Off Script: Want a Glimpse of Healthcare 3.0? Look Beyond Physician Burnout

SAN FRANCISCO, CA—We are back again at TCT, now in at the 31st year, in San Francisco, which has been uncharacteristically warm and sunny, at least for the first few days. The meeting’s opening keynote featured ZDoggMD, an internet phenomenon who has been described as the “authentic, unfiltered” voice of modern healthcare. A UCSF trained internist who was previously a hospitalist at Stanford for 10 years, ZDogg (aka Zubin Damania, MD) started a healthcare-themed comedy website which has accumulated millions of views. Through his skits and music videos, he has captured the mounting despair and frustration providers face on the front lines of what’s become an increasingly dehumanized and metric-focus healthcare delivery system. Having made the rounds since 2016, ZDogg’s public appearances have gained considerable momentum, with keynote invitations to audiences spanning the entire spectrum of healthcare delivery from insurance providers, healthcare executives, nursing, EMS providers, advanced practice providers, and physicians. He also delivered the keynote lecture at the American College of Cardiology Quality Summit in March this year.

The son of immigrant Parsi physicians, ZDogg offers a compelling narrative tracing the generational shift from his father’s primary care practice to modern day. As he describes it, his father’s experience embodied Healthcare 1.0, framed through the nostalgic lens of physician autonomy, human relationship-based patient care, long hours, and home-baked gifts—no electronic medical records, meaningless metrics, or insurance prior authorization requests. He is careful to point out that this idealized version of healthcare also lacked in evidence-based care, financial oversight, and standardization. Over the last 20 years, we’ve embraced Healthcare 2.0, which was supposed to address the deficiencies of 1.0 by introducing evidence-based medicine, fiscal accountability, practice standards, and electronic modernization. However, despite our best intentions, our baby has become our Frankenstein and we now recoil with daily disgust at the monstrosity of modern healthcare, the depersonalized patient interactions, destructive metrics of practice, meaningless bureaucratic tasks, and a focus on soulless industrial productivity. The changes have been especially felt in US cardiology where, in short order, the 90% private ownership that marked physician practices in 2008 had dropped to 17% in 2018, as cardiologists sold up and became employees within integrated healthcare systems.

These mounting pressures and mass dysfunction have led to vocal warnings that physician burnout is reaching crisis proportions. Originally described in 1974 as a diminishing interest in work and loss of energy in volunteers at a drug rehabilitation center, it has since been recognized with iteratively clearer definition by the WHO as a “problem” (not a disease) with its own ICD definition. Studied extensively, “burnout” is not unique to healthcare and has been described in all professional endeavors, especially in occupations with a high level of human interaction. Physicians who entered their professions with the masochistic expectations of long work hours, personal sacrifice, and missionary zeal have been the perfect at-risk population for experiencing burnout, with estimates of around 45% of physicians experiencing burnout compared to 28% in the general population in 2017. Today, meeting all the expectations of a modern patient care encounter—largely designed by “healthcare experts” who have never actually cared for patients—physicians are beginning to unravel.

Burnout in cardiologists specifically has not been well studied, and most of what we know is gathered from annual surveys of differing degrees of rigor that point to cardiologist burnout rates ranging from 27% to 43%. The field of burnout quantification is notoriously nonstandardized, as are the definitions of what it means to be burnt out: the most authoritative meta-analysis thus far of physician burnout published in JAMA in 2018 unearthed 142 unique definitions of the term! Despite these wide variations in methodology, several themes consistently emerge. Women have higher rates of burnout than men. Working longer hours results in higher rates of burnout. Meaningless bureaucracy and an excessive burden of low-level data entry are the clear root causes, with the rate of rise in the term “physician burnout” within our literature as measured by PubMed almost exactly tracking the rate of US Electronic Health Record adoption. Ultimately, whether or not the true proportion of “burnout” in physicians is one in two or one in four is unimportant. Instead, the threshold of “moral injury”—a phrase proposed to replace “burnout” borrowed from PTSD literature—should be zero.

ZDogg finished his TCT 2019 keynote by offering his vision of an idealized solution: Healthcare 3.0, he argued, should the best of both worlds, old and new—emphasizing a team-based, holistic, human model of care built around the patient while employing the strengths of electronic health. Turntable Health, the primary care medicine clinic ZDogg built in Las Vegas embodying those principles was inspiring, but the project was shut down after 3 years, despite the reportedly rave reviews of patients and a 50% decrease in readmissions. The reason? The insurance company funding the program went out of business.

So is Turntable Health a disappointing and cautionary tale? Soaring idealism grounded by fiscal realities? Or should it merely a single, failed effort on the path to a better tomorrow? For the latter to be realized, we must be resilient, stand fast, stand together, and organize ourselves in coherent ways in order to upgrade the Healthcare of tomorrow.

Off Script is a first-person blog written by leading voices in the field of cardiology. It does not reflect the editorial position of TCTMD.