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November 14, 2021
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By measuring it, we misunderstand it.
By quantifying it, we fail to understand the qualitative nature of physician burnout. A problem in healthcare that existed long before it was recognized and eventually accepted as a problem in the medical community.
Previously burnout was seen as a form of weakness. Eventually systems were set in place to provide physicians the assistance they would need. Now acknowledging burnout is seen as a sign of strength – the strength to express vulnerability.
Now healthcare systems and academic medical centers have stringent protocols to monitor physician well-being, ensuring that burnout is detected as early as possible. But in monitoring for burnout, we come across a familiar problem in healthcare, one in which we tend to quantify what is not necessarily quantitative and create metrics around something that is not easily measurable.
Since 2001, the Agency for Healthcare Research and Quality (AHRQ) began annual assessments of physician well-being. They would survey hundreds of physicians at various stages in their career – from medical students to seasoned attendings – gauging sources of their stresses, attempting to correlate burnout with its sources.
These surveys would always reveal the same predictable results – physician stress comes from time restrictions at work, documentation burdens, decreased autonomy, or a lack of control over patient scheduling. And the same predictable survey reports would then yield the same predictable solutions – provide more flexibility, limit working hours, limit physician responsibilities, and so on.
But physician burnout never decreased, and in some instances has actually increased, despite attempts to measure it through surveys and implement solutions that reflect survey reports. The counterintuitive trend does not reflect healthcare’s sincerity in trying to fix burnout, but a failure in how we understood and monitored for burnout.
The AHRQ may have stopped releasing the results of their annual survey on physician burnout in 2017, but interest in the field has rapidly exploded since then. Now many physicians devote their entire career to studying physician burnout. But more important than what they study is how they study.
Novel clinical study designs have emerged analyzing physician burnout from a uniquely qualitative perspective, eschewing the traditional tendencies to quantify and then simplify concepts in healthcare into a convenient data point.
For example, Dr. Lisa Rotenstein of Ariadne Labs has published numerous studies in the last few years analyzing physician burnout as a multi-dimensional concept that cannot be adequately represented through any one metric.
These studies provide unique insights not only in the study of physician burnout, but in the field of medical research as a whole. Just as history depends on the technology used to study history, medicine depends on the clinical research techniques used to advance medical knowledge.
And the more research techniques we use and the more study designs we adopt, the better we understand medicine. Surveys tell us a great deal about subjective parameters like personal beliefs and preferences. But they are also predictable. And the results of a survey can be manipulated by the survey design itself.
This is why physician burnout was poorly understood for so long. The way we studied it yielded predictable results that told only a part of the story. To get a full understanding of physician burnout, we need new ways to study it, more qualitative ways.
In the business world, management consultants often use consensus techniques to gauge individual insights and derive collective opinions. These insights and opinions form consensus beliefs on a range of complex topics, from business strategy to company culture. The most famous of which is the Delphi technique, in which respondents are asked questions in a series of two or three rounds, and in between each round, the results are shared in a selective manner.
There are no metrics or final conclusions as consensus is reached qualitatively, through discussions conducted over multiple rounds.
Such techniques may help physicians discuss their own burnout experiences relative to others, and by recognizing the unique sources and causes of burnout, we find common ground and even potential solutions – or to put it more succinctly, the act of identifying and discussing burnout in others helps physicians to address their own burnout.
This cyclical concept is well known among physicians who participate in narrative medicine – who see writing about medicine and healing as a form of therapy itself. Something poet Edward Hirsch describes as a circuit of communication.
“A poem is a two way street”, he said, “[it is] partially realized when written, and when someone reads it, the circuit of communication is complete.” Poetry is unmistakably qualitative, and ironically, the closest metaphor to medicine we have.
In both poetry and in medicine we speak indirectly, whether it is through rhyme and prose or through symptoms and clinical signs. And in both, we decipher the underlying meaning or diagnosis through the metaphors.
Similarly, physician burnout must be understood through metaphors, as something distinctly qualitative. This means the techniques and study designs used to analyze burnout must also be qualitative. For when we attempt to quantify the inherently qualitative, we forgo the essence of what we are studying in favor of elemental pieces that are then measured and monitored.
But physician burnout is far too complex to be studied in such a way. It is far more complex than the sum of its quantitative, elemental parts, the survey results and the data metrics. It is far more qualitative.
This is the irony of measuring physician burnout – the more we measure it, the less we understand it.
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