Potential Association Between Physician Burnout Rates and Operating Margins: Specialty-Specific Analysis

We wish to thank Richard J. Vincent and Lisa L. Goodrich for data contributions. We also wish to thank Mr. Alan B. Howard for helping in data analysis.

Between 2011 and 2014, physicians across all specialties reported higher rates of dissatisfaction with their professional careers, and the burnout rates for physicians continue to rise.(1,2) According to Shanafelt et al.,(1) physicians surveyed with the Maslach Burnout Inventory also reported lower satisfaction with work-life balance over the last few years.(1) Although these findings were consistent across all specialties, physicians in historically lucrative specialties such as radiology, dermatology, and urology reported proportionally higher burnout than in other specialties. This may be explained, in part, by changes in healthcare management techniques for specialties viewed as financial opportunities for healthcare networks and hospitals to balance costs.

The healthcare system recently has been facing a growing patient burden and constraints on financial reimbursement.(3) This has required hospital systems to improve efficiency metrics,(3) and physicians are now subject to close administrative management of their daily practices.(4) This loss of autonomy is one of several factors linked to increasing burnout and decreasing career satisfaction among physicians.(5) Not only do healthcare administrators direct the quantity of patients to see and the time allocated for physicians to see each patient, but they also negotiate reimbursement rates, pay salaries, and manage departmental finances. Self-insured hospitals and healthcare networks may now view different operating margins among specialties as an opportunity to shift costs.(4) As a result, factors that contribute to physician burnout, such as loss of autonomy, may be asymmetrically distributed among specialties that operate with fundamental financial differences. Under the management of administrators, economists, and consultants who seek opportunities to balance healthcare costs, physicians in specialties with higher revenue streams may be more vulnerable to burnout.

Different categorization systems can be used to provide the basis for analysis of the relationship between financial metrics and physician burnout in each specialty, as well as the underlying constructs that may contribute to these potentially differing relationships. Given the extent of management techniques utilized in healthcare systems, we hypothesized that specialties could be categorized by burnout rates and financial metrics.

Methods

In this study, we sorted specialties into four categories based on burnout rates for U.S. physicians and operating margins at the University of Vermont Medical Center (UVMMC) as shown in Table 1. These four categories were:

• High burnout and high operating margin;

• High burnout and low operating margin;

• Low burnout and high operating margin; and

• Low burnout and low operating margin.

Physician specialties were examined for both burnout rates and operating margin, the latter being a measure of profitable revenue generated from patient care services and operations in each specialty.(5) Data on burnout rates for each specialty were obtained from national surveys on physician burnout rates in 2011 and 2014 (previously reported by Shanafelt et al.(1,2) using the Maslach Burnout Inventory). The annual operating margins for each specialty at UVMMC were obtained from similar years, 2012 to 2015, inclusively. Only physician specialties with data available on both burnout and operating margin were included in analysis, for a total of 20 physician specialties (Figure 1). Thereafter, other specialties were eliminated from further analysis. The physician groups examined included 541 providers from the University of Vermont Medical Group, compared with 5747 (2011) and 5545 (2014) physicians represented in the studies by Shanafelt et al. UVMMC is an academic, nonprofit tertiary care center in Burlington, Vermont. It is a 562-bed facility that serves patients in Vermont and Northern New York as part of a five-hospital network.

Figure 1. Algorithm of specialties included in analysis. CT, cardiothoracic; OB/GYN, obstetrics/gynecology; PMR, physical medicine and rehabilitation; UVMMC, University of Vermont Medical Center.

