healthy4u: burnout

Guest Post: Incompetent Management Breeds Demoralized Physicians

<span style="color: blue;"><i>Health Care Renewal presents a guest post by <a href="http://imh.utmb.edu/about-us/faculty/howard-brody">Dr Howard Brody,</a> John P McGovern Centennial Chair of Family Medicine, Director of the  Institute for Medical Humanities at University of Texas - Medical Branch  at Galveston, and blogger at <a href="http://brodyhooked.blogspot.com/">Hooked: Ethics, Medicine and Pharma</a>. </i></span><br /><br /><span style="font-family: inherit;"><span style="font-size: small;">Danielle Ofri, a prominent internist/author at Bellevue in New   York, started a recent <a href="http://danielleofri.com/an-epidemic-of-disillusioned-doctors/">op-ed</a> piece, “Last week I was ready to quit medicine."</span></span><br /><br /> <br /><div class="MsoNormal"><span style="font-family: inherit;">She described an encounter most physicians can relate to—a 15-minute appointment slot, a new patient who spoke only Bengali, a long and complicated problem list, a bag containing 18 different medicines, two forms that had to be filled out by the doctor on this day’s visit, and a computer that froze while she was trying to keep up with the electronic charting. She described how, 45 minutes into the supposedly 15-minute visit, she had a phone in one ear with the Bengali translator and tech support on hold in the other ear.</span></div><div class="MsoNormal"><span style="font-family: inherit;"><br /></span></div><div class="MsoNormal"><span style="font-family: inherit;">Ofri’s plaint caught my attention because I had recently put up a <a href="http://hcrenewal.blogspot.com/2013/05/guest-post-physician-rebels-against.html">guest post on Health Care Renewal</a> about another highly skilled, caring physician who was seriously considering quitting practice. <span style="font-size: small;">This led me to write a <a href="http://www.utmb.edu/newsroom/article8763.aspx">column</a> for some of our local newspapers about demoralized doctors</span></span></div><div class="MsoNormal"><span style="font-family: inherit;"></span></div><span style="font-family: inherit;"><br /></span><div class="MsoNormal"> </div><div class="MsoNormal"><span style="font-family: inherit;">In the space allowed in an op-ed column, you can’t go into great depth in analyzing a complicated situation. So here’s what I would have wanted to say.</span></div><div class="MsoNormal"><span style="font-family: inherit;"><br /></span></div><div class="MsoNormal"><span style="font-family: inherit;">We can list all the management failures that this encounter represents. I won’t even start with the electronic record as that’s such a frequent theme in this blog. Who scheduled such a patient for a 15-minute visit? Where is the pharmacist who could have done a better job of going through all the lady’s medicines? Where is the staffer who could have filled out the forms for Dr. Ofri to sign? This is just to scratch the surface.</span></div><div class="MsoNormal"><span style="font-family: inherit;"><br /></span></div><div class="MsoNormal"><span style="font-family: inherit;">There are two things worrisome about this long list of management failures. If the goal of the health care system is actually to take good care of patients, then it seems obvious that Dr. Ofri, who wanted to try to provide high-quality care, had roadblock after roadblock thrown in her way.</span></div><div class="MsoNormal"><span style="font-family: inherit;"><br /></span></div><div class="MsoNormal"><span style="font-family: inherit;">Cynics will protest that this system obviously has no interest in quality patient care and seeks only to maximize revenue. If that’s so, is it really true that a board-certified MD is the most efficient labor source for keyboarding data into a computer, filling out paper forms, and doing all the other busy-work tasks that Dr. Ofri had to juggle? Can anyone really believe that this management structure supports <i style="mso-bidi-font-style: normal;">either</i> quality care <i style="mso-bidi-font-style: normal;">or</i>efficient resource use?</span></div><div class="MsoNormal"><span style="font-family: inherit;"><br /></span></div><span style="font-family: inherit;"><span style="font-size: small;"> If the management of U.S. hospitals was severely understaffed or underpaid, then we could perhaps forgive such lapses. But we know that while the growth of physicians in the U.S. has been slow, the number of administrators has grown by leaps and bounds [The number of health care managers increased by 726% from 1983-2000 while physician numbers increased by 39%, look <a href="http://hcrenewal.blogspot.com/2005/04/growing-proliferation-of-managers.html">here</a> - Ed]  . And we know that at least at the high end, these managers are paid <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">munificent sums</a>, and are lauded for their supposed genius (look <a href="http://hcrenewal.blogspot.com/2013/06/no-blues-but-lots-of-green-for-st-louis.html">here</a> for example). </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><br /> <br /><div class="MsoNormal"><span style="font-family: inherit;">So we appear to have a system that is slowly (in some cases rapidly) driving the best doctors out of practice, and yet somehow imagines that everything is going all right and there’s no problem—or if there’s a problem, it’s those whining doctors.