MANAGED CARE September 2012. ©MediMedia USA
Medical Directors Explain Hows and Whys of Burnout
These high-achievers wrestle with competing interests as they operate both in the medical and business worlds
After 13 years in neonatal intensive care, Marjorie Schulman, MD, became a clinician executive, working as a medical director. She left Aetna at the end of 2011. She loved it there, calling it an ethical company that has done more than any other in the industry to allow work-life balance. Still, there was pressure, and balance in the lives of medical directors can be difficult to come by.
On her first day at Aetna, one of Schulman’s new physician colleagues pulled her aside.
“‘Your specialty is neonatal intensive care, right?’
‘Yes,’ I answered.
‘Well, you are going to see a lot of hysteria in this industry. Everything is urgent, urgent, urgent when money is on the line. But remember, nothing in business is ever like medicine, especially the kind of medicine you practiced.’”
Medical director burnout often goes unseen and undetected. Most professionals, not just medical directors, don’t want to admit to burnout; it took a while to get anyone to speak to us about the problem. The attitude was “Medical director burnout? Never heard of it! Especially at my company!” Even an interview with a physican who works for one of the large consulting companies, someone you’d assume would be forthcoming, went nowhere.
A spokeswoman for America’s Health Insurance Plans advised us that we should instead be writing about how excited medical directors are to go to work every day to face the challenges of the health reform era, about how much they love their jobs. While we have no doubt that most do, to suggest that medical director burnout doesn’t exist pulls the reach of credulity out of its socket.
“The problem is quite real — not just for medical directors, but for any physician in a management role,” says Brent James, MD, the chief quality officer and executive director of the Institute for Health Care Delivery Research at Intermountain Healthcare. “We tend to be really compulsive and over commit. The problem afflicts all ranks of management.”
Despite appreciating her career, Schulman says that she hasn’t met many medical directors who don’t burn out at some point. Still, if she had it to do over again, she’d still become a medical director.
“My hope when I entered the health insurance field was to influence population health at the place where money drives clinical behavior,” says Schulman. “I have been lucky to see that up close.”
Now’s the time to define terms. Managed care medical directors provide clinical leadership and expertise related to health insurance programs including — but not limited to — quality improvement, utilization management, network design, policy development, accreditation, credentialing, care delivery, and working in a team/collaborative relationship with other organization leaders, says Jaan Sidorov, MD, a former medical director at Geisinger Health Plan and a member of Managed Care’s editorial board. Medical directors typically report to the chief medical officer.
Burnout is not a recognized psychiatric disorder, so there is no diagnosis, says Philip R. Muskin, MD, professor of clinical psychiatry at Columbia University and a distinguished life fellow of the American Psychiatric Association.
Sad every day
“Someone with burnout might be sad, or might be sad enough to qualify for a diagnosis of depression that has a main symptom of a pervasively sad mood for most of the day, every day, or significant loss of interest in usually enjoyable activities, plus other symptoms,” says Muskin. “The person might be anxious and might be anxious enough for a diagnosis of generalized anxiety disorder that has a main symptom of worry. I would not want anyone to think he or she has a mental disorder if experiencing burnout.”
Also, while someone might call himself a “burnout specialist,” there is really “no such specialty,” says Muskin.
Robert Forster, MD, is a health care consultant who has held various positions in his career, including chief medical officer (CMO) at BlueCross BlueShield of Florida for seven years. The medical director’s role is far too restricted and inflexible, he says. “They are really not treated as a professional, if you will. You might as well put information in a computer and not have any judgment.”
Abbie Leibowitz, MD, agrees. He is a former chief medical officer at Aetna and now is executive vice president and chief medical officer of a consumer advocacy company called Health Advocate. “Many medical director roles are pretty repetitive and don’t require a lot of creativity or encourage much strategic thinking,” says Leibowitz. “This is especially true of the utilization review jobs — a common entry point in many plans. Nearly all medical directors want to be on a professional advancement track, but that is not always available.”
Likes going to work
One medical director, who asked not to be identified, recently changed jobs, moving from a regional to a national plan. An 11-year veteran, she now finds herself in an unusual state: She likes going to work. Not that it was torture before. “In the very beginning it’s interesting because it’s a learning curve, but after a while it just ends up becoming tedious,” she says.
Some plans want medical directors to be involved in many extracurricular activities, such as meeting with specialty groups, serving on multiple internal committees, visiting practitioners and hospitals, “all the while being responsible for time sensitive turnaround cases without coverage from your peer physicians, which creates a huge amount of stress and job dissatisfaction.
“At the end of the day we’re still responsible for the basic widgets. That is more highly valued. And if you do external activities, that is an addition, not a substitution. So there’s less and less incentive to want to do outside activities.”
Would more money help? “It’s not really the compensation; it’s more that for the most part, your basic activities take eight hours, so I would go to an external meeting, get back at 3 p.m., and find that I was going to be working until 8 p.m. to finish my core job.”
Forster points out that medical directors’ performances are often judged by nonclinical people. “Ultimately, as they move up the ladder, there’s a non-clinician above them who has a difficult time grasping the subtleties.”
Forster is a mentor to medical directors, and most of what he teaches has to do with explaining medical information in terms that nonclinician executives can understand. “You don’t necessarily talk about the quality benefits that you can sustain by doing something in this method but about what it can bring in terms of dollars, in terms of saving the plan money, or allowing the plan to reduce premium and therefore become more competitive. Sometimes you have to talk their language.”
