Rethinking Burnout

Will solving physician burnout require sweeping changes to the U.S. health-care system? 

About 15 years ago, during the first year of his fellowship, Tait Shanafelt, MD, was riding a bus when he heard a famous radio broadcaster describing a small study Dr. Shanafelt had conducted during the last year of his residency. “I was shocked. Paul Harvey came on the radio and actually said there was a new study from the University of Washington showing physician burnout affects quality of patient care,” Dr. Shanafelt said. “It was like an out-of-body experience.”

The study, published in 2002, stemmed from an observation Dr. Shanafelt made during the third year of his residency: Many of the residents he was working with – people he’d considered exceptionally altruistic and compassionate – seemed to be growing cynical.1 When his supervisor asked why he cared, he answered, “Because it’s affecting our patients.” With those words, his supervisor greenlit the study which, Dr. Shanafelt said, became “a lightning rod.” “It was one of the first to look at the links between physicians’ wellbeing and quality of care.”

Dr. Shanafelt and coauthors asked 115 residents to assess their experiences of burnout using the Maslach Burnout Inventory, then to answer an additional five questions to assess self-reported behaviors that suggested suboptimal care (for example, “I did not fully discuss treatment options or answer a patient’s questions” and “I made … errors that were not due to a lack of knowledge or inexperience”). Three-quarters of participants met the criteria for burnout, and burned-out physicians were more likely than non– burned-out physicians to self-report at least one suboptimal patient care practice each month (53% vs. 21%; p=0.004).

Clinicians and researchers around the world have begun taking notice and raising awareness of an issue that affects more than half of all U.S. physicians. For years, interventions have been focused on the idea that physicians need to build more resilience to thrive in stressful and demanding positions. Now, some physicians are pushing back against that idea and turning their attention to interventions at the organizational and systematic levels – such as offering more flexible hours, increasing physicians’ autonomy, lightening their workload, and encouraging their meaningful interactions with patients.

“Ultimately, we need happy, healthy physicians to take care of patients,” Nisha Mehta, MD, a radiologist at the W. G. (Bill) Hefner Veterans Affairs Medical Center in Charlotte, North Carolina, and a wellness advocate, told ASH Clinical News. “If you look at things from a policy standpoint, it’s scary that physicians are not feeling happy or healthy.”

ASH Clinical News spoke with Drs. Shanafelt, Mehta, and others about the epidemic of physician burnout and the shifting approaches to its prevention and management.

Where Do We Start? 

The Maslach Burnout Inventory, a commonly used test for measuring professional burnout, was developed by psychologist Christina Maslach, PhD, in 1981,2 It measures three dimensions that distinguish burnout from run-of-the-mill stress or tiredness: emotional exhaustion, personal accomplishment, and depersonalization (which manifests as a lack of empathy or cynicism).

The consequences of burnout can be dire – for both patients and physicians. Burned-out physicians are more likely to make mistakes in patient care, and, as reported in a recent meta-analysis reviewing reports describing the occurrence and attempts to prevent physician suicide, the suicide rate in among physicians is more than that of any profession. Over the past 10 years, the suicide rate among physicians is 28 to 40 per 100,000 – nearly double that of the general population.3

The most common psychiatric diagnoses among physicians who completed suicide were mood disorders, alcoholism, and substance abuse, but fear of stigma was a major obstacle to seeking treatment for these issues. “Treatment interventions have not lowered the rates of physician suicide,” the researchers reported, adding that “there is little consensus on effective means of preventing physician suicide.”

When this problem entered the mainstream consciousness, interventions typically focused on building physician resilience, or the capacity to recover from difficulties or “bounce back” from the stress of the training and/or the clinical environment.4 According to the American Medical Association (AMA), a resilient doctor is better equipped to handle the many challenges of practicing medicine and therefore less likely to experience burnout. Resiliency improves with age and experience, but physicians “can deliberately enhance [their] resiliency by learning self-management skills and connecting with the meaning and purpose in our lives.”5

A Culture Shift 

Physicians are often drawn to the field of medicine by a desire to serve, which makes them more susceptible to experiencing burnout: Because their priority is caring for others, caring for themselves often takes a back seat.