</span></div><div class="MsoNormal"><span style="font-family: inherit;"><br /></span></div><div class="MsoNormal"><span style="font-family: inherit;">All us medical educators know that when we ask the first-year class how may of them have been told by practicing physicians that they’re making a big mistake coming to medical school, the majority will raise their hands. Yet the managers of America’s health systems apparently believe that they can go on demoralizing good practitioners and nothing bad will happen.</span></div><div class="MsoNormal"><span style="font-family: inherit;"><br /></span></div><div class="MsoNormal"><span style="font-family: inherit;">This may sound as if I am saying that health care managers are all evil people, but that’s an unfair characterization. These folks are simply trying to do what our society tells them. As I <a href="http://hcrenewal.blogspot.com/2012/03/golden-calf-explains-how-economism-lead.html">explained</a> some time ago,<span style="font-size: small;"> most of our popular and political discourse has been captured by a belief system that can be variously called neoliberalism, market fundamentalism, or <a href="http://hcrenewal.blogspot.com/search/label/economism">economism</a>. The ideology can be summarized as a quasi-religious faith in the so-called “free market,” steadfast opposition to government regulation of the market, and opposition to just about any form of taxes (for more on the nature of economism, look <a href="http://theeconomismscam.blogspot.com/2012/09/economism-primer.html">here</a>.)</span></span></div><div class="MsoNormal"><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"></span></div><div class="MsoNormal"></div><div class="MsoNormal"> </div><div class="MsoNormal"><br /><span style="font-family: inherit;">Among other things, this ideology teaches us that everything important in our society can be accurately captured in objective measures of “productivity” and “efficiency.”  [This is akin to the "shareholder value" theory of management (look <a href="http://hcrenewal.blogspot.com/2012/04/health-care-dysfunction-explained-by.html">here</a>), or "<a href="http://hcrenewal.blogspot.com/search/label/financialization">financialization</a>." - Ed]  Once one has mastered the basic concepts taught in MBA school, there’s no need to learn anything about health care and what makes it a unique activity; there’s no basic difference between providing health care and flipping burgers at McDonalds or making widgets. [We have called this <a href="http://hcrenewal.blogspot.com/search/label/generic%20management">generic management</a>. - Ed.]. And so we get the crazy style of management well documented on this blog, not because of personal nastiness or ill will, but due to the ideological Kool-Aid everyone has been drinking for several decades now. </span></div><div class="MsoNormal"><span style="font-family: inherit;"><br /></span></div><div style="margin-bottom: .0001pt; margin: 0in;"><span style="font-family: inherit;">Today’s physicians seem to be like the proverbial frog being boiled in the pot of water because the heat was turned up so gradually the frog never figured out it needed to jump. [That is, they are suffering from "<a href="http://hcrenewal.blogspot.com/search/label/learned%20helplessness">learned helplessness</a>." - Ed] Dr. Ofri herself seems to represent a typical frog. Why? Perhaps it’s the style of the blog or op-ed writer to start off with a downer and then try to end on an upbeat note. Or perhaps it’s the natural physician’s tendency to stay away from policy questions. I’m not sure.</span></div><div style="margin-bottom: .0001pt; margin: 0in;"><span style="font-family: inherit;"><br /></span></div><div style="margin-bottom: .0001pt; margin: 0in;"><span style="font-family: inherit;">After starting us off with this hard-hitting description of a dysfunctional system, Dr. Ofri ends by opining that things are going to be better in the future because more women are entering medicine and because today’s medical students are more tech savvy. She gives herself credit for managing to forge a bond with the patient because they sat together and faced this adversity. She cites an upbeat study, <b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;">“</i></b><i style="mso-bidi-font-style: normal;">when asked what was the most satisfying aspect of medical practice, the number one answer was relationships with patients. This is what keeps us going on even the most trying of days.”</i></span></div><div style="margin-bottom: .0001pt; margin: 0in;"><span style="font-family: inherit;"><br /></span></div><span style="font-family: inherit;"><span style="font-size: small;">Dr. Ofri gets full credit for remembering the importance of relationships, and feels that she bonded more firmly with her patient because they went through all this together. How about a word, though, about the people behind the curtain, who are responsible for all that she and her patient had to go through, and who don’t seem to have a clue how bad it is and what it all means? </span></span><br /><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: inherit;"><span style="font-size: small;">Dr Howard Brody </span></span></div><br />

Guest Post: Incompetent Management Breeds Demoralized Physicians

Health Care Renewal presents a guest post by Dr Howard Brody, John P McGovern Centennial Chair of Family Medicine, Director of the Institu...

