Research over the last 10 years has shown that burnout – the particular constellation of emotional exhaustion, detachment and a low sense of accomplishment – is widespread among medical students and doctors-in-training. Nearly half of these aspiring doctors end up becoming burned out over the course of their schooling, quickly losing their sense of empathy for others and succumbing to unprofessional behavior like lying and cheating.

Now, in what is the first study of burnout among fully trained doctors from a wide range of specialties, it appears that the young are not the only ones who are vulnerable. Doctors who have been practicing anywhere from a year to several decades are just as susceptible to becoming burned out as students and trainees. And the implications of their burnout — unlike that of their younger counterparts, who are often under supervision — may be more devastating and immediate.

Analyzing questionnaires sent to more than 7,000 doctors, researchers found that almost half complained of being emotionally exhausted, feeling detached from their patients and work or suffering from a low sense of accomplishment. The researchers then compared the doctors’ responses with those of nearly 3,500 people working in other fields and found that even after adjusting for variables like gender, age, number of hours worked and amount of education, the doctors were still more likely to suffer from burnout.

“We’re not talking about a few individuals who are disorganized or not functioning well under pressure; we’re talking about one out of every two doctors who have already survived rigorous training,” said Dr. Tait D. Shanafelt, the lead author of the study and a professor of medicine at the Mayo Clinic in Rochester, Minn. “These numbers speak to bigger problems in the larger health care environment.”

The doctors’ burnout appeared to have little to do with hours worked or even the ability to balance personal life with work. Instead, the only factor predictive of a higher risk was practicing a specialty that offered front-line access to care. More than half of the doctors in family medicine, emergency medicine and general internal medicine experienced some form of burnout.

The study casts a grim light on what it is like to practice medicine in the current health care system. A significant proportion of doctors feel trapped, thwarted by the limited time they are allowed to spend with patients, stymied by the ever-changing rules set by insurers and other payers on what they can prescribe or offer as treatment and frustrated by the fact that any gains in efficiency offered by electronic medical records are so soon offset by numerous, newly devised administrative tasks that must also be completed on the computer.

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For over a generation now, efforts to make health care more patient-friendly have focused on getting patients and doctors to work together to make decisions about care and treatment. Numerous research papers, conferences and advocacy organizations have been devoted to this topic of “shared decision-making,” and even politicians have clambered aboard the train, devoting several provisions in the Affordable Care Act to “preference-sensitive care.”

But one thing has been missing in nearly all of these earnest efforts to encourage doctors to share the decision-making process. That is, ironically, the patient’s perspective.

Now a study published in the most recent issue of Health Affairs has begun to uncover some of that perspective, and the news is not good. In our enthusiasm for all things patient-centered, we seem to have, as the saying goes, taken the thought of including patient preferences for the deed.

The researchers conducted several focus groups with 48 patients from five primary care physicians in the San Francisco Bay area. First, they showed the patient participants a short video on several equally effective but very different treatment approaches for a heart ailment. Then, they asked them questions about what they did with their own doctors when faced with a choice among several treatment options that might be equally effective but could differ in lifestyle effects, cost or range of complications. Finally, the researchers asked the participants if they were comfortable asking doctors about different treatments, discussing their values and preferences or disagreeing with their doctors’ recommendations.

The participants responded that they felt limited, almost trapped into certain ways of speaking with their doctors. They said they wanted to collaborate in decisions about their care but felt they couldn’t because doctors often acted authoritarian, rather than authoritative. A large number worried about upsetting or angering their doctors and believed that they were best served by acting as “supplicants” toward the doctor “who knows best.” Many also believed that they could depend only on themselves for getting more information about treatments or diseases. Some even said they feared retribution by doctors who could ultimately affect their care and how they did.

The findings fly in the face of previous optimistic assumptions about shared decision-making that were based mostly on studies that examined physicians’ intent, but not patient perceptions. “Many physicians say they are already doing shared decision-making,” said Dominick L. Frosch, lead author of the new study and an associate investigator in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute in California. “But patients still aren’t perceiving the relationship as a partnership.”

