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Medical News & Perspectives
March 30, 2022

Pushed to Their Limits, 1 in 5 Physicians Intends to Leave Practice

JAMA. 2022;327(15):1435-1437. doi:10.1001/jama.2022.5074

On the same day in March 2020 that President Donald Trump declared the COVID-19 pandemic a national emergency, researchers at the Larry A. Green Center in Virginia launched an ongoing survey of COVID-19’s effects on primary care practices. Over the past 2 years, more than 36 000 survey responses from clinicians across the country have painted an alarming picture of a workforce that’s increasingly burned out, traumatized, anxious, and depressed. As Green Center codirector Rebecca S. Etz, PhD, summed up her survey’s findings in a recent interview with JAMA, “It’s been bad for primary care over the pandemic and it’s getting worse.”

iStock.com/Armand Burger

Another national health care worker survey, the Coping With COVID study, found that burnout approached 50% in 2020 among 9266 physicians across medical disciplines. Last year’s survey results, which haven’t been published yet, are more dire still, according to study coauthor Mark Linzer, MD, a professor of medicine at the University of Minnesota whose research focuses on burnout. His takeaway: burnout has increased considerably as the pandemic has dragged on.

“It has been a very, very trying 2 years for the clinician workforce, and the health care workforce in general,” Linzer said in an interview. “Particularly over the last 6 months, I think people have really just needed to process what they’ve been through and have time to recuperate. But there really has not been time, given all the pent-up demand for care and the continuing pandemic and the Omicron surge.”

Meanwhile, Lotte Dyrbye, MD, MHPE, chief well-being officer for the University of Colorado School of Medicine, said that some physicians have had the opposite experience during the pandemic—too little work. “An important thing to realize is that how the pandemic has affected physicians is incredibly heterogeneous,” she said in an interview.

Many medical specialties saw the workload decrease in the pandemic’s first year and even during subsequent surges, when demand for non–COVID-19–related visits and elective procedures evaporated. Some practices watched their business and finances dry up.

Experts warn that the COVID-19 pandemic, now entering its third year, has pushed an already fragile workforce to the brink. For many clinicians the workplace challenges—ranging from high stress and burnout to understaffing and reduced income, often in combination—have become insurmountable.

Staffing Struggles

Worsening staffing issues are now the biggest stressor for clinicians. Health care worker shortages, especially in rural and otherwise underserved areas of the country, have reached critical and unsustainable levels, according to the National Institute for Occupational Safety and Health (NIOSH).

“The evidence shows that health workers have been leaving the workforce at an alarming rate over the past 2 years,” Thomas R. Cunningham, PhD, a senior behavioral scientist at NIOSH, wrote in a statement emailed to JAMA.

In the absence of national data, Etz says the Green Center data point to a meaningful reduction in the primary care workforce during the pandemic. In the February 2022 survey, 62% of 847 clinicians had personal knowledge of other primary care clinicians who retired early or quit during the pandemic and 29% knew of practices that had closed up shop. That’s on top of a preexisting shortage of general and family medicine physicians. “I think we have a platform that is collapsed, and we haven’t recognized it yet,” Etz said.

In fact, surveys indicate that a “great clinician resignation” lies ahead. A quarter of clinicians said they planned to leave primary care within 3 years in Etz’s February survey. The Coping With COVID study predicts a more widespread clinician exodus: in the pandemic’s first year, 23.8% of the more than 9000 physicians from various disciplines in the study and 40% of 2301 nurses planned to exit their practice in the next 2 years. (The Coping With COVID study was funded by the American Medical Association, the publisher of JAMA.)

A lesson that’s been underscored during the pandemic is that physician wellness has a lot to do with other health workers’ satisfaction. “The ‘great resignation’ is affecting a lot of our staff, who don’t feel necessarily cared for by their organizations,” Linzer said. “The staff are leaving, which leaves the physicians to do more nonphysician work. So really, in order to solve this, we need to pay attention to all of our health care workers.”

Nurses who said they intended to leave their positions within 6 months cited 3 main drivers in an American Nurses Foundation survey: work negatively affecting their health and well-being, insufficient staffing, and a lack of employer support during the pandemic.