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Health Care Academics' Unrest and Bad Health Care Leadership?

Last month we <a href="http://hcrenewal.blogspot.com/2012/08/will-another-study-on-physician-burnout.html">discussed</a> a recent, large scale study of physician burnout, and wondered whether it would finally inspire some discourse about why physicians are really so upset.  In particular, we hypothesized,  based on some real, if limited data, that physician angst, dissatisfaction, burnout, etc may mainly be a response to the problems with leadership and governance of health care organization we post about on <a href="http://hcrenewal.blogspot.com/">Health Care Renewal.</a><br /><br />After that post, one of our scouts found a very interesting and relevant article from earlier this year which got little attention at the time, but deserves more.  [Pololi LH, Krupat E, Civian JT, Ash AS, Brennan RT.  Why are a quarter of faculty considering leaving academic medicine? A study of their perceptions of institutional culture and intentions to leave at 26 representative U.S. medical schools.  Acad Med. 2012; 87: 859-69. Link <a href="http://www.ncbi.nlm.nih.gov/pubmed/22622213">here</a>.]<br /><br /><b>Study Design</b><br /><br />This was a cross-sectional survey of faculty at 26 medical schools in the US, selected to be similar to the general population of medical schools in the country.  At each school, 150 faculty were randomly chosen stratified by sex and age, and then the sample was enriched to include additional minority faculty and women surgeons, for a total of 4578.<br /><br />The faculty were sent a multi item survey to assess their perception of the organizational culture of their institutions, and asked about their intentions to continue in or leave their current positions and academic medicine.  Responses to each survey item were allowed to be from 1 = strongly disagree, to 5 = strongly agree.  The items on the survey were combined into various scales.  A number of items on the survey seemed to be related to issues we frequently discuss on Health Care Renewal.  These items ended up in three different scales, entitled Relatedness/Inclusion, Values Alignment, and Ethical/Moral Distress.  The survey items are listed below, grouped by issue, with the scales into which they were combined noted.<br /><br />Issue: <a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management">Mission-Hostile Leadership</a><br /><br />Administration only interested in me for revenue   (Reverse coded) (Values Alignment)<br />Institution committed to serving the public (VA)<br />Institution's actions well-aligned with stated values and mission (VA)<br />Institution puts own needs ahead of educational/clinical missions (RC) (VA)<br />My values well-aligned with school's (VA)<br />Institution awards excellence in clinical care (VA)<br />Institution does not value teaching (RC) (VA)<br />Have to compromise values to work here (Ethical/Moral Distress)<br /><br />Issue: <a href="http://hcrenewal.blogspot.com/search/label/deception">Deceptive</a>, Unethical Leadership<br /><br />Felt pressure to behave unethically (Ethical/Moral Distress)<br />Need to be deceitful in order to succeed (EMD)<br />Others have taken credit for my work (EMD)<br /><br />Issue: Generation of the <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">Anechoic Effect</a> by  Suppression of <a href="http://hcrenewal.blogspot.com/search/label/free%20speech">Free Speech</a>, <a href="http://hcrenewal.blogspot.com/search/label/academic%20freedom">Academic Freedom</a>, Dissent, <a href="http://hcrenewal.blogspot.com/search/label/whistle-blowers">Whistle-Blowing,</a><br /><br />Feel ignored/ invisible (RC) (Relatedness/Inclusion)<br />Hide what I think and feel (RC) (R/I)<br />Reluctant to express opinion/ fear negative consequences (RC) (R/I)<br /><br />So in summary, the survey contained quite a few questions about mission-hostile management, comprising nearly all of the Values Alignment scale, some questions about deceptive or unethical leadership, all in the Ethical/Moral Distress scale, and some about generation of the anechoic effect by suppression of free speech, academic freedom, dissent, and whistle-blowing, all in the Relatedness/Inclusion scale.<br /><br /><b>Results</b><br /><br />The response rate was 52% (N=2381.)<br /><br />Unfortunately, the article did not include the distributions of the responses to individual survey items, and only included the mean and standard error of the scale scores.  