April 17, 2017

The unwholesome cocktail of cynicism, exhaustion and feelings of inefficacy and apathy that has become universally known as burnout afflicts at least half of physicians.  And it is definitely an affliction, with far-reaching implications, not only for the distressed individuals, but also for the quality of care, patient safety, healthcare costs, physician turnover and patient satisfaction. Organizations tend to under-discuss it, but it’s not an issue that hospitals, health systems or individuals can disregard. A March 28, 2017 article on the Health Affairs blog by 10 health system CEOs calls burnout a national public health crisis and “a matter of absolute urgency.”

“A healthy, engaged, energized and resilient physician workforce is essential to achieving national health goals,” the article states.  “Leadership is needed to address the root causes of this problem and reposition the healthcare workforce for the future.”

Of course, anesthesiologists and pain specialists are not exempt from the array of chronic stresses that can drain energy, deplete passion for their profession and leave them questioning why they entered medicine.  According to the Medscape Lifestyle Report 2017, 51 percent of anesthesiologists surveyed reported experiencing this psychological phenomenon that has become an occupational hazard in healthcare.  Anesthesiologists ranked in the middle in terms of burnout prevalence among the specialties, with emergency medicine physicians, obstetrician/gynecologists, family medicine specialists and internal medicine specialists reporting the highest rates (59, 56, 55 and 55 percent, respectively).  The survey of 14,000 physicians found that, overall, burnout has risen 25 percent over the past four years.  The six most common causes of burnout in the 2017 study were too many bureaucratic tasks, too many hours, feeling like a cog in a wheel, increasing computerization (EHRs), insufficient income and too many difficult patients.  Following are summaries of selected research, thinking and initiatives related to what is increasingly being recognized as a serious trend.

Leaders Unite

In the Health Affairs blog piece, the authors urge healthcare leaders to recognize the gravity of burnout as a business issue as well as a personal and professional problem, and to take responsibility for working to mitigate it.  A summit at the American Medical Association (AMA) brought the 10 CEOs together in late 2016 to discuss the literature on burnout, share experiences and successful practices and interventions, and formulate recommendations for healthcare leaders.

At the meeting’s end, participants committed to the following 11 recommendations and urged healthcare organizations everywhere to join in.  Anesthesia leaders and practitioners might use these recommendations as a springboard for collaboration with the physician and nonphysician leaders at their hospitals, health systems and practices.

1. Regularly measure the well-being of the physician workforce at your institutions using one of several standardized, benchmarked instruments.

[One of these measures is the Maslach Burnout Inventory.  In a recent article in Becker’s Hospital Review, consultant Monique Valcour, PhD encourages leaders to be sure to choose a measurement tool that is psychometrically validated.  “Be a discerning consumer of surveys.  If you are using a consultancy firm, ask them specifically how they developed the measure and if it is validated.  Lots of consultants who are putting together these measures typically don't have the expertise to do so.  The results you get back may not be measuring what you think," she says.]

2. Where possible, include measures of physician well-being in your institutional performance dashboards along with financial and other performance metrics.

3. Evaluate and track the institutional costs of physician turnover, early retirement and reductions in clinical effort.

[A recent Mayo Clinic study found that every one-point increase in the seven-point scale of emotional exhaustion in the Maslach Burnout Inventory was associated with a 40 percent greater likelihood that a physician would cut their work hours over the next 24 months.  These reductions come at a cost.  In an article in HealthLeaders, Karen Weiner, MD of Oregon Medical Group estimated the cost of replacing a physician at $250,000 to $500,000.]

4. Emphasize the importance of leadership skill development for physicians and managers leading physicians throughout your organization.

5. Understand and address more fully the clerical burden and inappropriate allocation of work to physicians that is contributing to professional burnout.

[According to a study published in the December 2016 issue of the Annals of Internal Medicine, for every hour physicians provide direct clinical face time to patients, nearly two additional hours are spent on EHR and desk work.  Physicians spend another one to two hours each night doing additional computer and other clerical tasks.  The Centers for Medicare and Medicaid Services has launched an initiative to ease this clerical burden.  The first part of the initiative is an 18-month pilot project to reduce medical review for physicians participating in specified advanced alternative payment models.]

6. Support collaborative, team-based models of care where physician expertise is maximally utilized for patient benefit, with tasks that do not require the unique training of a physician delegated to other skilled team members. 

7. Encourage government/regulators to address the increasing regulatory burden that is driving inefficiency, redundancy and waste in healthcare and to proactively monitor and address new unnecessary and/or redundant regulations.

