Many primary-care physicians are close to burnout in caring for patients in pain


As the opioid crisis take a deadly toll in human lives, the complex needs of patients in chronic pain are also leaving their doctors increasingly exhausted and overwhelmed, a new Western-led study says.

In their detailed interviews and clinic observations, researchers found many primary-care physicians are close to burnout in caring for patients in pain.

“You are in between a rock and a hard place with this stuff,” one doctor said in describing the quandary of prescribing opioids appropriately.

“You are a compassionate individual who doesn’t want to leave your patients in pain (but) you’re also aware that if you continue down this road you run the risk of killing your patient.

What an awful dilemma to be in.”

Other doctors said the crisis is teaching them to be suspicious of patients seeking opioids – leading some to perceive their pain-relief-seeking patients as either addicts or potential addicts.

The peer-reviewed study, An ethnography of chronic pain management in primary care:

The social organization of physicians’ work in the midst of the opioid crisis, is newly published in the open-access journal PLOS One.

Researchers had designed their questions to learn more about physicians’ workload in caring for patients with complex chronic conditions, explained Health Sciences professor Fiona Webster, lead author and a medical sociobiologist.

But the consistent responses about the stress of dealing with pain relief and opiates were unexpected.

“That came up in the process, in real time. We weren’t expecting the kind of findings we received,” Webster said.

Researchers conducted hour-long interviews with more than 60 physicians (most of them family doctors) from urban, rural and Northern Ontario and took in more than 40 hours of observation, with patient and doctor consent.

They heard repeatedly of doctors’ emotional exhaustion, loss of job satisfaction, burnout and, at the extreme end of the continuum, depersonalization of the patient.

For some doctors, “policing and adjudicating the legitimacy of patients’ requests for pain medication” were troubling enough to keep them awake at night, the study said.

Many worried they were doing patients a disservice if they didn’t prescribe opiates for pain; they worried they’d cause more harm if they did prescribe the highly addictive medication; and they worried some patients were seeking opioids to feed an existing addiction.

The doctors’ stories are startling examples of the complexity of the issue, from a side of the examining table that’s usually overlooked.

Several doctors said they felt overwhelmed at their inability to solve a host of patients’ other issues – homelessness, mental illness and poverty – in addition to the pressing medical reasons for a visit.

One doctor outlined the case of a patient who had experienced childhood trauma, was mentally ill and suffered painful, recurrent infections after a leg amputation but who couldn’t leave his apartment for appointments because it had stairs.

“That’s an example of me putting hours and hours into helping a client who has lots of other medical issues going on, and I would love to be able to focus on that, but because he doesn’t have housing that’s appropriate, that’s taking over the forefront of my energy,” the doctor said.

The study also points to the fact there are few alternative therapies that are affordable to patients, Webster said.

“(Doctors) are trained to help people with their medical problems but so much of health is driven by social and economic factors.

The study also emphasizes the inequities of care, even unintentional ones.

Repeated studies show physiotherapy and massage therapy can help heal injury and reduce chronic pain, for example.

But people in poverty often can’t afford the cost, or lack jobs with benefits to cover the expense.

“Physicians are being left to offer alternative therapies that they know a significant portion of their patients can’t afford,” Webster said.

And so medication, often in escalating doses, becomes the only other option.

“Physicians are being left to offer alternative therapies that they know a significant portion of their patients can’t afford,” Webster said.

“We would argue that this represents a medicalization of poverty that diverts attention and resources from social services and education and toward clinical treatment where physicians are poorly situated to manage the situation”

She emphasized doctors are doing the best they can but often don’t have the resources they need.

“The provision of stronger supports, rather than potential sanction (against over-prescribing), would offer much needed assistance to those physicians dealing with the crisis of growing inequity on the front lines,” the study says.

But she believed there are solutions, even if they are difficult ones.

“Clearly in medical education, there needs to be, and in some cases there is, an effort to include more information about social inequities in health.”