The values for the scales of most interest were:<br />Relatedness/Inclusion  3.56 SE= 0.022<br />Values Alignment  3.25 SE=0.028<br />Ethical/Moral Distress 2.36 SE=0.022<br /><br />Note that the article did not address the degree individual items, especially those listed above, contributed to variation in the scale scores. <br /><br /><br />A small majority of faculty indicated their intentions to stay at their institutions (57%).  Of the remainder, 14% were considering leaving their school due to dissatisfaction, and another 21% were considering leaving academic medicine due to dissatisfaction.  The remainder were considering leaving due to personal/ family reasons or to retire.<br /><br />The authors did complex multinomial logit modeling to assess the relationships among the various scales, demographic factors, and intention to leave.  Most relevant to us, Relatedness/Inclusion was significantly related to intention to leave the institution due to dissatisfaction (Coefficient -0.69, p lt 0.001, OR =0.50), as was Values Alignment (-0.39, p=0.04, OR=0.68), but not Ethical/ Moral Distress.  Furthermore, Relatedness/Inclusion was related to intention to leave academic medicine due to dissatisfaction (-0.48, p lt 0.001, 0.62), as was Ethical/Moral Distress (0.60, p lt 0.001, OR =1.82). The article did not address whether individual survey items, including those of  most interest listed above, were related to intention to leave.  The article also did not address whether responses to the survey or intention to leave varied across faculty characteristics, medical school characteristics, or individual medical schools.  <br /><br /><b>Summary and Comments</b><br /><br />This very large survey of faculty from multiple US medical schools showed that more than one-third were considering leaving their institutions or academic medicine due to dissatisfaction, indicating a striking prevalence of faculty distress.  Their responses to questions about perceived organizational cultural and leadership problems, including those possibly related to leadership's perceived hostility to the mission, leadership's perceived dishonesty or unethical behavior, and leadership's suppression of dissent, free speech, academic freedom, and whistle-blowing were related to their intentions to leave due to dissatisfaction.<br /><br />These results suggest the hypothesis that much of faculty angst may be due to the sorts of problems with leadership and hence organizational culture that we discuss on Health Care Renewal.  Since this was a cross-sectional survey, it certainly does not offer scientific proof of this hypothesis.  Note that there is other evidence from numerous cases discussed in Health Care Renewal, qualitative studies and our much smaller study published only in abstract form that also supports this hypothesis (look <a href="http://hcrenewal.blogspot.com/2012/08/will-another-study-on-physician-burnout.html">here</a>).  <br /><br />One part of the author's discussion of their findings was particularly relevant:<br /><br /><br /><blockquote class="tr_bq">Our findings are congruent with metaanalyses of 25 years of organizational justice research outside medicine. These studies suggest that employee perceptions of organizational justice and an ethical climate are related to increased job satisfaction, trust in leadership, enhanced performance, commitment to one’s employer, and reduced turnover.<br /><br /> The scale of ethical/moral distress (see Table 1) reflects<i> reactions to the prevailing norms and possible erosion of professionalism and increased organizational self-interest</i>. There is a growing belief that organizations influence and are responsible for the ethical or unethical behaviors of their employees.To our knowledge, faculty perceptions of 'moral atmosphere' and 'just community' embedded in our survey have not been previously investigated in academic medicine, even though the ethical concepts of professionalism and justice can be used to guide the pursuit of excellence in the missions of medical schools. Several scholars have called for academic medicine to attend to its social justice and moral mission. Faculty perceptions<br />of organizational justice are pivotal to the critical issue of professionalism in medicine. The ethical/moral distress scale in the survey reported here included items such as 'the culture of my institution discourages altruism' and 'I find working here to be dehumanizing.' (See Table 1 for other items in this scale.) In that ethical/moral distress was more strongly related to intent to leave academic medicine entirely than intent to leave one’s own institution, these negative feelings among faculty must be particularly disheartening to them and may color major career decisions.