Interestingly, most participants in this study were over 50, lived in affluent areas and had either attended or completed graduate school. “It’s hard to think that people from more disadvantaged backgrounds would find it any easier to question doctors,” Dr. Frosch said.

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STATEN ISLAND, N.Y. - Teams of EMTs walked into a tense situation yesterday.

Bertha, a 70-something-year-old grandmother, was struggling to breathe. As she quipped about wanting another cigarette, her grandson relayed her history of health conditions. Gently, with practiced hands, the EMTs held stethoscopes to her chest and listened to her breathing, being careful not to disturb her nightgown. In soothing voices, they asked her to describe her symptoms.

Using a series of medical checks along with information provided over the phone by a doctor, they determined they had to treat a build-up of fluid in her lungs, take intermediary steps to help her get oxygenated and get her to the hospital. It was a well-practiced dance for the teams of EMS personnel, who demonstrated an ease in working together and a vast repertoire of emergency medical knowledge -- gleaned from hours logged on the job. Watching them from behind one-way glass in the simulation lab at Staten Island University Hospital's Regina M. McGinn M.D. Education Center in Ocean Breeze, a team of five judges assessed their responses to the patient in distress.

"I was floored by their knowledge base and their competitive edge," said Dr. Paul Barbara, an emergency medicine physician with a sub-specialty in emergency medical services, who dreamed up the idea for the first ever "Sim Lab Wars."

"Their enthusiasm was huge."

A kick-off to the hospital's EMS Week, the friendly competition brought seven teams of four emergency medical responders from across the Island to the hospital's state-of-the art Simulation Lab to compete in a test of knowledge, communication and efficiency.

"This isn't just to get everyone to play in the Sim Lab," said Dr. Barbara, noting that having a good time -- which all participants indeed seemed to do -- was only part of the goal. "It's to educate."

He and nearly a dozen other emergency medicine physicians, nurses and hospital educators and administrators planned the event -- drawing up scenarios for the sick patients, a schematic by which participants would be judged and getting the word out to local EMT teams, to encourage them to sign up.

The 28 participants applied their skills to an uncannily convincing dummy -- a high-tech machine that costs upwards of $100,000 and can simulate dozens of medical conditions. It has "eyes" that dilate, "lungs" that can breathe in and out, and "skin" that feels soft to the touch.

While the four Advanced Life Support Teams worked on Bertha, the three Basic Life Support teams had to treat Tyler, a 20-something amateur bombmaker whose experiment had backfired, leaving him unconscious, with chemical burns all over his body -- the wounds convincingly covering the medical dummy's body.

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PHILADELPHIA — Having a virtual copy of a patient’s blood in a computer would be a boon to researchers and doctors. They could examine a simulated heart attack caused by blood clotting in a diseased coronary artery and see if a drug like aspirin would be effective in reducing the size of such a clot.

Now, a team of biomedical engineers and hematologists at the University of Pennsylvania has made large-scale, patient-specific simulations of blood function under the flow conditions found in blood vessels, using robots to run hundreds of tests on human platelets responding to combinations of activating agents that cause clotting.

Their work was published in the journal Blood.

Patient-specific information on how platelets form blood clots can be a vital part of care. Normally, clots prevent bleeding, but they can also cause heart attacks when they form in plaque-laden coronary arteries. Several drugs, including aspirin, are used to reduce the size of such clots and prevent heart attacks, but, as platelets differ from person to person, the efficacy of such drugs differs as well.

“Blood platelets are like computers in that they integrate many signals and make a complex decision of what to do,” said senior author Scott Diamond, professor of chemical and biomolecular engineering in the School of Engineering and Applied Science. “We were interested to learn if we could make enough measurements in the lab to detect the small differences that make each of us unique.  It would be impossible to do this with the cells of the liver, heart or brain. But we can easily obtain a tube of blood from each donor and run tests of platelet calcium release.”