Each physician specialty was ranked ordinally according to operating margin and burnout rate from all years considered. All raw financial data were subsequently eliminated, and ordinal ranks were used for further analysis. Each of the 20 physician specialties was compared across U.S. physician burnout ranking and UVMMC operating margin. Burnout ranking for each specialty from 2011 was compared with operating margin ranking from 2011 and 2012, and burnout ranking for each specialty from 2014 was compared with operating margin ranking from 2012 to 2015, for a total of six analyses of each specialty. For the purposes of categorization, a ranking of 1 to 10 was considered a high ranking, and a ranking of 11 to 20 was considered a low ranking. For each of the six analyses, the specialties were partitioned into one of four categories based on high or low ranking: high burnout and high operating margin; high burnout and low operating margin; low burnout and low operating margin; or low burnout and high operating margin (Table 1). The total number of times a physician specialty fell into each category for the six analyses was constructed into a frequency histogram (Figure 2).

Figure 2. Frequency of specialties in four categories of burnout rank and operating margin rank. IM, internal medicine; PMR, physical medicine and rehabilitation.

Results

Seven specialties fell into the category of high operating margin and high burnout rank in more than half of the six analyses: radiology, dermatology, otolaryngology, emergency medicine, family medicine, anesthesia, and neurology (Figure 2). Physical medicine and rehabilitation was categorized by high burnout and low operating margin rank in every analysis conducted, whereas other specialties appeared in this category in less than half of the six analyses. Radiation oncology fell into the category of low burnout and high operating margin rank in every analysis conducted. Pediatric subspecialty and pathology also appeared in this category in more than half the analyses. Finally, six specialties fell into the category of low burnout and low operating margin in more than half the analyses: obstetrics and gynecology, internal medicine subspecialty, neurosurgery, psychiatry, general surgery, and general surgery subspecialty.

Discussion

We found that many specialties can be consistently categorized by physician burnout and operating margin ranking. For example, specialties such as radiology, dermatology, otolaryngology, emergency medicine, family medicine, anesthesia, and neurology were consistently ranked high among both burnout and operating margin. In contrast, although radiation oncology consistently demonstrated a high operating margin ranking, it was categorized with a low burnout ranking across all our analyses. Finally, although some specialties such as physical medicine and rehabilitation demonstrated a distinct operating margin/burnout ranking pattern, other specialties had more variable operating margin/burnout ranking profiles across analyses (Figure 2). These categorical differences warrant further consideration of the underlying factors that may be related to differing burnout rates among specialties with different financial frameworks.

Against the backdrop of decreasing healthcare reimbursements, questionable technological advancements, and increasing compliance demands, the increasing rates of burnout and career dissatisfaction scores reported by physicians seem understandable. These trends are alarming because U.S. physicians are outpacing their counterparts in a relatively stable market economy.(1) Recently, Ariely and Lanier(6) pointed to three main factors that contribute to increasing burnout and decreasing satisfaction among physicians: asymmetrical rewards, cognitive scarcity, and loss of autonomy. The asymmetric cost of making a mistake wears on physicians, who hence “spend more time and mental energy fearing the consequences of making mistakes.”(6) Physicians must continually make decisions, each with the potential for far-reaching consequences. The act of repeatedly weighing opportunity costs of these mentally taxing decisions results in cognitive scarcity and leads to emotional and physical exhaustion.(6) Finally, physicians’ loss of autonomy may be attributed to a management style whereby physicians are directed regarding the quantity of patients to see, the time to spend per session, and which procedures to perform. Many physicians today are experiencing a reversal of the “social transformation” that occurred during the 20th century.(7)

This analysis is notable on two fronts. First, healthcare has undergone a tremendous amount of consolidation over the past two decades, and networks have evolved under the banner of population health. However, the underlying financial infrastructure for many healthcare systems is the same fee-for-service model that has been present since the 1950s.(7) Consolidation limits the potential revenue streams for hospitals and their physician-provider base. For example, the management strategy of shifting healthcare costs from low- to high-reimbursement plans becomes less tenable with fewer choices.