</blockquote>I believe that the study by Pololi et al adds to the evidence that physician distress is a symptom of a dysfunctional system in which major health care organizations have been taken over by leaders more devoted to self-interest and short-term revenue than the values prized by health care professionals and academics.  This applies obviously to academic medical institutions, but also to other organizations that might have been expected to defend such professional and academic values, such as professional associations, accrediting organizations, and health care foundations.  As we <a href="http://hcrenewal.blogspot.com/2012/08/will-another-study-on-physician-burnout.html">said before</a>, if physicians really want to address what is making them burned out and  dissatisfied, they will have to regain control of their own societies,  organizations, and academic institutions, and ensure that these  organizations put core values, not revenue generation and providing  cushy compensation to their executives, first.   <br /><br />

Health Care Academics' Unrest and Bad Health Care Leadership?

Last month we discussed a recent, large scale study of physician burnout, and wondered whether it would finally inspire some discourse abou...

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Will Another Study on Physician Burnout Finally Lead to Addressing its Causes?

The latest article on physician burnout has actually attracted some media attention.  e.g., <a href="http://www.usatoday.com/money/industries/health/story/2012-08-20/physician-burnout/57173110/1">here</a> and <a href="http://www.bloomberg.com/news/2012-08-20/about-half-of-doctors-say-they-re-burned-out-by-workload.html">here</a>.<br /><br /><strong>The Latest Article</strong><br /><br />The article was a survey of physicians in all specialties with over 7000 respondents (unfortunately a less than 27% response rate.)(1)  Its most notable findings were:<br />- The rate of burnout among physicians was <em><strong>45.4%</strong></em><br />-  Physician specialties with higher than average rates were emergency medicine, general internal medicine, neurology, and family medicine.<br />- The proportion of physicians who may have been depressed, (using the Primary Care Evaluation of Mental Disorders screening instrument,) was <em><strong>37.8%</strong></em><br /><br />So almost half of all physicians, and more than half of the front-line physicians who treat adults appear to be burned out, while more than one-third of physicians may be clinically depressed.  So it is not surprising that the authors called the rate of burnout "alarming."  <br /><br />They also commented on the implications of their data,<br /><blockquote>Unfortunately, little evidence exists about how to address this problem. Although extensive literature suggests that contributors include excessive workload, loss of autonomy, inefficiency due to excessive administrative burdens, a decline in the sense of meaning that physicians derive from work, and difficulty integrating personal and professional life, few interventions have been tested. <em>Most of the available literature focuses on individual interventions centered on stress reduction training rather than organizational interventions designed to address the system factors that result in high burnout rates. </em></blockquote><strong>Previous Studies of Burnout and Dissatisfaction</strong><br /><br />This study, in fact, is just the latest in a long series of studies showing physicians' growing angst, dissatisfaction, burnout, or whatever one calls it. In 1987, in an AMA survey of physicians over 40, 44% replied that were they given chances to do it all over again, they would not go into medicine.(2)  In a 2001 survey of Massachusetts physicians, 62.3% were dissatisfied with the practice environment.(3)  In 2002, a national survey by the Kaiser Family Foundation showed that 45% of physicians would not recommend that a young person should go into medicine.(4)   In a survey of primary care physicians in 2007, 38.7% were somewhat or very dissatisfied.