Loss of autonomy fuels burnout. Involving physicians and other clinicians in designing burnout interventions could be an important step toward a solution.
Subject Matter Experts: Jeni Bowers-Palmer; Edward W. Cheesman, M.D.; Benjamin Clyburn, M.D.; Constance Guille, M.D.; Robert J. Malcolm, M.D. and Alejandro M. Spiotta, M.D.
by Kimberly McGhee
Illustrations by Emma Vought
On completion of this article, readers should be able to:
- Recognize the warning signs of physician burnout.
- Explain why physician burnout is a patient safety issue and recognize that obtaining help to address it is the best way to ensure that patient care is not impaired.
- Discuss institutional and physician-directed strategies to address physician burnout.
Physician burnout is a syndrome characterized by emotional exhaustion, depersonalization and a loss of meaning in work and is driven principally by stressors in the workplace.1 Although physician burnout is not new, recent years have seen a spike in its prevalence. According to one much-cited Mayo Clinic–led study, the proportion of physicians reporting at least one symptom of burnout on the Maslach Burnout Inventory increased almost ten percent in just three years, from 45.5 percent in 2011 to 54.4 percent in 2014.2 The 2016 Medscape Lifestyle Report showed that, though burnout is rising rapidly among all physicians, women have higher rates of burnout than men (55 vs. 46 percent).3 Clinical leaders and administrators as well as physicians have begun to recognize the problem: 96 percent of those responding to a recent survey by NEJM Catalyst identified burnout as a moderate or serious threat to the health care system.4
What fuels burnout?
Most physicians go into health care to provide quality care to patients, and obstacles that prevent them from doing so are, in the opinion of Danielle B. Scheurer, M.D., MUSC Health chief quality officer, leading causes of burnout.
“Anything that makes it difficult for clinicians to take good care of a patient burns them out,” explains Scheurer.
In recent years, the health care industry has undergone unprecedented changes that have affected the ways physicians deliver care. At one time, most physicians were small business owners who could control the parameters of care. Now, in part because of need to pay back large student debts, most physicians are employees of health care systems and some feel a loss of autonomy that is a risk factor for burnout.
“What makes work really stressful for physicians is that we have a really high degree of responsibility but increasingly a lower degree of autonomy and control,” says Constance Guille, M.D., an associate professor in the Department of Psychiatry and Behavioral Medicine, who has studied the effects of stress on medical students and interns and is a member of the physician burnout workgroup created by the American Psychiatric Association. “So when we are unable to make decisions that are going to affect patient outcomes but are completely responsible for those outcomes, it is incredibly stressful and those are the things that are leading to burnout,” explains Guille.
Increases in regulatory and payer demands, pressures to increase productivity and the institution of the electronic health record (EHR) have dramatically affected clinicians’ workflows, leaving many physicians feeling overwhelmed and unable to control the quality of care they provide. Some worry that the physician-patient relationship could be one unintended casualty of the requirements for increased documentation. A recent study of physicians working in ambulatory care revealed that they spend almost twice the time on the EHR and clerical and administrative tasks (49.2 percent) as on direct clinical face time with the patient (27 percent).5 Many of the physicians report spending another one to two hours each evening finishing documentation and administrative tasks at home, which physicians have dubbed “pajama time.”5 Feeling overwhelmed by clerical responsibilities, physicians lose sight of what brought them into medicine — the desire to interact with and heal patients.
Feeling the fallout
Burned out physicians are also more likely to leave the profession or to recommend against others pursuing it, exacerbating already severe physician shortages in some areas. A recent survey by the Physicians Foundation revealed that 63 percent of respondents said they have negative feelings about the future of the medical profession, 49 percent said they often or always experience feelings of burnout and 49 percent said that they would not recommend a career in medicine to their children.6
Burnout is a risk factor for depression, and studies have shown an association between burnout and substance abuse, particularly alcohol abuse.7 Both depression and substance abuse are in turn risk factors for suicide. Male physicians are 1.5 times more likely and female physicians 2.2 times more likely to commit suicide than their counterparts in the general population.
Positioned at the apex of medical care, a burned out physician can demoralize his or her staff and colleagues. Burnout is not solely a physician problem and can affect all members of the clinical care team.
Most important of all, burnout can affect patient care. A well physician is better able to “heal” patients and to earn his or her patients’ trust, whereas burned out physicians are more prone to experience compassion fatigue and to make medical errors. Each one point increase in depersonalization (on a scale from 1-33) or emotional exhaustion (on a scale of 1-54), both measures of burnout, led to an increase of 11 percent and five percent, respectively, in the likelihood of a surgeon reporting a medical error.8
“It’s overdue to have a local, state and national conversation around clinician burnout and its impact on patient care,” says Scheurer.