“Health care is a team sport,” L. Casey Chosewood, MD, MPH, director of the NIOSH Office for Total Worker Health, wrote in the agency’s emailed statement. “When nurses and other support personnel are under tremendous strain or not able to perform at optimal levels, or when staffing is inadequate, the impact flows both upstream to physicians who then face a heavier workload and loss of efficiency, and downstream impacting patient care and treatment outcomes.”

The Pandemic in Primary Care

The pandemic began to take its toll on primary care clinicians early on, says Etz, who is a professor in the department of family medicine and population health at Virginia Commonwealth University. Although primary care offices typically handle the vast majority of respiratory infections in the community, they weren’t prioritized for personal protective equipment (PPE) and other crucial supplies when COVID-19 struck. “Our survey showed, going as far as 6 months into the pandemic, half the [clinicians] still didn’t have PPE,” Etz said. “People were wearing coffee filters and garbage bags to take care of their patients.”

The Green Center survey showed that primary care clinicians’ stress levels improved last summer as vaccines became widely available in the US, but the Delta variant surge reversed this. Since then, physician mental and physical exhaustion has returned to prevaccine levels.

As of this February, only about a fifth of Green Center survey respondents were fully staffed, and 44% had open clinician positions they could not fill. Still, 40% of respondents said they had taken on an influx of new patients whose previous practices closed. The pandemic also required primary care practices to provide new or expanded services—telehealth, home monitoring of patients with COVID-19, and more mental health care, to name a few.

They’ve done all this with limited resources. Throughout the public health crisis, primary care physician practices have struggled with low reimbursement for telehealth and long-overdue payments from insurers, Etz says. Applying for aid, such as Paycheck Protection Program (PPP) or Small Business Association (SBA) loans, was onerous and itself often costly. “The primary care practices that I know that were able to get money from PPP and the SBA loans that were available had to hire accountants to help them figure out how to do it,” Etz said. Unpublished data from various states and task forces suggest that less than 5% of health care sector financial assistance may have gone to primary care, she noted.Trying to do more for patients while dealing with shrinking staff and resources—all during an unprecedented infectious disease crisis—has left some clinicians traumatized. “In our qualitative comments,” Etz said of the Green Survey, “we still get people sharing suicidal ideation. Talking about panic attacks in their sleep and pulling over on their way to work to puke because they’re under so much stress.” Recent survey responses reflect the ongoing distress:

“I cannot continue to work at this pace and retire at 65. I am 50. I am chronically exhausted. There is no relief in sight.”

“I’m burned out. The patients have so much anxiety and it has affected me. I see 21 patients daily for relatively low pay. I’m on my way out of this position—I can’t remain healthy and stay here.”

“I am emotionally traumatized and experiencing severe burnout. I would quit if I was able.”

“I had planned to work for at least 10 more years, now I’m thinking about ways to retire as soon as possible.”

“I have been in practice for over 30 years and have never felt so emotionally and physically drained as I have this year. I have given up trying to correct COVID misinformation and this is so very discouraging.”

“I’ve exited practice. Pray I don’t ever need to go back. It’s miserable with no positive indicators for improvement.”

More Than Words

Etz, who trained as a cultural anthropologist, sees a troubling pattern in the responses: lack of hope. Hopelessness was also apparent in a mid-2021 survey by the nonprofit Physicians Foundation. About 20% of 2504 physicians said they knew a physician who had either considered, attempted, or died by suicide during the COVID-19 pandemic.

Today, frontline clinicians are experiencing high rates of depression, anxiety, sleep disturbance, and posttraumatic stress disorder, according to Dyrbye, who is a member of the National Academies of Medicine’s Clinician Well-being Collaborative. “Many of them are running on the very last steam,” she said. She noted that compassion fatigue, a result of high levels of work stress, has also set in for some: “They’re getting tired of taking care of patients who are incredibly sick and aren’t vaccinated.”

“There’s clearly still widespread burnout, fatigue, and frustration not only related to the earlier phases of the pandemic, but also the aftermath related to shortage of staffing,” Lou Baptista, MD, MPH, executive vice chair of the department of psychiatry at Columbia University Medical Center (CUMC), said in an interview.

