Ira Zunin, M.D., M.P.H., M.B.A

Medical Director of Manakai O Malama


In Sept of this year, a local medical association invited me to speak about the mounting problem of physician burnout, its causes and possible remedies. Hawaii is already struggling to solve a severe, ongoing physician shortage. Why are they burning out, and what can be done to prevent our doctors from running for the door?

In speaking with physician colleagues, their most common complaints are declining reimbursements amid increased operating costs. In addition to changing payment schemes from carriers, there are also more time-intensive burdens for documentation.

In addition, it is increasingly difficult to obtain authorization for testing and treatment. In a recent meeting with one of Hawaii’s largest emergency departments, physicians complained that because of increased efforts required to gain approval for an MRI, patients are now being sent to the emergency department just to get the study. While this relieves pressure in the outpatient office, it takes up resources better spent on true emergencies, and it obviously adds to the cost of care.

Using information technology, patients are also better informed, which is a benefit to self-advocacy but also results in increased demands for care that are not always medically justified.

Concerns regarding liability and medical malpractice continue today as they have for quite some time. Added to this are worries that a very small fraction of disgruntled patients can now easily cause a negative splash on social media damaging a hard-earned good reputation.

Uncertainty about the future is also unsettling. Obamacare, a beneficial yet still imperfect system, has been under fire for the past two years. While efforts to repeal and replace the Affordable Care Act have failed repeatedly, the ACA has been systematically weakened as its provisions are cut or modified. Health care is in such a state of flux that physicians are concerned about their ability to properly care for their patients.

The rapidly changing landscape has caused a great deal of industry consolidation. Smaller practices are closing, physicians continue to move out of state, and those who remain tend to look for jobs in larger practices or institutions. New graduates rarely consider entering private practice, instead favoring job security and lifestyle.

How can our physicians weather these turbulent times and continue to find gratification in the practice of medicine?

Team up. Especially for primary care providers, the environment is no longer so conducive to the single-physician practice. Group practices enable sharing of administrative burdens and can offer the ability to insource functions such as billing, payroll and IT, resulting in more practice control and better outcomes.

Build a supportive, efficient and nourishing work environment consistent with the adage, “Physician, heal thyself.” While there are many external factors beyond our control, physicians can still create their own oasis amid the tumult. There is much to be said for an intermediate-size practice where many of the burdens of a small practice are now shared but the multiple layers of administration in large organizations can be avoided. Manakai has seen a welcome increase in physician inquiries, which, happily, continue to expand the clinical team.

A few weeks ago I met with Dean Hedges of the University of Hawaii John A. Burns School of Medicine and discussed ongoing rotations for medical students at Manakai. Much of our meeting focused on the importance of team-based, collaborative care. I also just visited the University of Washington where I have been working with leadership in the Department of Family Medicine. The department leaders would like to establish a new rotation for its residents at our facility, again with a view toward imparting a culture of mutual support and synergy among providers.

Be pragmatic and pick your battles. We would all be burned out if we sought to fight every injustice. The key is to be discerning and to know when to let go, when to take a swing and which issues are worth taking to the mat.

The opportunity to practice the sacred art of medicine is still among the greatest privileges. The ability to sit with another human being to understand and treat what ails can still be as gratifying as it has been in years gone by. Faced with the decision to practice medicine today, I would do it all over again. No question.

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