Joining the national conversation
In late March 2017, the CEOs of the American Medical Association and ten leading health care systems declared physician burnout a public health crisis, committed themselves to addressing it and issued a call to arms for other health care administrators to join them in their efforts.9 A number of MUSC Health physicians heard that call and have begun to work to raise awareness about the issue among both resident and attending physicians.
With the help of Jeni Bowers-Palmer of the MUSC Employee Assistance Program (EAP), Benjamin Clyburn, M.D., senior associate dean for graduate medical education at the Medical University of South Carolina, has begun discussing the topic at new resident orientations and chief resident conferences to ensure residents can recognize the warning signs of burnout (Table) and know how to find help on campus. Clyburn and Bowers-Palmer are working to ensure that residents have 24/7 access to EAP services, a new requirement for graduate medical education.
Pediatric ophthalmologist Edward W. Cheeseman, M.D., became concerned about burnout as more and more of his colleagues confessed to feeling overwhelmed, and his concern only grew as he versed himself in the literature surrounding burnout, including an influential series of articles10,11 in Mayo Clinic Proceedings by Tait Shanafelt, M.D., who runs the physician wellness program at Mayo. Feeling compelled to raise awareness about the scope of the problem, he delivered a grand rounds presentation on the topic to his fellow ophthalmologists, prompting the department to decide to survey its physicians about burnout.
“The Maslach Burnout Inventory is the best in class in the industry for measuring burnout,” explains Scheurer, who attended Cheeseman’s grand rounds at his request. Scheurer, Cheeseman and Andrew S. Eiseman, M.D., chair of the Department of Ophthalmology, are working together to purchase a license for the inventory as well as an extra set of questions that more deeply probes the drivers of burnout. They will use the inventory to gauge burnout among residents and faculty in the ophthalmology department and to inform the development of interventions to address it. The inventory and the interventions that prove useful will be made available to other interested departments, which are encouraged as well to develop new interventions tailored to their specialty.
“We started with ophthalmology because they were the first to raise their hand,” says Scheurer. “To roll the effort out further, we will need more departmental champions and physician partners to help develop meaningful interventions.”
Interventions to address physician burnout
Most interventions to target burnout focus either on developing physician resiliency or on making institutional changes that reduce the triggers of burnout. Although both types of initiatives are effective,12 a recent meta-analysis1 of 19 randomized controlled trials (RCTs) of burnout interventions suggests that institutional efforts are more effective, not surprising since workplace stressors are the primary triggers of burnout. Subgroup analyses showed that organization-directed interventions reduced burnout measures of emotional exhaustion significantly more than physician-directed ones (standardized mean difference [SMD], -.045 [95% confidence interval ,–0.62 to –.28] vs. SMD, –0.18 [95% CI, –0.32 to –0.03).1
In May 2017, the Physician Burnout Workgroup of the American Psychiatric Association began work on its own meta-analysis of 26 RCTs of burnout interventions, three quarters of which were physician-directed interventions and a quarter of which were institution-directed efforts. Early findings show that 71 percent of institution-targeted interventions successfully reduced burnout, while only 42 percent of physician-directed efforts did so. “If you are burned out, you should by all means go get help for that,” says Guille, who is a member of the APA workgroup. “But if there are going to be real changes in burnout, that has to come at the organizational level because burnout is the function of an organization, not an individual.”
Most physician-directed interventions attempt to improve physicians’ resiliency — their ability to withstand stress with their self-esteem, love of their profession and ability to relate to others intact — by teaching them communication and coping skills through cognitive behavioral therapy (CBT) and stress reduction techniques such as mindful meditation. They also encourage small group discussions that build camaraderie and physician wellness programs.
Most EAPs offer, or can make confidential referrals for, CBT and mindfulness-based interventions. Online resources are also available, including a free CBT training program intended to help identify and address depression and anxiety (https://moodgym.anu.edu.au /welcome), mindfulness-based and other wellness tools at Stanford Medicine’s Well MD (https://wellmd.stanford.edu) and four modules on physician wellness developed by the AMA Steps Forward program (https://www.stepsforward.org/).
Small group discussions have shown promise in helping physicians feel less isolated, one of the symptoms of burnout, and provide a necessary release valve for stress. Balint groups, for example, which dedicate weekly sessions to exploring a case that has proven emotionally difficult for one of the participants, enable physicians to express their feelings in a safe, controlled environment and to reconnect with and draw support from colleagues. (Learn more at http://americanbalintsociety.org.)
In light of evidence that physicians-in-training often experience a deterioration in both physical and mental health, a number of training programs have instituted physician wellness programs. Long hours, a stressful work environment, heavy workloads, disturbed sleep cycles, poor diet and lack of physical activity all take their toll, leading to burnout, which in turn increases the risk of depression and anxiety. A 2010 study showed that the percentage of students meeting criteria for depression increased from 3.9 percent the year before internship to a mean of 25.7 percent during internship.13 Indeed, suicide is the second leading cause of death among residents.
