Physicians report moral distress and burnout over policies that force inadequate care

Being forced to provide inferior care due to the patient's immigration status was a significant burden to the clinicians.

Jeff Lagasse, Associate Editor

Add another reason physicians are feeling burned out to the oft-expanding list: hospital policies that prevent them from treating patients to the best of their ability. 

Yesterday, literally, it was the onslaught of alerts, alarms, text messages, pagers and even phone calls that a whopping 82 percent of clinicians and IT leaders said in research from Vocera and HIMSS Analytics contributes generously to burnout. Today, it's hemodialysis. 

Specifically, clinicians in safety net hospitals describe feeling moral distress and being driven toward professional burnout because of policies that prevent them from performing hemodialysis for undocumented immigrants, except in the case of an emergency, says a study published in the Annals of Internal Medicine. 

Being forced to provide inferior care due to the patient's immigration status was a significant burden to the clinicians who reported feeling a sense of admiration for these patients and a desire to advocate on their behalf.

In the U.S., nearly half of undocumented immigrants with end-stage kidney disease receive hemodialysis only when they are evaluated in an emergency department and are found to have life-threatening renal failure. This type of "emergency-only" hemodialysis, or EOHD, is nearly 4 times more costly than regularly scheduled hemodialysis and has a 14-fold higher mortality rate. This approach to care is distressing for the patient, but little is known about how it affects the clinician.

That it may contribute to burnout is distressing not only for the physician but for the organizations that employ them. A Medscape report earlier this year found that nearly two-thirds of U.S. physicians report feeling burned-out, depressed or both, with one in three admitting that their feelings of depression have an impact on how they relate to patients and colleagues.

Physician burnout can hurt the bottom line. Research has shown, for instance, a consistent relationship between higher levels of physician burnout and lower levels of patient safety and quality of care.

For the new study, researchers from the University of Colorado interviewed 50 interdisciplinary clinicians in a safety net hospital in Denver to determine how physicians feel about emergency-only hemodialysis. The clinicians reported that they felt emotionally and physically exhausted by daily organizational and system-level barriers to providing care.

They also were troubled by witnessing unnecessary suffering and high mortality. In their paper, the researchers identified and explained four high-level themes that emerged from their interviews: drivers of professional burnout, moral distress from propagating injustice, confusing and perverse financial incentives, and inspiration toward advocacy.

The researchers conclude that emergency-only hemodialysis is harmful to patients and is also harmful to clinicians that are forced to provide inadequate care to their patients. The burden on clinicians of providing emergency-only hemodialysis should inform policy discussions and systemic approaches to support provision of an adequate standard of care to all patients with end-stage renal disease, they said.

Now, that may or may not actually happen in the short-term, but it's safe to say that more causes of physician burnout will emerge soon.

Twitter: @JELagasse
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