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In a study on Physician Burnout by Rosenstein, the three top external factors given as contributing to their stress included the overall economy (52%), health care reform (46%), and Centers for Medicare and Medicaid Services’ (CMS) policies (41%). The top three work-related factors contributing to stress were paperwork and administrative demands (40%), too many hours of work (33%), and on-call schedules and expectations (26%).[13] 2.3 Mechanisms of impact, medical decision making, and executive functions Human compliance with legitimized authority tends to be high despite distress that occurs when authority requires you to do something that you may feel is intrinsically wrong.[14] Physicians are trained to use what they have learned for medical decision making (MDM). Prefrontal cortex (PFC) is the part of the physician’s brain that (together with widespread neuronal networks) is responsible for executive function (EF). EF weighs the multiple factors at hand to make the best diagnosis and treatment plan and is a limited resource. It includes the ability to manage time, attention, switch focus, plan and organize, remember details, curb inappropriate behavior and speech, and integrates past experience (e.g. medical training and experiences) with present needed action to practice medicine of the highest order. The PFC is a collection of interconnected cortical areas that send and receive projections from virtually all brain cortical sensory systems, motor systems, and many other brain structures. Hence, the PFC is important when "top-down" processing is needed to decide what is relevant and what distraction from the intended action.[15] PFC is the most evolved brain region and sub serves our highest-order cognitive abilities. Unfortunately, it is also the brain region that is most sensitive to the detrimental effects of stress exposure. Even quite mild acute uncontrollable stress can cause a rapid and dramatic loss of prefrontal cognitive abilities, and more prolonged stress exposure causes architectural changes in prefrontal nerve cells.[16–23] This constant prioritization processing induced by uncoordinated mandates and subsequent diminished attentional resources available then increases "goal shielding" that attempts to help the doctor filter out other factors and get overly narrow in focus. Over-focus on specifically allocated task-relevant processing (for example, making sure all the Meaningful Use in the electronic record are noted as "marked as reviewed" by properly clicking the appropriate buttons), then detract from cognitive flexibility needed in the clinical moment with the patient needed to weigh factors at hand. Habit memory then predominates over the cognitive flexible memory[19] that would have been used to examine factors in more accurate diagnosis, more comprehensive and effective care planning, as well as the emotional availability to the patient and family. MDM requires efficient and successful decisions and actions, frequently in situations of fast-changing environmental demands. Cognitive control processes allow individuals to flexibly adjust their thoughts and behaviors in accordance to their internal goals and contextual requirements. Acute stress however has been shown to reduce this flexibility.[19, 23–25] Furthermore, it results in more interference between tasks that are performed at the same time, limiting the individual’s multitasking abilities.[26] Cognitive processing capacity of the human mind is limited by the cognitive load put on these capacities. Intrinsic vs extraneous vs. germane cognitive load are the factors involved in best decision making.[27] Intrinsic load refers to the inherent difficulty of the mental task. Extraneous load refers to a burden of unnecessary information that uses up cognitive processing. Germane load refers to an organized pattern of thought that helps in efficient learning and mental tasks. Excessive extraneous load will deplete EF away from the ability to make good medical decisions.[28] Cognitive dissonance and occupational stress occurs in physicians when practice control has to be relinquished to entities that are more remote, faceless, and who do not allow feedback from direct care-providing physicians who see the negative impact and burden of the authoritative order.[29] 3 Work and home environment synergistic factors 3.1 Recent potential contributory factors and neurocognitive impact Adding more mandates, regulations, laws or complex policies to an overworked workforce is not a harmless endeavor, especially if there is no clear scientific evidence that quality of care will be improved. Several recent studies show that the Value Based Pay for Performance Initiatives have not sustained long term improvements in care.[30] The strategy used a government financial muscle approach to reward doctors for positive outcomes not procedures. To some decision-makers, this initiative looked intuitively appealing but did not work out as well as hoped.[31] Tailoring pay-forperformance programs to hospital’s specific situation may have a greater effect on healthcare quality[32] and this later approach would have more individual hospital collaboration with payers instead of adopting a mandatory one size fits all. Meaningful Use (MU) is the CMS initiative in electronic health documentation meant to electronically capture provider behaviors, by clicking buttons that you have completed CMS prescribed tasks. High compliance with the prescribed tasks means you qualify for federal money to offset electronic record expenditure.
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