Rules and Regulations

An exploration of how accreditation, high-stakes assessments, insurance policies, and litigation risk all contribute to worsening burnout.

Accreditation, licensure, insurance policies, reimbursement, and litigation risk can add pressure and stress for clinicians and may significantly impact when and how clinicians experience burnout.

Accreditation and Licensure

State medical boards and accrediting institutions may significantly hinder clinician’s ability to seek help for burnout and other mental health conditions. Two-thirds of states require physicians to report mental health conditions to state medical boards regardless of impairment, and despite national concern about physician well-being and suicide, many physicians are reluctant to disclose and seek treatment because it could have negative consequences when they apply for their license. Fear of negative consequences is not unfounded. A recent study found that states are more likely to ask for history of treatment and prior hospitalizations for mental health and substance use, compared with physical health disorders, even when mental health disorders are not causing impairment. Seeking mental health services can be overwhelming for clinicians in part to due anxiety about licensure, credentialing, and hospital privileging. State medical boards tend to ask physicians broad questions that intrude on privacy and do not necessarily identify impaired physicians. The American Medical Association recently approved a policy asking state medical boards to refrain from asking applicants about a history of mental illnesses and substance abuse treatment and to focus only on current impairment by mental illness or addiction. Some dental and nursing state licensing boards ask similar questions about mental health and could follow similar lessons in focusing on current impairment instead of past history. Health care organizations can also consider offering third-party options for clinicians and other health care professionals to seek help in non-punitive ways.

Insurance Policies, Reporting, and Reimbursement

A major cause of burnout seems to be myriad administrative tasks that clinicians must endure in order to be reimbursed and to prove that they are effectively tracking patient care. In a recent survey, 23% of physicians reported that they and their staff completed more than 40 prior-authorization requests in the week before taking the survey, amounting to more than 20 hours per week completing such requests. Not only do these requests result in an enormous time suck for many clinicians, physicians and nurses alike, they often delays patient access to necessary care. Ultimately, pre-authorization remains a draining burden that disrupts workflow and pulls clinicians away from patient care. Recently, the American Medical Association and a coalition of 16 other organizations issued a comprehensive set of 21 principles designed to reshape the pre-authorization process.  The implementation of these principles can make way for clinicians to have more time with patients, less paperwork, and ultimately, better patient care.

Documentation for reimbursement is also tied to burnout. For every one hour of face-to-face care, physicians spend two hours documenting to meet billing requirements. The design of electronic health records has not made this easier. In fact, computerized physician order entry is an independent predictor of burnout. Additionally, in the last decade, the number of quality measures directed at health care organizations by Medicare, Medicaid, and private health insurers has skyrocketed. There are thousands of measures in use today and a clear lack of consistency, compatibility, reliability, focus, and organization. In a recent study, researchers found that physician practices spent an average of 785 hours per physician and more than $15.4 billion dealing with the reporting of quality measures to report to Medicare, Medicaid, and private health insurers. These measures are used as a basis for financial “pay-for-performance” incentives to physicians. More than 159 measures of outpatient physician care are now available and reporting on these measures imposes a considerable burden to medical practices. While the health system has much to gain from quality measurement, the current operation is not efficient and encumbers clinicians from providing care. To achieve better health at lower cost, leadership must prioritize efforts to reduce the number of measures and standardize their use across the health system. The less time clinicians have to spend reporting on measures, the more they can focus on providing patients with the best care possible.


Licensure requirements, litigation risks, and high-states assessments all contribute to clinician burnout and further inhibit #ClinicianWellBeing

Litigation Risk

Malpractice suits can also take a profound personal toll on clinicians. The allegation of medical malpractice can be extremely traumatic to the accused clinician and may result in feelings of anger, denial, guilt, isolation, anxiety, and depression. Most physicians, regardless of specialty, will face a claim made against them, resulting in a long-term, high-stress litigation process. In fact, it has been noted that more than one-third of physicians spend more than 40 hours on their defense, including getting records together, meeting with their attorney, and preparing for discussions. This is valuable time that physicians lose.  While medical malpractice suits may be an inherent part of providing medical care, most clinicians, including nurses, pharmacists, and dentists, are ill-prepared to deal with the devastating effects litigation can have on them, their families, and their medical practices. In a study of U.S. surgeons, researchers found that malpractice suits were strongly and independently linked to surgeon depression and career burnout. The stress caused by malpractice litigation was rated as equivalent to that of financial worries, pressure to succeed in research, work/home conflicts, and coping with patients’ suffering and death. Finally, surgeons who experienced a recent malpractice lawsuit reported less career satisfaction and were less likely to recommend a surgical or medical career to their children or others. Litigation-related stress is also known as medical malpractice syndrome and the accused clinician should seek support, understanding, and comfort from immediate family members, close friends, defense counsel, and professional colleagues. Education is crucial to dealing with medical malpractice syndrome and clinicians may derive therapeutic benefit from being actively involved with the defense attorney team, becoming educated and comfortable in dealing with tactics of the plaintiff’s attorney, and by becoming educated about medical malpractice stress and its effects on clinicians.

Bottom Line

Accreditation, high-stakes assessments, publicized quality ratings, licensure requirements, litigation risk, and insurance policies all play a role in how and when clinicians experience burnout. Health insurance companies, state medical boards, and other accrediting institutions must consider ways in which their current systems and processes contribute to the broader problem of burnout in our health care system. These organizations should begin to adopt solutions that help reignite professional fulfillment and allow clinicians to focus on what they do best—providing the best possible care to patients.