When blood platelets are exposed to the conditions of a cut or, in a more dangerous situation, a ruptured atherosclerotic plaque, they respond by elevating their internal calcium, which causes release of two chemicals, thromboxane and ADP.  These two activating agents further enhance calcium levels and are the targets of common anti-platelet drugs such as aspirin or clopidogrel, also known as Plavix.  By preventing platelets from increasing their calcium levels, these drugs make them less able to stick together and block blood vessels, decreasing the likelihood of a heart attack.

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Eight-year-old Perry moaned in pain as doctors rushed to his bedside. His grandmother demanded answers of the physicians clapping electrodes to his chest. But things were going downhill quickly, and the half-dozen doctors and nurses in the room focused on threading a tube down Perry's windpipe and shocking his stalled heart back into action.

Then, as Perry's vital signs stabilized, a voice bellowed over the emergency-room loudspeakers: "Scenario over." Perry, a computer-powered manikin, shut down, and the staff filed out of the ER.

That scene, on a recent afternoon at North Shore-Long Island Jewish Health System's medical simulation center, is part of the latest in medical education at hospitals and medical schools: increasingly sophisticated simulations that offer hands-on training, much of the intense pressure of hospital work, and none of the risk.

Part robotics and part theater, these simulations combine ever more lifelike manikins and other technology with stagecraft. Perry is a boy-size medical manikin with a pulse, breathing sounds, blinking eyes and the ability to spurt blood on command.

But the manikins aren't the biggest innovation in medical simulation. Rather, it's the re-creation of lifelike experiences for doctors and nurses. That's where the stagecraft comes in. "Grandma" was an actress from Long Island. In another simulation at the Lake Success, N.Y., center, a nurse planned to give a $70,000 manikin a skin infection by gluing honey-filled bubble wrap to its leg.

The goal is to inure doctors to the tense situations they'll face in real-life hospital wards and emergency rooms. That means juggling technical skills with angry family members, malfunctioning equipment, short-handedness and unpredictable medical complications. To that end, modern simulation focuses not on rote memorization, but practicing teamwork in real time.

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Mimicking an illness is far more than play-acting.

"It's absolutely key to medical student training," said Dr. Paul Paulman, professor of family medicine and assistant dean for clinical skills and quality at the University of Nebraska College of Medicine. The clinical training department oversees the use of "standardized patients" to help teach medical students.

"The students can make errors, and they're not going to cause harm," Paulman said. "You can be observed and get feedback, and you can stretch out the encounters.

Doctors must have good communication skills, he said. "People who are fearful and ill are not at their best. If there's not a relationship developed, the physician isn't going to give good care and the patient is not going to receive good care."

Standardized patients work one-on-one with medical students and also come to classrooms, where students practice dealing with difficult situations such as talking about reproductive issues, delivering bad news and dealing with adolescents or angry patients.

Sometimes students will use a manikin to practice a procedure, such as chest compressions, while simulated family members become upset and do things that might distract a doctor or nurse — a realistic situation that students must learn how to manage.

"We pull our training from real life," Paulman said, and the students love it.

"Would you rather do a paper case or would you rather talk to a human?" he said. "This is what we're going to do for the rest of our lives, so let's practice the real thing. We want to be able to parallel the real world as closely as we can."

To add more reality to the training and bolster its cast of about 70 standardized patients, the college is seeking more minorities, including Hispanics, and young people who are available during daytime class hours.

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If ever an industry were ready for disruption, it is the American health care industry. Americans spend about $7,600 a year per person on health care, one in two adults lives with a chronic disease and the average wait time to see a doctor in a metropolitan area is 20 days. Entrepreneurs have responded by starting health care technology companies that are changing the way we interact with the entire system.

They are also responding to an evolving model of health care, which will ultimately be focused more on outcomes than on services, and to the Medicare and Medicaid Electronic Health Records Incentive Program, which, in an effort to improve the coordination of care, gives providers financial incentives to adopt electronic health records and report how they use them. “We are about to see a fundamental transformation in the way care is delivered and the way patients are engaged with that care,” said Frank Moss, head of the New Media Medicine Group at the M.I.T. Media Lab. Here is a sampling of the innovative companies pushing that transformation.

