Pediatrician Burnout: Similar, yet Different

The first clue came as I walked into the office just before noon, ready to start my afternoon and evening of scheduled patient time. One of the nurses said, "We're out of appointments for the evening."

Translation: "At best, I have no cushion for extending an existing appointment. At worst, I'll need to consider double booking."

The next clue was discovered as I reviewed my schedule. My patients for that day were light on the medical needs, heavier on the social/mental health challenges.

Translation: "The 15 minutes (900 seconds) allotted for each appointment just ain't gonna be enough."

The final clue came as I paged through my pile of papers on my desk and saw more than a few letters of medical necessity that needed to be written, two of them with ASAP post-it notes stuck to them.

Translation: "And when I have finished seeing my patients for the afternoon and evening and documenting in the chart, I still have some writing to do."

The notion of physician burnout is not new. I recall having heard about it as a medical student, but given my unbridled enthusiasm for all things medicine, I dismissed it as an outlier concept. Indeed, in 1994, when I was a medical student, a scholarly article^[1] published on the topic cited "emotional exhaustion" as affecting 58% of physicians and called on organizations to address structural reform and changes in policies to mitigate this alarming trend. Apparently, that professional call to action went largely unheeded, because 14 years later, we have a classic case of what once was old is new again.

The lay press, in the meantime, is replete with articles on the topic, eloquently written by practicing physicians who are familiar with both the noble calling that is medicine as well as the bureaucratic/administrative/professional challenges that contribute to physician burnout. A 2008 article in the New York Times described burnout among medical students. (Where had all of that enthusiasm gone?)

In 2012, a blog reported on the results of a study in which nearly 50% of seasoned physicians reported symptoms of burnout, loosely defined as a "particular constellation of emotional exhaustion, detachment and a low sense of accomplishment." The highest rates were noted to be among the ranks of front-line physicians, such as internists, family practitioners, and those in the emergency department.

Pediatrics is also a front-line specialty, and after 20 years as a primary care pediatrician, I know that some days are just going to be one of those days. Schedules book up on the basis of seasonal variation, proximity to holidays, and clinician vacations.

Separating the outlying "one of those days" from the pattern is important. And when there is a palpable shift of those days from outlier to common, it's time to look for root causes.

Fixing All the Small Places

Burnout can start in small places. Does your practice permit too many clinicians to take vacation at the same time? Could an additional clinician, either part-time or full-time, be warranted? Are schedules optimized in terms of a balance of urgent and nonurgent appointment types for the day of the week and the season? Are more complex patients, whose care necessitates additional time, flagged so that the scheduler can offer appointments of the appropriate length?

If your answers to each of these questions already confirms that you have these items addressed, consider a reevaluation of your triage/appointment-making workflow. Perhaps some of these appointments could have been addressed via phone triage and a "wait and see" approach. On the other hand, perhaps a high-quality urgent care center may be more appropriate for some clinical scenarios, particularly if such ancillary services as radiology, labs, or casts/splints are a possibility.

Taking up an appointment slot for something that could have waited is not ideal. Nor is an appointment that merely serves as a preliminary stop on the way to getting an x-ray and a boot (unless your practice has those services available). These latter tweaks will require additional education for your staff and a method of monitoring improvement.

This is the first level of evaluation for burnout: Is your practice or organization efficient in its workflows? This is the low-hanging fruit. However, efficiency will only get you so far.

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