March 13, 2018

Physician Burnout Simmering Below the Surface

“Ebony and ivory live together in perfect harmony 
Side by side on my piano keyboard, oh Lord, why don't we?”
— Sir Paul McCartney and Stevie Wonder, 1982


Left alone in a small examining room, I scrolled the Associated Press news app on my cell phone, waiting for my physician to arrive. It was the last day of Black History Month, with little more than 12 hours remaining before it became another chapter in the long history of America recognizing the accomplishments of African-Americans.

My appointment, scheduled at the last minute, would not involve my primary care physician, an engaging and cheerful young woman of Indian descent who is part of the health system’s residency program. Once, when I asked her about experiencing any signs of burnout, she told me that she was not, but that all of her colleagues seem to monitor one another for it. According to media reports, burnout is an epidemic among U.S. physicians, and appears to contribute to between 300 and 400 suicides each year: a doctor a day.

There was knock on the door and in a hurried rustle of papers, my physician arrived. She was black.

She was energetic and animated. We exchanged perfunctory greetings and she mentioned that she was a mother to two teenagers. When she asked me what I did for a living, I told her and also mentioned that the day before, on Talk Ten Tuesdays, we had as a special guest: Crystal Watkins, MD, PhD, director of the Memory Clinic at Sheppard Pratt Health System and assistant professor of psychiatry and behavioral at Johns Hopkins University School of Medicine. During the broadcast, Dr. Watkins related her experiences as a young African-American growing up in Baltimore.

This tribute to the accomplishments of Dr. Watkins, as I told my physician, was in recognition of Black History Month. At that point, she promptly showed me her petite black, red, and green Black History month ribbon, tucked behind her white coat. Her mother was an English teacher, she explained, and her father was a mathematician and worked for IBM.

When I mentioned “ICD10monitor,” she shuddered, and the tenor of the conversation changed dramatically.

“I hate to code,” she told me, pointing to the monitor on her computer. “And then they’ll come and say, ‘this isn’t the right code,’ and I’ll say, ‘OK.‘ I don’t let it bother me.”

When I asked her about burnout, she became even more somber, explaining mounting pressures of the job and then, almost offhandedly, making a passing reference to a recent suicide, assuming I was aware of the incident. I was not. When I mentioned my primary care physician and how the residency program tended to watch for signs of burnout among young physicians, that was not the case, she said, in her situation.

Unprompted, she continued discussing the intricacies of being black in an all-white community, insisting that her teenage son not pull his hoodie over his head under any circumstances, for example. She was also alarmed by the presence of swastikas in her upscale neighborhood. She also referenced post-traumatic stress syndrome (PTSD) and wrote on a paper towel the name of a local African-American physician, Rodney Hood, MD, who evidently has linked PTSD to slavery.

It seemed for a moment that I was the therapist and she the patient.

Moments later, she looked at my chart and dispensed a logical diagnosis and a succinct plan of care.

Our brief engagement ended, far too soon.

Because burnout has been a recurring subject on both ICD10monitor and Talk Ten Tuesdays, I described my experience with H. Steven Moffic, MD, the nationally renowned psychiatrist who shared his perspective on the topic. What follows are highlights of that interview.

  1. Buck: Given the historical challenges black Americans face growing up in this country, I would assume that the path to become a physician must be extremely daunting.

Dr. Moffic: It sure has been, and is, Chuck. That can relate to the challenges of successfully navigating our educational systems, which vary in quality, as well as the remaining conscious and unconscious racial bias in our healthcare systems. The percentage of black Americans entering medical school is still less than their percentage of our population.


  1. Buck: What are the most recent statistics about physician burnout and the alarming rate of physician suicide?

Dr. Moffic: According to the American Foundation for Suicide Prevention, physicians have higher rates of burnout, depressive symptoms, and suicide risk than the general population. As you said, an estimated 300-400 physicians die by suicide annually, though due to underreporting, that figure is likely higher, maybe twice as high.
As to burnout, that seems to be becoming epidemic, at 50 percent or higher in many medical specialties. Of note is that black American physicians seem to have a slightly decreased rate of burnout compared to other minority groups and to white physicians.
Burnout, depression, and suicide have also been escalating in medical students and their residency training following medical school. You mentioned the promising program your own resident physician is involved with; that is so important, because it seems that currently, about 28 percent of physicians in residency training, that time before you go out to practice on your own, experience major depressive episodes. This rate is four times that of similar age groups in the general population.
  1. Buck: In describing her experience as a black American, my physician seemed rather resilient and stoic. Can you explain that reaction?