8. Encourage and support the AMA and other national organizations to work with regulators and technology vendors to align technology and policy with advanced models of team-based care and to reduce the burden of the EHR on all users.

9. Encourage and support the AMA and other national organizations in developing further initiatives to make progress in this area by compiling and sharing best practices from institutions that have successfully begun to address burnout, profiling case studies of effective well-being programs, efficient and satisfying changes in task distribution and outlining a set of principles for achieving the well-being of health professionals.

10. Continue to educate your CEOs as well as other stakeholders in the healthcare ecosystem about the importance of reducing burnout and improving the well-being of physicians as well as other healthcare professionals.

11. Support and use organizational research at your centers to determine the most effective policies and interventions to improve professional well-being among your physicians and other healthcare professionals.

“We must make both the prevention of burnout and the restoration of the joy of a career in medicine core priorities, and address this issue with the same urgent methods we would use to solve any other important business problem:  commit to measurement, develop strategy and tactics, and allocate the resources necessary to achieve success,” the authors state.  “Boards should hold CEOs accountable to implement these approaches to address physician burnout.”

Shared Responsibility

An article in the January issue of Mayo Clinic Proceedings also emphasizes the business case for organizations to invest in efforts to reduce physician burnout.  The article asserts that these efforts must be the shared responsibility of organizations and individual physicians.

“Any healthcare organization that recognized it had a system issue that threatened quality of care, eroded patient satisfaction, and limited access to care would rapidly mobilize organizational resources to address the problem.  Burnout is precisely such a system issue,” write co-authors Tait D. Shanafelt, MD, director of Mayo Clinic’s physician well-being program, and John H. Noseworthy, MD, CEO.

They put forth nine strategies to engage physicians and maintain a more resilient work force.  Many of these ideas can be adapted to your own practices and departments.

1. Acknowledge and assess the problem.  Communicate to physicians that burnout is recognized as a problem at the highest level of the organization. Mayo Clinic uses face-to-face meetings, town halls, radio broadcasts, letters, videos and other communication vehicles.  Once the problem is acknowledged, measure physician well-being as a routine organizational performance metric.
2. Harness the power of effective leadership.  Identify leaders with the ability to listen to, engage and develop physicians.  A Mayo Clinic study of more than 2,800 physicians found that each one-point increase in the leadership score (60-point scale) of a physician’s immediate supervisor was associated with a 3.3 percent decrease in the likelihood of burnout.  
3. Develop and implement targeted interventions.  Not all departments or units will have the same severity or sources of burnout. Tailor interventions to local needs.
4. Cultivate community at work.  Mayo Clinic has created a dedicated meeting area offering free fruit and beverages for physicians and provides one hour of protected time weekly to allow physicians to meet with small groups of peers to build camaraderie. 
5. Use rewards and incentives wisely.  Incentives such as greater scheduling flexibility or protected time to allow physicians to pursue meaningful aspects of work may be more effective than financial incentives, which can foster overwork and contribute to burnout.
6. Align values and strengthen culture.  Make sure your organization is living its stated values by periodically surveying physicians.
7. Promote flexibility and work-life integration. Look for ways to give physicians greater flexibility in when and how they work, such as starting the day earlier or later, and give physicians the option to work less (with an adjustment in compensation).  
8. Provide resources to promote resilience and self-care.  Give physicians objective information on how their well-being compares with physicians nationally and then link them with resources that can help them take the appropriate action.  These resources should cover work-life balance, sleep habits, nutrition, hobbies, personal financial health, relationships and preventive medical care.
9. Facilitate and fund organizational science.  In addition to implementing efforts to reduce burnout, vanguard institutions have the added responsibility of developing evidence-based strategies that will be used by other organizations.  “Given the profound effect of physician well-being on quality of care, patient satisfaction and access to care, such knowledge will be critical to the long-term health and viability of the nation's health care delivery system,” according to the article.

While this article has focused on what healthcare administration can do to minimize physician burnout, physicians must also do everything in their power to manage the controllable aspects of their practice.  One opportunity to do that exists with your billing and practice management vendor.  The scope of services offered by anesthesia billing and practice management companies varies widely, and a quick review of the scope of service in your current agreement may identify additional opportunities to minimize your administrative burden.

Look for the article in the spring issue of our newsletter, Communique, on the role of professional identity in the ability to develop resilience, bounce back from stress and resist burnout.

With best wishes,

Tony Mira
President and CEO