As a result, some physicians are cutting their clinical hours for the first time or jumping ship to different institutions where they feel they’ll be better cared for. Baptista says that many mental health professionals at CUMC are leaving for private practice, where they can work fewer days, make more money, and practice telemedicine from the comfort of their own home.

An important mitigator of health care burnout and intention to leave, it turns out, is feeling valued by one’s organization, which Linzer says requires more from employers than simply expressing the sentiment. Dyrbye says health care organizations must undertake systemic steps to improve the work environment. That means finding ways to reduce workload, improve work efficiency, maximize teamwork, and promote a culture of wellness.

Linzer, who directs the Hennepin Healthcare Institute for Professional Worklife, offered a workload solution: if resources allow, float physicians can be hired for periodic coverage, or locum tenens clinicians could be brought in to cover shifts during critical times. “I’m hoping that our health system has learned that as we go through these crises, not unlike in the military, one needs to plan how many times you deploy someone, how long you deploy them for, when you give them a rest to put somebody else in place,” he said.

Modeling Change

Early in the pandemic, when time off wasn’t a reality for New York City’s frontline health workers, Baptista helped organize a group of CUMC psychologists and psychiatrists who began volunteering their services to other clinicians in the health system. The program, called CopeColumbia, offered 30-minute peer-to-peer telehealth support sessions, small group sessions customized for different clinical departments, and larger webinars and town halls devoted to topics like stress, trauma, and grief.

“Our thinking was, can we create these brief spaces of just half an hour to give them support,” said Baptista, who last year was named chief well-being officer at ColumbiaDoctors. About a third of the early peer-to-peer sessions led to referrals for clinical care. Over the past 24 months, CopeColumbia has expanded to become the main platform that provides well-being resources and peer support to all medical center employees, not just clinicians.

Last year, NIOSH launched a campaign to address health worker stress, burnout, depression, anxiety, substance use disorders, and suicidal behavior—long-standing problems exacerbated by the pandemic. A goal of the Health Worker Mental Health Initiative is system-wide, organizational-level improvements. The program’s research, funded by the American Rescue Plan Act, could help inform fundamental changes to health care worker shifts, workloads, benefits, time off, and more.

NIOSH’s Chosewood acknowledged the challenge ahead: “The design of work in healthcare needs an overhaul,” he wrote. “Ideally, health worker jobs are so well-designed that doctors, nurses and technicians go home at the end of a fulfilling work day even healthier than when they arrived. I don’t think that’s a pipe dream.”

Linzer agrees that changes are overdue to reduce burnout. “I think there’s a lot of ways that things could be done differently—a lot of work that could be done by others, that would give a chance for physicians to grieve, debrief, heal, and then continue again,” he said. “But the idea of just rushing to start again is, I think, not going to work.”

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Article Information

Published Online: March 30, 2022. doi:10.1001/jama.2022.5074

Conflict of Interest Disclosures: Dr Dyrbye reports being a coinventor of the Well-being Index instruments and receives a portion of any royalties paid to Mayo Clinic for use of these instruments; receiving honoraria for lectures and presentations related to health care professional and trainee well-being; serving as a paid adviser to various medical schools and health care organizations; and receiving grant support from the National Science Foundation. Dr Etz reports receiving funding for work to assess primary care capacity and response to the COVID-19 pandemic from the Andrew and Corey Morris-Singer Foundation, the Samueli Foundation, the American Board of Family Medicine Foundation, and the Agency for Healthcare Research and Quality (AHRQ) and honoraria for related presentations on her data; and serving as CEO of Smart Measures, LLC, which provides electronic ability to field patient-reported measures. Dr Linzer reports being supported through his employer, Hennepin Healthcare, for burnout reduction projects by the American Medical Association, the American College of Physicians, Optum Office for Provider Advancement, the Institute for Healthcare Improvement, the American Board of Internal Medicine, Essentia Health, and Gillette Children’s Hospital; receiving support from the National Institutes of Health and AHRQ; and consulting on a grant for Harvard University on work conditions and diagnostic accuracy. Dr Baptista, Chosewood, and Cunningham reported no disclosures.

8 Comments for this article
Personal Experience
Arvind Joshi, MBBS MD FCGP FAMS FICP | Founder Convener, Our Own Discussion Group, Mumbai, Consultant Physician.
In the first year of the Covid-19 pandemic, from 25 March 2020 to 28 February 2021, I started seeing patients via teleconsultation.