Second, many hospitals and healthcare networks are self-insured, and hospitals may now view different operating margins among specialties as an opportunity to shift costs.(4) As a result, specialties with different revenue streams may report different rates of burnout. Again, healthcare administrators negotiate reimbursement rates, pay salaries, and, ultimately, manage the bottom line for many departments via a faculty practice group compensation plan. More physicians probably have become affected by these managerial techniques in recent years, due to the decline of independent practices and the increase of multigroup practices and hospital-employed physicians.(8,9) Therefore, in addition to the three factors pointed out by Ariely and Larner,(6) operational changes under financial frameworks also may contribute to physician burnout in certain specialties. This study demonstrates categorical trends in burnout data and operating margins for several specialties across multiple years. The analysis inherently calls for further exploration of a specialty-specific relationship between physician burnout and financial metrics. The mechanistic components of these relationships may prove invaluable in minimizing provider burnout, and ultimately optimizing patient care in the context of healthcare’s changing financial framework.

Finally, both controllable lifestyle and financial metrics such as physician compensation are variables historically identified by medical students as affecting their career choices.(10,11) For example, specialties known as the R.O.A.D. specialties (i.e., radiology, ophthalmology, anesthesiology, and dermatology) have been perceived by students to have the most favorable lifestyle. Consistent with the financial benchmarks of this study, these specialties are also some of the highest compensated specialties over the last decade.(12-14) With regard to these specialties, burnout rates in anesthesia have remained higher than average, while burnout rates in dermatology and radiology have actually increased.(1,2) Furthermore, other specialties reporting high burnout, such as family medicine, have faced drastic financial reconstruction as a result of the Affordable Care Act of 2010.(15) Primary care practitioners have demonstrated not only an increase in workload, but also an increase in practice revenues.(16) When viewed through the scope of financial frameworks, changes in burnout rates have the potential to influence medical students’ career decisions.

Our study does have several limitations. First, the studies by Shanafelt et al.(1,2) did not include financial metrics. Thus, we were unable to directly compare national financial data, and the financial data at this institution may not reflect those across all U.S. medical institutions. Second, several specialties were not included in the initial analysis, because we were unable to obtain data on both operating margin and physician burnout for all specialties. Although it would be valuable to calculate the relationship between financial data and burnout for physician specialties in the four categories examined, there are too few specialties to perform corollary statistical measurements by category. This remains an important topic for investigation for future studies. Third, rank levels were described as exclusively high or low. It is possible that some specialties may be better described in an intermediate rank category; however, there were too few specialties to include this category in the rank structure. In addition, our analysis simplifies the finances of a subspecialty to its operating margins. There are many revenue streams for any department, and this analysis does not pretend to account for different funding mechanisms or costs (e.g., capacity subsidies, medical education payments, infrastructure costs for offices and staff).

Changes in burnout rates have the potential to influence medical students’ career decisions.

Finally, although Shanafelt et al.(1,2) extracted their data on physician burnout scores from 2011 and 2014, we analyzed for a correlation to operating margins at this institution between 2012 and 2015. Although factors contributing to physician burnout are fluid, it is possible that burnout data from 2012, 2013, and 2015 may be more accurately compared with financial data from these years. However, this information was not available for analysis. To counteract this argument, we show that the proportion of specialties represented at this institution and in the national survey are positively correlated, r(20) =.861, p <.0001, 95% CI (0.667, 0.943); r (20) = .807, p <.0001, 95% CI (0.567, 0.920), respectively.

In summary, a previous editorial by Ariely and Lanier(6) emphasized that management techniques may actually prevent physicians from pursuing their profession to its original intent. This concept of progress-limiting administrative regulation applies not only to the growth of one’s career, but also to the advancement of humanistic medicine. Our analysis provides hospital administrators, medical students, and physicians a basis for understanding the importance of a potential association between financial frameworks (e.g., institutional revenue streams, capacity payments, and nonclinical expenses) and physician career satisfaction and burnout, and, more importantly, expands the discussion centered on building a better healthcare delivery system.(16)

References

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