“We are here to serve our patients,” said Arun Singavi, MD, a hematology/oncology fellow at the Medical College of Wisconsin, and a member of the American Society of Hematology (ASH) Trainee Council. “Complaining seems to be viewed as a sign of weakness, especially in the training environment. You can’t take a break, because exhaustion is a rite of passage.”

Dr. Mehta was quick to point out that physicians have always worked long hours and always had a “lack of relative work-life balance.” In recent years, though, growing piles of paperwork and a diminishing sense of autonomy have eroded the time that physicians spend with patients. “In the past, clinicians had the feeling of really making a difference in their patients’ lives,” she said. “Now, they don’t get to experience that at the same level.”

The increasing workload is one of the “external” factors identified by the National Academy of Medicine (NAM) as a contributor to physician burnout. To better understand physician burnout, the organization developed a conceptual framework of the issue, broken into seven categories. Four of those categories are external factors (related to workload and the environment in which a clinician is practicing medicine) and three are internal factors (related to personal skills, abilities, and roles).6 See a detailed diagram of the NAM’s framework in the FIGURE.

Many organizations have shifted their approach to burnout to address its external causes, like sociocultural, regulatory, business, payer, and organizational factors.

“If you look at things from a policy standpoint, it’s scary that physicians are not feeling happy or healthy.”

—Nisha Mehta, MD

Hospitals also are providing more on-site opportunities for clinicians to practice self-care, like exercise machines, time-out rooms, and gardens.

Dr. Singavi, for one, is searching for alternatives to resilience training and an approach that avoids the implication that individual practitioners need “fixing.” “If you keep punching me, but then you give me Tylenol for the pain and tell me, ‘This is how it’s going to get better,’ I don’t think that’s the answer,” he said. “The answer is you need to stop punching me. Prevention is worth way more than treatment.”

Literature on the topic of burnout tends to focus on the efficacy and application of individual interventions, such as communication-skills training; facilitated and nonfacilitated small-group curricula; and mindfulness, stress management, resilience, and self-care skills.7 That approach has the unintended consequence of placing the onus of solving burnout on the people experiencing it.

Dr. Shanafelt emphasized that, while building individual resilience should be encouraged, “we are now thinking about this from a systems mindset and at the national organization level. Those organizations that don’t follow suit are going to get left behind quickly.”

“Significant system-level changes that address the root causes of burnout must be implemented at each level of the profession,” according to findings from the Best Practices Subgroup of the Collaborative for Healing and Renewal in Medicine (CHARM) project, an initiative of the Alliance for Academic Internal Medicine. “Without these improvements, individual efforts, no matter how intensive, will be futile.”8

Earlier this year, the CHARM Project published its “Charter on Physician Well-being,” outlining appropriate individual, organizational, and system-level interventions to address physician burnout (TABLE).

This is encouraging and, he predicts, is going to make all the difference. “This is an exciting time because there is a higher degree of commitment … to driving change that can be seen across the country,” he explained.

Like the CHARM project, NAM’s Action Collaborative brings together several members of the health-care system (regulators, electronic health record (EHR) vendors, and leaders from professional societies and academic centers) to discuss what can be done to combat burnout.9 “[The group is] having conversations about changes that no individual physician, practice group, or medical center can effect. Those types of changes have never been on the table before because the powerful groups that control those levers have never been engaged in the conversation,” Dr. Shanafelt said. “They are now.”

The EHR Elephant in the Room 

Ask a random sample of practicing clinicians about the causes of burnout, and, more than likely, they will lay blame on EHRs.

“EHRs have been around for a long time,” Dr. Singavi said. “They were meant to provide better communication between providers, more accessible health records for patients, and better, safer care.” Over the past 15 years or so, though, that noble goal has transformed, with “a billion codes, the pressures of meaningful-use measures, and an endless number of clicks.”

Maintaining EHRs has morphed into almost a full-time job: A 2017 study showed that, for every average 11.4-hour workday, clinicians in southern Wisconsin spent nearly six hours in their hospital’s EHR system.10 That means doctors were spending less of their day building relationships and treating patients, and more time entering data – often after they’d left the office.

Increased administrative work, like entering patient information into an EHR, forces doctors to limit time spent with patients, increasing the risk that they will feel disconnected from their work. This limited patient interaction directly hurts physician wellness, according to Beth Lown, MD, chief medical officer of the Schwartz Center for Compassionate Healthcare in Boston. “We need to grow the sense of engagement, happiness, and enjoyment in our work,” she said.