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Nine national medical groups are launching a campaign called Choosing Wisely to get U.S. doctors to back off on 45 diagnostic tests, procedures and treatments that often may do patients no good.

Many involve imaging tests such as CT scans, MRIs and X-rays. Stop doing them, the groups say, for most cases of back pain, or on patients who come into the emergency room with a headache or after a fainting spell, or just because somebody's about to undergo surgery.

A child with low belly pain and suspected appendicitis? Don't rush her to the CT scanner. Do an ultrasound first. That will give the answer 94 percent of the time, is cheaper and doesn't expose the child to radiation.

Don't put heartburn patients on high doses of acid-suppressing drugs when lower doses and shorter courses will do, they say. You might just be making their symptoms worse when they try to stop the medicine.

An apparently healthy middle-aged guy with few cardiac risk factors comes in for a yearly exam and wants to know how his ticker is. Don't give him a full cardiac workup, with a treadmill test and fancy imaging. This kind of patient accounts for almost half of unnecessary cardiac screening.

Postpone repeat colonoscopies for 10 years if the first one is negative, or if it found and removed one or two early-stage colon polyps, the guidelines state. And stop prescribing antibiotics for mild-to-moderate sinus infections.

And here's one that raises some tricky questions: Most patients who are debilitated with advanced cancer shouldn't get more chemotherapy.

"When somebody is literally bed-bound and unable to walk or take care of himself, it's almost futile to use cancer-directed treatment and will probably have negative consequences," says Dr. Lowell Schnipper, a Boston cancer specialist who helped develop the new guidelines.

Schnipper tells Shots many cancer patients are getting chemotherapy in the last weeks of their lives. He says that does no good, makes patients miserable and may shorten their life.

The Choosing Wisely project was launched last year by the foundation of the American Board of Internal Medicine. It recruited nine medical specialty societies representing more than 376,000 physicians to come up with five common tests or procedures "whose necessity ... should be questioned and discussed."

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In 2007, Kurt Edwards figured he would be stacking and racking 80-pound boxes of dog food and celery in the back of a grocery store for the rest of his working life. And he was fine with that.

But that June, after nine years on the job, layoff notices arrived on the warehouse floor at the Farmer Jack store in Detroit where he worked. His employer, Great Atlantic and Pacific Tea Company, closed the Farmer Jack chain. Today he still does a lot of lifting, but of people, not boxes. Mr. Edwards joined the ranks of former warehouse, factory and autoworkers trading in their coveralls and job uncertainty for nurses’ scrubs.

At 49, divorced with no children, he now tends to patients on the graveyard shift at Sheffield Manor Nursing and Rehab Center, a two-story, gray brick building in a ramshackle neighborhood on Detroit’s west side. Interviewed last month, he says he is making about $70,000 annually, $20,000 more than he did at the warehouse.

The story of how he made the transition is one that men like him appear to be telling with increasing frequency, and the demand for their services is what is setting so many of them on similar paths.

Hard figures are elusive, but the Michigan Department of Energy, Labor and Economic Growth estimates a shortage of 18,000 nurses in the state by 2015 — and the labor force is adapting.

Oakland University in nearby Rochester, Mich., has established a program specifically to retrain autoworkers in nursing — about 50 a year since 2009. And the College of Nursing at Wayne State University in Detroit is enrolling a wide range of people switching to health careers, including former manufacturing workers, said Barbara Redman, its dean. “They bring age, experience and discipline,” she said.

David Pomerville brings a few more years than Mr. Edwards. A 57-year-old nursing student, he spent most of his career as an automotive vibration engineer, including almost 10 years at General Motors. His pink slip arrived in April 2009.

At the time, Mr. Pomerville was earning almost $110,000 a year at the General Motors Milford Proving Ground in Milford Township, Mich.

But having watched another round of bloodletting at G.M. three years earlier, he had already decided on nursing as his Plan B. “I thought, ‘Well, I worked on cars for this long, now I’m going to work on people for a while,’ ” he said.

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