Dr. Moffic: What an excellent observation about her likely being resilient, Chuck! Given the micro- and macro-traumas that so many black Americans go through, they often have to develop even more resilience than the high degree that most all physicians have to obtain. After all, among other challenges, most physicians have to rebound from patients who don’t get better or die, working long hours, and the demands of always learning new information. Seeming stoic can be the external expression of that resilience, appearing that nothing much will faze you, which can be reassuring to patients. Developing such post-traumatic strength has many benefits, but it can also make one less attuned to one’s burning out, at the same time.


  1. Buck: When she mentioned the black American physician who suggests a link between PTSD and slavery, is that a causal connection?

Dr. Moffic: I hope I can do this idea justice, Chuck. That is a really complicated question, for which I can only provide some speculative answers from my own knowledge and career focus on cultural psychiatry. First of all, as we just discussed, there is still implicit (and explicit) bias in American society against black Americans. That can result in experiencing various levels of trauma, and a certain degree of trauma is what leads to PTSD.
By most accounts, Black Americans who can trace their history to slavery tend to accomplish somewhat less than Black Americans who have come more recently from the West Indies. Why might that be?
We have some sense that trauma can be transmitted across generations, whether that stems from slavery long ago or from the Holocaust of Nazi Germany in World War II. That transmission can make the children of each traumatized generation more anxious.
That transmission can come via two different paths, socially and/or genetically. Socially, parents who have some degree of traumatic repercussions can convey some undue fears to their children. In my part time work in a medium security prison for men, I found that there was an extraordinary amount of undiagnosed PTSD in the Black Americans. Reviewing their criminal records revealed a family and community exposed to everyday trauma. Fortunately, in my hometown of Milwaukee, Marquette University has just announced the “President’s Grand Challenge” to collect proposals for reducing the trauma in the surrounding community. In the same day of that announcement, Oprah Winfrey said that the story of trauma in Milwaukee was “the reason I came to 60 Minutes. I’ve done a lot of stories in my lifetime, but I think this is the key.” The key she is referring to is to reduce the trauma in the chaotic environments that has caused so many social and economic problems in certain environments, whether in Milwaukee or South Africa.
Genetically, we now know that changes in genes before child-bearing time can be transmitted to children. This is termed epigenetics. In this process, real life trauma can alter the glucocorticoid receptor gene, which is then passed on in the child’s biological inheritance, leading to more production of the “stress” hormone, cortisol.
  1. Buck: Are there early warning or telltale signs of burnout that coders and clinical documentation integrity specialists could detect in their working relationships with physicians? If so, what are they?


Dr. Moffic:  Well, if they could only follow your example, Chuck. However, if they don’t have your experience and curiosity, there are still some usual telltale signs of burnout. Those include increased frustration in their work, especially with the coding demands that your physician conveyed to you. Such burning-out physicians tend to be more brusque, less caring, and make more mistakes, many of which coders need to try to correct. These are actually warning signs that patients can see in their own physicians.


  1. Buck: Finally, what is the link between burnout and PTSD?


Dr. Moffic: We are continuing to explore this possible link, Chuck. While most tend to think that burnout is somehow connected to depression, it actually may be more connected to PTSD, or at least sub-clinical, less severe PTSD. Why do we need to consider that possibility? Many physicians who write about their own burnout describe being subject to thousands upon thousands daily micro-traumas in their attempt to do all that they can for patients. They feel dis-empowered. Then, at least one research study indicates brain changes in those burned out that seem similar to the brain changes of traumatized children.
If anything, Chuck, it is trauma that connects the experience of black Americans and black American physicians with the epidemic of burnout in physicians. That at least allows us to have a clear target for intervention to reduce the trauma and its consequences – which, if successful, will have rippling benefits for the health and mental health of our society.


Thank you, Dr. Moffic.

About H. Steven Moffic, MD

H. Steven Moffic, MD, is an award-winning author whose fifth book, “The Ethical Way: Challenges & Solutions for Managed Behavioral Health,” is considered a seminal study on healthcare ethics. Always in demand as a writer, Dr. Moffic has attracted a national audience with his three blogs: Psychiatry Times, Behavior Healthcare, and Over 65. Dr. Moffic, who is also a popular guest on Talk-Ten-Tuesdays, received the Administrative Psychiatry Award from the American Psychiatric Association (APA) and the American Association of Psychiatrist Administrators (AAPA).

Specifically related to the topics of this interview, Dr. Moffic is a member of the new Workgroup on Psychiatrist and Physician Wellness and Burnout of the American Psychiatric Association, and will be a co-editor of a new book on psychiatrist burnout. He also received the one-time Hero of Public Psychiatry award from the American Psychiatric Association. Just recently, he was told that his name will be added to the Wall of Tolerance as part of the Civil Rights Memorial in Montgomery, Ala. for his career work in addressing intolerance and hate.

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Chuck Buck

Chuck Buck is the publisher of ICD10monitor and is the executive producer and program host of Talk Ten Tuesdays.

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