One suggestion for alleviating the administrative burden on physicians is outsourcing these duties. For example, in the emergency department setting, medical scribes increased efficiency; they had a neutral effect on patient satisfaction, but, importantly, they were heavily favored by providers.11

Breaking the Stigma Cycle 

While she believes that delegating administrative labor to scribes can help, Dr. Lown emphasized that physicians need support to remain engaged and compassionate. She manages regular meetings in which all members of the health-care team can discuss issues in a patient’s case that have troubled them.12

The alarmingly high rates of suicide among doctors indicates a need for this type of open, supportive environment – replacing a culture where many physicians feel they must “suffer in silence.” The level of support can vary greatly among different hospitals and departments, and shame and stigma about seeking help for mental health issues persist.

“When one of our trainees needed a break, people stepped up. People said, ‘I can help. I can take your call, or I can take your block for a couple of weeks to give you a break,’” Dr. Singavi recalled. “All of us recognize we are vulnerable to stress, and we’re willing to help get each other through it.”

“Physicians have to play a role in reorganizing care by reasserting the values that are important to us and looking at new ways … to address them.”

—Beth Lown, MD

Unfortunately, many doctors and trainees hesitate to seek help, out of the fear of appearing weak or decreasing their chances for career advancement.

For some trainees, this is particularly distressing; one-third of states include a question on initial and renewal licensing applications about applicants’ mental health and whether they have ever received treatment.13 Forty percent of physicians in states where the questions were used said they would be reluctant to seek help for a mental health issue because of the licensing implications.

“There’s tremendous stigma,” Dr. Lown said. “Students are afraid they’re not going to get the residencies they want if they fess up that they need help. Physicians are afraid that they’re not going to be sustained in their employment.”

In response to growing concerns about the mental health of physicians and medical students, the AMA has adopted a new policy to reduce the stigma associated with medical professionals seeking mental health care.14

They are urging state medical licensure boards to remove questions regarding mental health from licensing applications or to ask physicians only about current mental or physical disabilities that could affect the provider’s ability to practice medicine in a competent, ethical, and professional manner. The recommendation would reduce the most severe consequences for reporting or seeking treatment, such as dismissal or suspension of medical license.

The new policy is part of the AMA’s Professional Satisfaction and Practice Sustainability initiative, intended to improve health care by focusing on the well-being of physicians and their practices. The AMA brought together physicians, hospital administrators, business leaders, and other stakeholders to discuss processes for reducing physician burnout, creating healthier educational practice environments, and allowing physicians to better care for themselves and their patients.

A primary goal of the initiative is to give physicians more control over their work environments. In 2015, the group published guidelines for how to integrate physicians into the decision-making process with administrative leadership of hospitals and health systems.15 “There’s a huge degree of separation between who makes decisions and the people that are practicing medicine. The culture is top-down,” said Dr. Singavi.

A Values-Based Approach 

Dr. Shanafelt called the work being done at the national level “exciting,” but he also stressed the importance of individualizing organizational approaches. In his work at Stanford, his team has looked at the factors contributing to burnout within the entire organization, as well as identifying specific issues it can tackle in each department.

Different departments may require different approaches. “For example, bone marrow transplant physicians do not have the same challenges that radiologists have, or that family medicine doctors have, or that oncologic surgeons have,” he said. “Although some policy changes will benefit all of those groups, like those top-of-the-house decisions, there are other things that we need to understand about the specific challenges that the bone marrow transplant physician is dealing with in that local unit.”

Physician burnout has been a problem for decades. It’s been getting progressively worse, but as physicians and stakeholders team up to combat its causes, doctors and patients finally have reasons to be optimistic.