At MUSC Health, a number of training programs have begun wellness programs for their residents. For example, in the two years since the creation of Operation La Sierra, a wellness program for both resident and attending physicians in the Department of Neurosurgery, the physical and mental health of its participants has markedly improved, drawing the notice of leading institutions across the country. Two keys to the success of the program have been the involvement of resident and other physicians in the design of the assessments and interventions and the decision to make the program voluntary, leaving it to physicians to decide, without consequence, whether they wanted to participate.
Participants in the program underwent a battery of health screenings, military style drills and psychological tests to establish baseline values for physical and emotional health. The results were shocking: 80 percent of participants had abnormal findings on screening, 67 percent had a higher-than-ideal body weight and 79 percent reported a quality of life that was below that of an average healthy adult.14
“Many of our residents had been college athletes,” says Alejandro M. Spiotta, M.D. “But within a couple of years of residency, we had high rates of anxiety, depression, poor sleep, high cholesterol and high blood pressure, and this was in physicians in their late twenties and early thirties. It was really alarming. This was having a drastic, negative and almost toxic effect on both the physical and mental health of our trainees. This was not really the physician that patients wanted coming out the other end of training.”
The Department of Neurosurgery set out to change that by integrating presentations on wellness topics such as sleep hygiene, stress management, substance abuse and mental health disorders into their weekly departmental meetings. It also instituted a weekly one-hour trainer-supervised group exercise section for all departmental members. These department-level efforts inspired independent efforts by faculty members: one invites resident and attending physicians to a weekly game of squash and another runs a cycling group from his home on weekends. Overall, the efforts have increased camaraderie and made it less likely that residents feel isolated. When the participants were retested after these interventions, it was clear that they were getting healthier both physically and mentally — blood pressure and cholesterol levels were down, quality of life and sleep quality had improved and anxiety levels had fallen to levels below those seen in the general population (unpublished results; accepted for publication in Neurosurgery).
“You can work hard and sacrifice for patient care and still find time for yourself,” says Spiotta. “They are not mutually exclusive. It’s a philosophical change. You will live longer, have a longer career, be more productive academically and it will help everybody, including the patients you are taking care of.”
More and more institutions have begun showing their commitment to addressing burnout by making physician wellness and satisfaction one of their quality indicators. Many create an institution-wide physician wellness committee to assess the degree of burnout, identify drivers and create and trial interventions with input from front-line physicians, resurveying periodically to measure success. That same committee can also identify inefficient processes that frustrate physicians and develop performance improvement initiatives to resolve them.
Since burnout develops when job demands and performance expectations are high while the ability to control work is limited, institutional interventions that seek to mitigate workplace stressors by adjusting workloads or schedules and decreasing clerical burden, all with an eye to restoring physician autonomy, are among the most successful.
Physicians who are allowed to spend at least 20 percent of their work life doing something that they care deeply about are less likely to develop burnout. Flexible scheduling can increase physician satisfaction and decrease stress. An ICU study found lower degrees of burnout, better work-life balance and lower levels of physician distress with cross-coverage on the weekends than with continuous scheduling.15 At Hennepin County Medical Center in Minneapolis, MN, stress levels of female physicians came down when an effort was made not to schedule complicated cases as the last case of the day so that they could more reliably leave to pick up their children from daycare by 5:30 pm (https://www.stepsforward.org/modules/physician-burnout).
A number of measures have been developed to reduce the clerical burden on physicians. Tap and go devices enable physicians to instantaneously log into the EHR with the swipe of a badge, saving the physician the frustration of logging in dozens of times each day and as much as an hour a day of work time. Medical scribes, who sit in on the visit and document its details in the EHR, can also help relieve physicians of administrative burden and are allowed per MUSC Health policy. However, some authorizations in the EHR must be completed by providers and many of the EHR-provided clinical decision aides are intended for them as well. Adding advanced care providers to the care team, who could complete the necessary authorizations and documentation and discuss salient features with the physician before the patient visit, could be one answer. Other ideas for optimizing workflow to reduce physician burnout are available through the AMA Steps Forward program (https://www.stepsforward.org/modules?category=workflow).
To date, small reductions in burnout have been achieved with a variety of interventions, but institutional efforts are showing the most promise. To make real headway with burnout, however, more research is needed to determine which of the institution-directed interventions are most effective, whether a combination of institution-directed and physician-directed interventions works better than either alone and whether involving physicians in designing the intervention improves its efficacy. If loss of autonomy fuels burnout, restoring it by calling on frontline physicians to help craft solutions could well be an important step in loosening its grip.
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6 Physicians Foundation. 2016 survey of America’s physicians: practice patterns and perspectives. Boston (MA): Physicians Foundation; 2016 Sep.
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