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The Problem With Prestige | MedPage Today

Burnout is a growing problem in medicine, affecting 44% of physicians and impeding the quality of medical care they provide. Though the industry is well aware of this problem, much remains unknown about its etiology.

According to a 2020 survey of fifteen thousand doctors, which was issued prior to the COVID-19 pandemic, all physician specialties reported a burnout rate above 29%. If you look at the bottom of the list, where burnout rates are lowest, you’ll find several surgical specialties. They include ophthalmologists (30%), orthopedists (34%), and otolaryngologists (35%). Strangely, you also find a couple of surgical specialties near the top of the list, too.

In fact, before critical care physicians overtook the top spot in 2020-21, urologists were experiencing the highest rate of burnout among all doctors (54%), a far higher percentage than any primary care specialty, including internal medicine (44%) and family medicine (46%).

The survey findings raised an interesting question: Why do burnout rates vary so greatly across surgical specialties?

In surveys on the causes of burnout, doctors complain most about working too many hours at the office, logging too many clicks on their computers, and performing too many bureaucratic tasks without enough pay. All are accurate. But look closer, and you’ll see these complaints don’t adequately explain the dramatic variation in rates of burnout from one specialty to the next.

For example, look at pay. Urologists earn an above average salary of $408,000, which is $42,000 more than the average ophthalmologist. Yet, at the time of the survey, urology was the specialty with the highest burnout rate, 24% higher than in ophthalmology. This suggests that income is not as much of a burnout factor as physicians may think. The fact that urologists earn nearly twice as much as pediatricians — while experiencing a 15% higher rate of burnout than their pediatric colleagues — confirms it.

What about the commonly held belief among physicians that spending “too many hours” at the office causes burnout? That is a contributing factor, but when you look specialty to specialty, there are multiple exceptions. As an example, orthopedists put in more hours at work than three-quarters of the specialists surveyed, and yet they are among the profession’s least burned out doctors.

Finally, what about the bureaucratic impositions that physicians face? Once again, this is an aspect of the healthcare system that doctors detest, but it fails to account for the variation in burnout rates by specialty. All surgical specialties use similar electronic health record systems, and each must obtain prior authorization from insurers for the procedures they perform. When it comes to the number of computer clicks and annoying administrative tasks, urologists have it no different than orthopedists, ophthalmologists, or otolaryngologists.

If variation in burnout rates among different specialties can’t be explained by money, work hours, or bureaucratic paperwork, what else is there? The answer lies in the illogical and perverse obsession doctors have with prestige and status, two of the strongest influences in physician culture.

How Does Status Influence Burnout?

Sir Michael Marmot, a British epidemiologist and chair of the World Health Organization’s commission on social determinants of health, is renowned the world over for his Whitehall studies. Through his groundbreaking research on health inequalities, Marmot found a strong association between the occupational rank of British civil servants and their chances of dying.

Men with jobs at the bottom, he found, were four times more likely to die than the men in charge, even when adjusting for the usual social-class killers like smoking, drinking, and poor diet. His findings transformed the establishment’s thinking on the link between hierarchy and health.

Marmot was among the first to point out that social and professional status have a tremendous influence over a person’s mental and physical well-being. Specifically, he found that our real or perceived rank — at work, among friends, or in society — greatly affects our stress levels and self-esteem.

Importantly, numerous psychological studies confirm that the loss of social or professional status produces the same symptoms we associate with burnout: anxiety, fatigue, and depression. This is the missing link.

Physicians, having spent most of their youth competing for academic honors, are acutely aware of their standing and the importance of hierarchy in medicine. Yet, they seem mostly unaware of the correlation between their status and the risk of becoming burned out.

To understand this association, let’s examine urology, a specialty that has undergone a significant uptick in burnout and a major decline in status.

The number of hours urologists work and the income they earn are similar to other surgical specialties and relatively unchanged from the past. Neither factor adequately explains the high level of dissatisfaction they report.

What’s unusual about urology is that a few years ago, the burnout rate was relatively low. What changed? In the first decade of the twenty-first century, medical school graduates flocked to urology for the prestige and the opportunity to perform robotic prostatectomy, a “cool” (video-game-like) procedure for men diagnosed with localized prostate cancer. During that time, the number of patients choosing this surgical option rose, as testing for prostate cancer became standard and these multimillion-dollar robots became available in every hospital. But starting around 2010, all of that changed.

The number of prostatectomies being performed in the U.S. began to decline as a result of research studies that found testing all men over the age of fifty for elevated levels of prostate specific antigen (PSA) resulted in overdiagnosis and overtreatment. Men with high PSA levels were being biopsied more than necessary, leading to painful and problematic complications one-third of the time. These included bleeding, urinary obstruction, and infection. Because of this, the U.S. Preventive Services Task Force recommended in 2012 that men and their doctors rethink PSA testing. In subsequent years, additional studies found that for many prostate cancers, “watchful waiting,” during which the malignancy is carefully monitored but not treated, proves just as effective as operating. What’s more, waiting averts the risks of surgery, which include lifelong impotence and incontinence.

With the total volume of cases shrinking and with an increasing percentage of patients choosing to get their surgeries done at high-volume “centers of excellence,” most community urologists have been left with fewer opportunities to perform the very procedure that attracted them to the specialty in the first place. And with lower surgical volumes, many have been forced by hospital credentialing authorities to remove the procedure entirely from their clinical practices. These setbacks have devastated the field’s prestige, bumping urology down near the bottom of the healthcare hierarchy, thus contributing to the specialty’s high incidence of burnout.

The Healthcare Hierarchy

Medicine’s imagined order may be news to some patients, but it is well known to every doctor in the profession. And it influences everything from a specialty’s perceived value to a doctor’s feelings of self-worth and, ultimately, the quality of care patients receive. Because the doctor’s place in this hierarchy is so culturally important, physicians are unlikely to admit to patients when they lack experience in the areas of greatest clinical and technical complexity. And they’re likely to keep on performing procedures that boost their relative status — regardless if they’re the best physician for the job or if a more conservative approach might yield better results.

The healthcare hierarchy is a powerful force, one that influences the mental health and overall happiness of physicians. Until doctors alter what they value, their obsession with status will continue to inflict harm on themselves and their patients.

Every medical student understands the relative value system. When planning their careers, they run the numbers and figure out what test scores they need in order to earn an elite residency spot toward the top of the list. As you examine the order of healthcare’s hierarchy, it’s easy to see which doctors are accorded the highest prestige. Those who care for patients with urgent, life-threatening problems are more valued than those who help prevent patient diseases in the first place. Surgeons who hold the scalpel rank higher in the hierarchy than those who wear stethoscopes around their necks. And those with expertise in a single organ system are given higher esteem than physicians who are responsible for the entire patient.

American doctors and patients are hurting. They blame the healthcare system’s weaknesses for compromising medical care and increasing physician burnout. What they overlook, however, is how physician culture — and the profession’s preoccupation with status — contributes to their unhappiness.

This excerpt was adapted from Uncaring: How the Culture of Medicine Kills Doctors and Patients by Robert Pearl, MD. All profits from the book go to Doctors Without Borders.

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