“Physicians have to play a role in reorganizing care by reasserting the values that are important to us and looking at new ways to create opportunities to address them,” said Dr. Lown. “Let’s focus on the values of our profession. Let’s put connection, relationship, patient care, and service back at the center in a way that’s meaningful to the people who are providing it.” —By Emma Yasinski

References

  1. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358-67.
  2. Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behav. 1981;2:99-113.
  3. T’Sarumi OO, Ashraf A, Tanwar D, Hicks A. Physician suicide: a silent epidemic. Abstract 227. Presented at the 2018 American Psychiatric Association Annual Meeting, May 5, 2018; New York, NY.
  4. Epstein RM, Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Acad Med. 2013;88:301-3.
  5. American Medical Association. “Improving Physician Resiliency.” Accessed September 26, 2018, from https://www.stepsforward.org/modules/ improving-physician-resilience.
  6. Brigham T, Barden C, Dopp AL, et al. A journey to construct an all-encompassing conceptual model of factors affecting clinician well-being and resilience. Accessed September 26, 2018, from https://nam.edu/ journey-construct-encompassing-conceptual-model/.
  7. Fox S, Lydon S, Byrne D, et al. A systematic review of interventions to foster physician resilience. Postgrad Med J. 2018;94:162-70.
  8. Thomas L, Harry E, Quirk R, et al. Evidence-based interventions for medical student, trainee and practicing physician wellbeing: a CHARM annotated bibliography. November 2017.
  9. National Academy of Medicine. Action Collaborative on Clinician Well-Being and Resilience. Accessed September 26, 2018, from https://nam.edu/initiatives/ clinician-resilience-and-well-being/.
  10. Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med. 2017;15:419-26.
  11. Addesso LC, Nimmer M, Visotcky A, et al. Impact of medical scribes on provider efficiency in the pediatric emergency department. Acad Emerg Med. 2018 August 1. [Epub ahead of print]
  12. The Schwartz Center. “Schwartz Rounds.” Accessed September 26, 2018, from http://www.theschwartzcenter.org/ supporting-caregivers/.
  13. Dyrbye LN, West CP, Sinsky CA, et al. Medical licensure questions and physician reluctance to seek care for mental health conditions. Mayo Clin Proc. 2017;92:1486-93.
  14. American Medical Association press release. “AMA Adopts Policy to Improve Physician Access to Mental Health Care.” Accessed September 26, 2018, from https://www.ama-assn.org/amaadopts- policy-improve-physician-access-mental-health-care-0.
  15. American Medical Association press release. “AHA and AMA Offer New Guiding Principles on Integrated Leadership.” Accessed September 26, 2018, from https://www.ama-assn.org/ aha-and-ama-offer-new-guiding-principles-integrated-leadership.

To accomplish its mission of conquering blood diseases worldwide, the American Society of Hematology (ASH) recognizes that a strong workforce of clinicians, researchers, and other members of the health-care team is necessary. The Society has advocated on behalf of its members to streamline administrative work and has compiled resources to support the well-being of its members. The “Well-Being and Resilience” section of the ASH website includes materials from the Society’s publications and live meetings that address the myriad factors affecting physician well-being. Visit hematology.org/resilience for more information.

AMA’s Steps Forward

In 2015, the AMA launched the Steps Forward program, a collection of 50 online modules to provide clinicians with proven strategies that can improve practice efficiency, leading to a better patient experience, better population health, and lower overall costs with improved professional satisfaction.1 The modules in the realm of “Professional Well-Being” include:

  • preventing physician distress and suicide
  • improving physician resilience
  • creating the organizational structural elements that support joy, purpose, and meaning in work

The NAM’s Clinician Well- Being Knowledge Hub

In early 2017, the NAM launched its Action Collaborative on Clinician Well-Being and Resilience, a group that includes approximately 200 health-care systems, hospitals, and medical societies (including ASH) committed to reversing trends in clinician burnout.2

This year, it launched the Clinician Well-Being Knowledge Hub, an online repository for hundreds of resources, including peer-reviewed research and tool kits, to help organizations learn more about physician burnout and solutions, including organizational and individual strategies to promote well-being.

REFERENCES

  1. American Medical Association. “Steps Forward.” Accessed September 26, 2018, from https://www.stepsforward.org/.
  2. National Academy of Medicine. “Clinician Well-Being Knowledge Hub.” Accessed September 26, 2018, from https://nam.edu/clinicianwellbeing/.

At the 2017 ASH Annual Meeting, attendees were invited to visit the “ASH Whiteboard Wall on Resilience,” where they were asked to answer the following question: “As a hematologist, or as a trainee, how do you build resilience and face factors that might contribute to professional burnout?”

Hundreds of attendees visited the whiteboard and shared their stories with graphic artists who illustrated their words in real time. Below are a few photos from the display.

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