Thomas J. DeLong, PhD, points out that medical directors are high performers and that they burn out the way high performers in most professions burn out. They are addicted to achievement and sometimes become self-absorbed. “They don’t understand how their behavior affects others,” says DeLong, the Philip J. Stomberg Professor of Management Practice at Harvard Business School. “I believe, based on the interviews that I’ve done, that it is an addiction — as much of an addiction as being on prescription drugs or on heroin. It’s that hard to break.”
Physicians who become businesspeople might feel divided. The positive medical part is “being with the patient and forming an intimate relationship and seeing the patient get better,” says DeLong. “But once you are a medical director, it becomes more about policy and procedures and numbers. That is degenerative. It doesn’t refill the vessel by giving a feeling of growth and renewal and some sense of peace.”
In the world of practicing physicians, corporate medical directors are viewed as the enemy, not as peers, which can be very depressing, says Schulman. “It is still the rule that practicing physicians carry stereotyped views of medical directors as paper pushers, care deniers, and little more than claims processors. Every medical director can cite dozens of incidents when network doctors or their former colleagues in practice accuse them of having gone over to the dark side.”
Arlen Collins, MD, president and chief science officer at Remedia, a company that addresses problems of overuse and misuse of medications, has worked as a medical director at US HealthCare and also — as a chief medical officer — turned around several ailing health plans. He cites competing interests. “I was on a call the other day with some folks at a major national health plan and they invoked the lawyers at least six times as an impediment when discussing what everyone on the call agreed would be a real positive move for the plan and its members. Increasingly there are regulatory compliance issues that impede progress that drive many medical directors nuts.”
He never experienced burnout, he says; his US Healthcare experience was constantly exciting and with the turnarounds, he was too busy trying to fix companies. “These plans were in such extremis that no one bothered me and I was able to do what needed to be done.”
Marla Tobin, MD, a recently retired senior medical director at Aetna, says that “physician burnout in the medical community is rampant — especially in the boomers.” (See “Burnout Rooted in the System.”)
The medical director community sees burnout, too, “and it often involves two main issues — task work and travel. Especially with the utilization review work and completing tasks in the queue, often physicians get into a production mode and have little personal contact or job satisfaction, as their feedback loop is often negative.” In addition, she says, the peer-to-peer interaction involved in denials can get nasty.
Leibowitz contends that peer-to-peer review, where denials for coverage are examined and sometimes challenged, runs much more smoothly if the treating doctor or a specialty expert discusses the case with the medical director. “At Health Advocate we arrange these frequently to help our members. It is not common that the discussion between a treating physician and the plan’s medical director gets confrontational, but as I am sure one can appreciate, that can happen.”
Though the focus in this article is on medical director burnout, medical directors need to be able to spot it in their subordinates as well. Then it’s time to have a talk, says DeLong.
“One thing I do is to say to a subordinate [showing signs of burnout], ‘Number one, what’s the desired outcome? Number two, how will you know when you’ve achieved success? Number three, if you were to throw a celebration in five years, what would you celebrate? How many people are you helping along the way other than just yourself?’”
Can be managed
DeLong says that there is hope, though it might be hard-earned. “I have seen 35-year-olds, 45-year-olds, and 55-year-olds make dramatic changes in managing this need for achievement and this overdrive. But you must manage it every day. This is not a problem that you fix and then do not think about.”
How to spot it
Philip R. Muskin, MD, defines burnout as a special type of job stress. “It might be described as a state of physical, emotional, or mental exhaustion combined with doubts about the person’s competence and/or the value of the person’s work,” says Muskin, professor of clinical psychiatry at Columbia University and a distinguished life fellow of the American Psychiatric Association.
Signs include feeling cynical or critical while at work, feeling that you have to drag yourself to work, becoming irritable or impatient with others, and becoming disillusioned with the job.
The main symptoms of burnout, says Marjorie Schulman, MD, a former medical director, are negativity and cynicism, often directed at the bureaucracy of one’s own company. “In the case of medical directors who perform medical management, it is also easy to become very jaded and angry at the network physicians who are supposed to be one’s peers. This is often because physicians can be extraordinarily rude and dismissive to medical directors when they are contacted.”
“Some people may notice a drop in their productivity or experience little satisfaction from realistic achievements,” says Muskin. “Changes in sleep or appetite or new and/or unexplained physical symptoms such as headaches, backaches, or general aches and pains might occur. When the person notices he or she is using alcohol, food, prescription drugs, or illicit drugs to feel better or to create a sensation of not feeling at all, that is a serious warning sign that something is wrong and that intervention is necessary.”
A classic sign of burnout is overreaction — to almost everything. “When something happens, you take it very personally,” says Thomas J. DeLong, PhD, the Philip J. Stomberg professor of management practice at Harvard Business School. “There’s a spillover effect in your private life where you find yourself being more curt and more judgmental, and you listen less. You find fault in others faster. You can’t self-monitor.”
Successful people are usually smart and welcome an overloaded agenda, says DeLong. “You define yourself on what you’ve accomplished, not on what kind of person you are. You define yourself based on how many things you cross off your to-do list.”
Certain professions are predisposed to have such people in them, says DeLong; surgeons, professional athletes, and investment bankers for instance. The person knows something isn’t right.
“The fun is less,” says Muskin. “Don’t sweat the small stuff? Suddenly the small stuff looms much larger. There’s a change in your behavior — inability to control your irritation with somebody. If you never had road rage, now you have road rage. You notice changes in yourself but not changes for the better. You notice that the creative stuff that got you where you are isn’t functioning the way it should be.”