Health -care reform is also needed so that services such as massage therapy, physiotherapy and counselling are available free of charge to low-income-earners.

It’s crucial that public policy and public attitudes towards opioid addiction evolve, she said.

“We need to understand the opioid crisis as a public health issue, not just a medical issue. It has become a significant problem of life and death.”

Physician burnout has been a significant area of concern and investigation for decades.

A broad body of literature addresses both the causes of physician burnout and potential interventions to prevent or alleviate it.

In addition, this issue has been covered in popular media.3

The literature shows that there is a high risk of physician burnout in the United States.

A broad-based study that assessed U.S. physicians using the Maslach Burnout Inventory (MBI) showed that 54.4% of all physicians combined reported experiencing at least one symptom of burnout.

The same study found a 63% burnout rate among U.S. family physicians.

Further, the study found that only 35% of family physicians report being satisfied with their work-life balance. These striking findings bear out across medical specialties, career phases, and demographics.5

Definition of Burnout
The following is a classic definition of burnout:

  • “[Job burnout is] a psychological syndrome in response to chronic interpersonal stressors on the job. The three key dimensions of this response are an overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment.”6

Common Drivers of Burnout
The importance of identifying and addressing the root causes of physician burnout cannot be overemphasized. Despite much research, definitive data on causes of physician burnout still may not exist.

Studies indicate that common drivers of family physician burnout include the following: paperwork; feeling undervalued; frustrations with referral networks; difficult patients; medicolegal issues; and challenges in finding work-life balance.

These factors have varying impact at different stages of a physician’s career.

Inability to resolve work-life conflict has the greatest impact on physicians early in their careers.

Long hours, frequent call, frustration with administrative burden, and reimbursement issues strongly affect physicians in the middle of their careers.

In 2013, the American Medical Association (AMA) commissioned a study by the Rand Corporation to identify high-priority determinants of physician professional satisfaction.

The authors reported that two important factors influencing professional satisfaction are the use of electronic health records (EHRs) and physicians’ perceptions of their ability to provide high-quality care.

Other factors that affect physician professional satisfaction include the following:

  • Autonomy and work control
  • Practice leadership
  • Collegiality, fairness, and respect
  • Work quantity and pace
  • Regulatory and professional liability concerns
  • Work content, allied health professionals, and support staff

Effects of Burnout
Understanding of how physician burnout directly affects patient health outcomes continues to increase.

Research shows that symptoms of physician burnout can be connected with increased rates of medical errors, riskier prescribing patterns, and lower patient adherence to chronic disease management plans.

Middle-career physicians report long hours and frequent call, resulting in greater burnout and dissatisfaction among these physicians compared with physicians in other career stages; middle-career physicians are also more likely to leave clinical practice.

This is a notable concern because the middle of a physician’s career typically is the most productive phase in terms of providing patient care, serving as a leader and mentor, and assuming important administrative roles.

The fact that burnout causes some physicians to leave practice early may explain why reported levels of satisfaction are highest among older physicians.

Data from recent annual Medscape physician burnout studies reveal an increasing gender gap in rates of burnout.

Across all specialties, the burnout rate among female physicians (55%) is 10% greater than the burnout rate of their male peers (45%).

The reasons for this disparity are unclear and may require additional study.

The U.S. health care system needs physicians to lead the transition to new methods of health care delivery and to sustain effective participation.

However, the fact that more than half of U.S. physicians experience symptoms of burnout could compromise their ability to be effective in leading and sustaining change.

Reducing physician burnout is critical to achieving the goals of redesigning the health care system and improving the health of patients, families, and communities in the United States.

More information: Fiona Webster et al. An ethnography of chronic pain management in primary care: The social organization of physicians’ work in the midst of the opioid crisis, PLOS ONE (2019). DOI: 10.1371/journal.pone.0215148
Journal information: PLoS ONE
Provided by University of Western Ontario


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