(5)  I have a 6 inch thick set of paper files containing articles on the subject, although it is remarkable how many research studies reported only average scores on instruments, and hence did not report proportions of physicians who were burned out or dissatisfied. <br /><br /><strong>The Causes of Dissatisfaction and Burnout</strong><br /><br />What is most remarkable about this voluminous literature is its relative lack of attention to the external forces and influences on physicians that are likely to be producing burnout, and the general aversion to promoting any interventions that could conceivably affect these external threats. Instead, burnout etc has been addressed as if it were some sort of psychiatric disease of physicians. This was noted above by Shanafelt et al. <br /><br />In fact, the reason that we did the crude qualitative literature that lead to my articles on health care dysfunction (6), and to the establishment of <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a> was a general perception that physician angst was worsening (in the first few years of the 21st century), and that no one was seriously addressing its causes.<br /><br />Our first crude research suggested that physicians' angst was due to perceived threats to their core values, and that these threats arose from the issues this blog discusses: concentration and abuse of power, bad governance and leadership of health care organizations, and the rise of various dishonest and unethical practices that affect physicians. We have found hundreds of cases and anecdotes supporting this viewpoint.<br /><br />There is some corroboration of these assertions.  Some written comments from the 2001 Massachusetts survey made similar points about the causes of dissatisfaction, for example: "too much emphasis on the bottom line.  Taken over by large corporations.  Quality of care and interaction now subsumed by productivity and profit," and "the once most noble profession has become a factory job with a facade of ethics"(3)  Pololi and colleagues' qualitative interviews of young medical faculty included anecdotes of angst due to academic leaders who put revenues ahead of patient care, teaching, and research; and who allegedly used deception for personal gain.(7)  (Also, see our comments on this paper)(8)  Pololi and colleagues' large survey of US medical faculty showed that over half thought that managers were only interested in them because of the money they brought in.(9)   We were able to show in a preliminary analysis of data from a physician survey that an instrument meant to measure physicians' perception of the integrity of the leadership of their organizations, which incorporated questions about whether leaders supported core values, put patient care ahead of revenue, supported transparency about quality issues, put patient care ahead of self-interest, and displayed honesty strongly correlated (negatively) with stress, intention to leave the practice, and burnout.(10) <br /><br />Yet at best studies of physicians' burnout, angst, or dissatisfaction only vaguely allude to "system factors" and not greedy, money-focused, self-interested, or corrupt leadership, etc at its causes.  And again as noted above, most interventions meant to improve burnout have treated it like a psychiatric illness, not a rational response to a badly lead, dysfunctional health care system.<br /><br /><strong>Why Has Nothing Changed?</strong><br /><br />The real question is why so little has changed given this now 20 plus year history of the documentation of burnout, and why there has been such avoidance of what appears to be the real causes of the problem. One question worth raising again at this time is why the organizations one might think would be interested in helping physicians address causes of burnout have not done so.<br /><br />One might think that medical societies, foundations interested in improving health and health care, bodies that accredit physicians, and academic medicine in general would all be interested in addressing the causes of physician burnout, dissatisfaction, and angst.  However, I am aware of no significant action on their part.  (There have bee some some marginal actions by the smallest of these organizations, e.g., the Society of General Internal Medicine's call to "chuck the RUC," see this <a href="http://hcrenewal.blogspot.com/2009/08/sgim-urges-chuck-ruc.html">post</a>)<br /><br />We should not be surprised, since most of these organizations have become more creatures of health care corporations than noble proponents of physicians' core values.  Most of these organizations have substantial institutional conflicts of interest, and are often lead by individuals with their own individual conflicts of interest.    <br /><br />Medical societies, in particular, now often get significant financial support from industry (pharmaceutical, biotechnology, medical device and even health insurance companies).  The societies' leaders are often full-time executives, not necessarily physicians, who may look to their industry sponsors to continue to provide the funds that support nice salaries and luxurious offices.  