework. J Eval Clin Pract. 2020 Jun;26(3):687–696. https://doi.org/10.1111/jep.13181
Wennberg JE. Unwarranted Variations in Healthcare Delivery: Implications for Academic Medical Centres. BMJ. 2002 Oct 26;325(7370):961–964. https://doi.org/10.1136/bmj.325.7370.961
Rattelman CR, Ciemins EL, Stempniewicz N, Mocarski M, Ganguly R, Cuddeback JK. A Retrospective Analysis of Therapeutic Inertia in Type 2 Diabetes Management Across a Diverse Population of Health Care Organizations in the USA. Diabetes Ther. 2021 Feb;12(2):581–594. https://doi.org/10.1007/s13300-020-00993-w
Calvin JE, Shanbhag S, Avery E, Kane J, Richardson D, Powell L. Adherence to Evidence-based Guidelines for Heart Failure in Physicians and Their Patients: Lessons from the Heart Failure Adherence Retention Trial (HART). Congest Heart Fail. 2012 Mar-Apr;18(2):73–78. https://doi.org/10.1111/j.1751-7133.2011.00263.x
Uppal TS, Chehal PK, Fernandes G, Haw JS, Shah M, Turbow S, Rajpathak S, Narayan KMV, Ali MK. Trends and Variations in Emergency Department Use Associated With Diabetes in the US by Sociodemographic Factors, 2008–2017. JAMA Netw Open. 2022 May 2;5(5):e2213867. https://doi.org/10.1001/jamanetworkopen.2022.13867
Ryser MD, Lange J, Inoue LYT, O’Meara ES, Gard C, et al. Estimation of Breast Cancer Overdiagnosis in a U.S. Breast Screening Cohort. Ann Intern Med. 2022 Apr;175(4):471–478. https://doi.org/10.7326/M21-3577
Starr LT, Ulrich CM, Corey KL, Meghani SH. Associations Among End-of-Life Discussions, Health-Care Utilization, and Costs in Persons With Advanced Cancer: A Systematic Review. Am J Hosp Palliat Care. 2019 Oct;36(10):913–926. https://doi.org/10.1177/1049909119848148
Veroff D, Marr A, Wennberg DE. Enhanced Support for Shared Decision Making Reduced Costs of Care for Patients with Preference-sensitive Conditions. Health Aff (Millwood). 2013 Feb;32(2):285–293. https://doi.org/10.1377/hlthaff.2011.0941