I had no difficulty handling people's calls, which kept coming in 16 hours a day, often more.

I often worked without fees, which I did not feel like asking for when people were suffering so much physical, emotional, economic hardship.

The picture became slightly different the next year. The original shock due to the completely unexpected calamity gave way to a blunted and resigned attitude.

The amount of work continued to be the same
but it was less related to CoVID-19 and more related to non-CoVID-19 Conditions.

People had become accustomed to teleconsultation but their adherence to instructions was not very rigorous.

Continued extended working hours, difficulty in motivating people to follow instructions very rigorously, extra strain in getting people to follow instructions meticulously, and certain other factors did result in lot of fatigue.

COVID and the Teenage Soul
Sarah O'Neil, MD | Private Practice, McLean; Child, Adolescent, and Adult Psychiatry
As a psychiatrist teaching at an affiliate hospital and working in private practice in March 2020 and prior, I worked 15-25 hours per week not including administrative tasks and phone calls. By the start of April 2020, though my transition to providing telehealth from home was seamless, I was working 12-18 hours per day 3-4 days a week, as my primarily high school and college age patient population became so acute. In addition to worsening of conditions I'd been treating I saw an influx of severe, new onset anxiety and mood disorders, as well as abrupt onset first episode anorexia nervosa. It was stressful. I recall being grateful for colleagues on the patient team with me, and weirdly, being very sweaty.

It was difficult and also doable for about 18 months.

And then my own teenage child almost died by suicide. Friends of mine have heard me say this: for four hours one morning in October 2021 the pediatric ER doctor and I were the only two people, doctors, women, mothers - we were the two souls in the entirety of the universe who knew that we did not yet know if my child’s life was to be measured in hours or decades.

The terror that began near my knees and filled me to the very brim of my neck was a cold, cogwheeling, wriggly awfulness that was most especially in my chest - the pre-presentation butterflies that one gets when waiting to learn if your child is dying already.

She was, but with excellent care is now medically and mentally well.

I’m not though. I’m okay: safe, not a danger, at no imminent risk, with no ideation/plans/intent. But I grieve for the pain that my child will never have not endured. I am in the same world I’ve always been in. I simply now understand that every possibility is both going to and never will happen. All the gleaming wonderful and dank oily dripping horrors are ready now.  

I wonder if I am the only clinician who is leaving medicine by the end of this year, or has already left because COVID ripped their child’s soul, too, and the clinician parent can not be who they were, now that they know what can never be not-known.

Not Only Physicians: Nurses Have It Worse
Anne Dreesen, MSRNRZd | Hospital
This article discusses physician burnout, using other staff to perform non-physician medical functions, and staffing issues. Realistically it is nurses who are left to actually care for patients, with high workloads in hospitals and clinics. Abuse of nurses - both physically and mentally - has increased over the past three years. Hospital nurse-to-patient ratios are at unsafe levels. Nurses are leaving the health profession too. State laws mandate emergency hours when hospitals are short-staffed for nurses, not physicians.

And where are the professional healthcare organizations in this? Are these organizations really advocating for safer less
workload for the healthcare team, or is profit the goal? Contracts with corporate health insurance companies have decreased amounts of pay to the primary physicians so double or triple the number of patients have to be seen each day to cover costs. America is not first in healthcare in the world because of our multilayered healthcare insurance payment system. The frontline staff are burnt out and leaving.

Review the salaries of health insurance CEOs and their bonuses for cost containment. Prices of health insurance stock have increased...while the health insurance documentation and coding is driving physician burnout.

Congress says Big Pharma is to blame for increased administrative costs and increased treatment costs but it is really administrative burden and coding required by health insurance companies driving the process.

