Letters to the Editor

Combating physician burnout

I read with interest the column “Students and residents are also burning out” by ACP President David A. Fleming, MD, MA, MACP, in the January 2015 ACP Internist. The loss of 2 young lives at the beginning of their careers is indeed heartrending. However, to tie these tragic events to “burnout” is unfortunate and further trivializes the need for mental health assessments, substance use identification, treatment access, and support from the profession.

Medicine has always been demanding. As physicians, we are reminded of our own mortality on an ongoing basis. In the same vein, the opportunities to lead, innovate, and reform the system have never been greater. The message from the bully pulpit ought to be one of solidarity, positive encouragement, and broader acknowledgment of unmet mental health needs, even among the youngest and brightest in our profession.

Anshul Dixit, MD, MPH, ACP Member
Des Moines, Iowa

I was happy to see the column “Students and residents are also burning out” in the January 2015 ACP Internist. The important operative word is also. Not only residents but also practicing physicians are suffering from the increasing regulation of medicine. I am concerned that in the over 30 years since I became a Fellow, I have seen ACP's leadership ignoring the practicing physician's viewpoint.

Since ACP began taking “political positions” in 1993, it has supported a global health care budget, pay for performance, accountable care organizations, and the elimination of fee for service. It has advocated reduced health care costs, mandatory recertification, mandatory electronic health records, and increased funding of development of best practices (guidelines). Most practicing physicians do not favor these concepts. ACP seems to take these positions because it does not want to appear self-serving and wants to have a “seat at the table.” If we represent 141,000 internists, we should feel freer to stand up for ourselves. The more we are suppressed, the fewer physicians will choose primary care or even the practice of medicine. I was shocked when CMS eliminated consult coding without a fight from ACP. These political positions have contributed to the early burnout of the internist.

In addition to mandatory recertification, a new threat to the well-being of practicing internists is Maintenance of Certification (MOC), an unnecessarily complex system through which the American Board of Internal Medicine (ABIM) proposes to completely and continually control us. This troublesome concept was covered in the President's Message in the June 2014 ACP Internist. Physicians are the first to agree that continuing education is important, but having a small board of self-appointed, highly paid people determining how 200,000 physicians should behave and what they should believe is not acceptable. Although ABIM recently announced changes to the MOC process in response to criticism, I do not believe they go far enough.

ACP frequently refers to the concept of professionalism. However, an important component of professionalism, autonomy, is conveniently ignored. Without autonomy the physician is a mere functionary monitored closely by ABIM.

Physicians are generally happy to satisfy continuing education as other professions require. The public is generally satisfied with that assurance. In my experience, physicians are much more likely than other professionals to keep up with the literature and attend continuing education sessions.

I am happy that ACP is negotiating with ABIM, the Accreditation Council for Graduate Medical Education (ACGME), and the Association of American Medical Colleges, but because of its previous positions, I do not trust it to eliminate unnecessary burden of regulation. I would like to see ACP consider its constituents as the independent professionals that they are.

Jerry F. Meyer, MD, FACP
Washington, D.C.

President Fleming responds:

I appreciate Dr. Dixit's thoughtful comments. I couldn't agree more that we need to remain ever vigilant of the stresses and needs of our learners, including having sensitivity to and awareness of their mental health needs and having mechanisms in place to intervene effectively when needed. This was part of the message I was hoping to convey in my column. The pressures and stressors leading to burnout in practice often begin very early in training. The tragic events surrounding the 2 suicides punctuate that for us and are a wakeup call for systems, schools, and training programs to redouble their efforts in protecting the bright young minds who are the future of health care in our country.

It is also critically important that the legitimacy of regulatory processes in improving health care outcomes and value be well-founded and evidence-based before they are laid on physicians already burdened by many administrative hassles that interrupt patient care. I have found that the growing concern about burnout in training is a worldwide problem and that this discussion is occurring in many of the professional organizations I have visited as ACP's President.

I also appreciate Dr. Meyer's detailed response. ACP has made administrative burdens affecting physicians a top priority in both advocacy and practice support in an effort to assist our members and others in recapturing the joy of medicine that many have lost as a result of the present sometimes oppressive practice environment. We also know that the growing requirements of MOC are contributing to this sense of burden and anguish throughout the country. The leadership of ACP hears and agrees with these concerns. This is why we are working closely and regularly communicating with the leadership of ABIM to foster and help guide important changes that are needed to ensure sustainability and maintain the integrity of our profession.

I can assure Dr. Meyer and others that ACP will continue to work tirelessly to effect important change in our regulatory and practice environment, including the MOC requirements of ABIM. As a general internist and geriatrician who practiced for almost 20 years in a small rural community and now as president of a professional specialty organization that represents generalists and subspecialists equally, I recognize that a balanced perspective is needed in our advocacy efforts to ensure that all voices are heard and all views are represented in policy development, educational offerings, and practice support.

I strongly feel we are providing balanced leadership and representation that respects all of our members and, more globally, the house of medicine. At least, this is the majority opinion of the many members from whom I have heard in my year as president. We will also continue to strive for balanced and well-reasoned leadership in these efforts by representing the health care needs of all patients and society.

I would like to thank Dr. Dixit and Dr. Meyer for their response and concern. Feedback like theirs is extremely helpful and will impact the discussions I and other ACP leadership will have in the days to come about policy issues and the welfare of ACP's members, but most important that of our patients.

David A. Fleming, MD, MA, MACP
Columbia, Mo.

More thoughts on hepatitis C

The article “Hepatitis C drugs offer new options” in the January 2015 ACP Internist highlighted this underdiagnosed and undertreated chronic condition. It also raised the possibility of having general internists get involved in the care of hepatitis C patients. Historically, patients infected with the hepatitis C virus (HCV) were cared for by hepatologists, while a few infectious disease specialists dabbled in the field. As stated in the article, the up-to-date treatment for hepatitis C is an interferon-free regimen with all oral agents. The writer, Stacey Butterfield, did an excellent job summarizing this complex disease, and I would like to share a few thoughts that I think might be pertinent to clinical practice:

1. 1. Patients with extra-hepatic manifestations of HCV, such as cryoglobulinemia and rheumatological symptoms, should also have a higher priority for HCV treatment.
2. 2. As mentioned in the article, treatment is very expensive. In our clinic, I have a team of nurses and staff members who handle the approval/denial process on a daily basis. The time involved in this process could be quite overwhelming and time-consuming. Internists who are interested in hepatitis C treatment need to be aware of this.
3. 3. More new medications are forthcoming and will add more options for clinicians and patients alike. On Dec. 19, 2014, the FDA approved ombitasvir/paritaprevir/dasabuvir with ribavirin (Viekira Pak, AbbVie) for treatment of patients with and without cirrhosis who are infected with HCV genotype 1a/1b. Another combination that was recently approved by the FDA is combining sofosbuvir (Sovaldi, Gilead) with simeprevir (Olysio, Janssen) taken daily for 12 to 24 weeks, depending on whether the patient has cirrhosis.

Deciding which medication should be used to initiate therapy is a complicated process for some patients. Clinicians need to be aware of treatment history, fibrosis stage, viral resistance, medication side effects, and drug interactions. Hepatitis C treatment can now be viewed as easier, but the new drugs can introduce another layer of complexity, and more medications are in the pipeline in the near future.

Anthony K. Leung, DO, FACP
Akron, Ohio