The society's officers and boards are often dominated by physicians with their own conflicts of interest.  (Look <a href="http://hcrenewal.blogspot.com/search/label/medical%20societies">here</a> for more examples, and see, in particular, <a href="http://hcrenewal.blogspot.com/2007/11/aaos-patient-discussion-guide-regarding.html">the case of the AAOS</a>).<br /><br />Similar conflicts may affect accrediting organizations, <a href="http://hcrenewal.blogspot.com/search/label/health%20care%20foundations">health care foundations</a>, and especially academic medical institutions, as we have profusely discussed.  (Look at our posts on <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">conflicts of interest</a>, and <a href="http://hcrenewal.blogspot.com/search/label/institutional%20conflicts%20of%20interest">institutional conflicts of interest</a>.)<br /><br />So if physicians really want to address what is making them burned out and dissatisfied, they will have to regain control of their own societies, organizations, and academic institutions, and ensure that these organizations put core values, not revenue generation and providing cushy compensation to their executives, first.   <br /><br /><strong><span style="font-size: x-small;">References</span></strong><br /><br /><span style="font-size: x-small;">1.  Shanafelt TD, Boone S, Tan et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population.  Arch Intern Med 2012; available online </span><a href="http://archinte.jamanetwork.com/article.aspx?articleid=1351351"><span style="font-size: x-small;">here</span></a><span style="font-size: x-small;">.</span><br /><span style="font-size: x-small;">2.    cited in Schroeder SA. The troubled profession: is medicine's glass half full or half empty? Ann Intern Med 1992; 116:583-592. </span><br /><span style="font-size: x-small;">3. Massachusetts Medical Society. Physician satisfaction survey (2001). Link </span><a href="http://www.massmed.org/AM/PrinterTemplate.cfm?Section=Home6&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=2504"><span style="font-size: x-small;">here</span></a><span style="font-size: x-small;">.</span><br /><span style="font-size: x-small;">4.  Kaiser Family Foundation. National survey of physicians - part III: doctors' opinions about their profession.  Link </span><a href="http://www.kff.org/kaiserpolls/upload/Highlights-and-Chart-Pack-2.pdf"><span style="font-size: x-small;">here</span></a><span style="font-size: x-small;">.</span><br /><span style="font-size: x-small;">5.  Merritt Hawkins & Associates. 2007 survey of primary care physicians.  Link </span><a href="http://www.merritthawkins.com/pdf/2007_survey_primarycare.pdf"><span style="font-size: x-small;">here</span></a><span style="font-size: x-small;">.</span><br /><span style="font-size: x-small;">6. Poses MD. A cautionary tale: the dysfunction of American health care.  Eur J Int Med 2003; 14: 123-130.  Link </span><a href="http://www.ejinme.com/article/S0953-6205%2803%2900029-3/abstract"><span style="font-size: x-small;">here</span></a><span style="font-size: x-small;">.</span><br /><span style="font-size: x-small;">7.Pololi L, Kern DE, Carr P, et al. The culture of academic medicine: faculty perceptions of the lack of alignment between individual and institutional values. J Gen Intern Med 2009; 24: 1289-95. Link </span><a href="http://www.med.upenn.edu/focus/user_documents/CultureofAcademicMedicine_Pololijgim.pdf"><span style="font-size: x-small;">here.</span></a><br /><span style="font-size: x-small;">8.  Poses RM, Smith WR. Faculty values. J Gen Intern Med 2010; 25: 646. Link </span><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2881965/"><span style="font-size: x-small;">here</span></a><span style="font-size: x-small;">. </span><br /><span style="font-size: x-small;">9. Pololi L, Ash A, Krupat E. Faculty values in the culture of academic medicine: findings of a national faculty survey. Link </span><a href="https://www.aamc.org/download/154216/data/your_career_is_more_than_your_specialty_-_246.pdf"><span style="font-size: x-small;">here</span></a><span style="font-size: x-small;">.</span><br /><span style="font-size: x-small;">10.  Poses RM, Baier-Manwell L, Mundt M, Linzer M. Perceived leadership integrity and physicians’ stress, burnout, and intention to leave practice. J Gen Intern Med 2005; 20: S182.  Link </span><a href="http://onlinelibrary.wiley.com/doi/10.1111/jgi.2005.20.issue-S1/issuetoc"><span style="font-size: x-small;">here</span></a><span style="font-size: x-small;">.</span>

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