No one speaks to this.
Jesse Bohrer-Clancy, MD | Hospital
Thank you for the article. I wish you would have expanded on the last paragraph of the article. What are the ways that we can decrease burnout and start to enjoy our profession again? What specifics can we use to drive policy change within our systems and at the federal level. I see plenty of articles on burnout, but not many about the specifics of actually fixing it. That we are burned out is no longer the question, how we fix it is. It reminds me of what Charles Warner once said; everyone talks about the weather, but nobody does anything about it.
Richard J. Salm, BSc., DPM | Hospital, Private Office
One of the biggest reasons I see fellow physicians retiring early is strictly due to the fact that insurers haven't acknowledged the true rate of inflation. Here in SW Florida our average expenses are up by close to 30%. Rent is up 25%, fuel 70%, staff wages 35% (and still losing staff) I know the official Biden administration figure is 7% but every expense that matters to me is at least 4 times that. I guess we shouldn't be surprised when $10 trillion dollars are added to an existing circulation of $20 trillion. Simple math tells us that inflation would be 33%. Why isn't this a major talking point? Bring on the concierge.
Burnout Effects
David Treen, MD | Community Hospital
For me, burnout has expressed itself in many very predictable ways: exhaustion, depression, looking for a way to retire, all the usual stuff. But the saddest byproduct of burnout in my case is the loss of empathy for virtually everyone involved, from employees, to coworkers, administrators, and even my patients. I find that deep down I remain highly empathetic, but on the charred exterior, I find myself just going through the motions of “caring” and being unwilling to invest in my patients like I always have in the past. I have begun to resent work because of the ever increasing sheer amount of my responsibilities with no end in sight. I pray that I will find a way back to the profession that I have loved, and that it will one day love me back ... again.
Great MD Resignation
Patrick Aufiero, MD | Private Practice
I am retiring after 30 yrs of an infectious diseases practice: solo, private, 4 days office 4 hours each day, rounding at 3 hospitals, serving wound care patients at those hospitals 4 days, work M-F, every 3rd weekend call, covering 2 other ID doctors.

There are severely decreased reimbursements, increasing overhead, and the hospitals are taking over all practices: IM, FP, and specialties. If you are not part of that, referrals go only to the hospital-owned MD's
so with that, all my work for the last 3 years is just paying the overhead.

So it is time
to go.

I love the medical profession, the MD's I work with, and the patient relationships I have had for up to 30 years, though those don't occur in this new medical world

Medicine was always a business, but the patient was always first. Now profits above all are the priority. Most EMRs are set up purely to get every billable item, nothing to do with patient care.

Michael Lambke, MD | Family Practice, Redington Fairview General Hospital (RFGH)
I appreciate the comment desirous of potential solutions to burnout. Here's mine.

I have been a proponent of system changes to improve medical care for most of my 29 years in practice (my Dad even predicted I would be using a computer every day of my life as early as 1978). Unfortunately, system changes are too often driven by non-clinicians and by numbers thinking of specialists (HbA1C, mammography) with the unfortunate consequence that the system privileges results/numbers over the value of building therapeutic relationships with patients and colleagues. Collecting high quality data informs clinical practice but is not a
therapeutic action and certainly cannot dictate individual clinical decisions without harming the patient. Ideally, we work in conjunction with each other to apply the data to the individual rather than a hierarchy of dictates.

Once the patient and the people in the profession are not at the center of action and thinking, the work and mission devolves into yet one more distracting 'innovation.' Medicine and Nursing are human professions and unfortunately we have evolved a tower of Babel in our efforts to build a temple of health.

More highly trained clinicians, supported in practice to continue in practice as long as possible while supporting the growth of future clinicians, is the best humanity can offer in the quest of health. We have distracted our focus. Innovation really does take time and if done well moves slowly ... unfortunately, very slowly. Belief in a high functioning PCMH or hospitalist admitting system is like pretending we can all achieve the greatest of Brazilian football in the 1950s and 1960s. These examples are anomalies to be marveled at and enjoyed, but this recognition does not lessen the importance or enjoyment of play with a six year old in the parking lot. 'Striving towards' and 'expectation of' are not to be confused. Dynasties of highly functioning medical or sports teams are transient and discontinuous. Working within the vagaries and complications of the human condition is disruptive by its very nature.

I recommend we focus our efforts on training physicians in sound clinical, empathic, ethical reasoning and then heavily support them in general practice more than specialty practices. No medical school is exempt and residencies are funded to redesign their training workloads to develop independently thinking clinicians capable of assuming responsibility for care of the patient, not just their referral. There is plenty of waste in the system to fund the human work of caring for others.

Teach your children well...