Preventing physician burnout: caring for those who care for us
Aparna Shekar1,2, Gerald L. Klein, MD3, and Peter C. Johnson, MD3
1Ph.D. Candidate, Vanderbilt University, Nashville TN, 2Intern, MedSurgPI, LLC., Raleigh NC, 3Principal, MedSurgPI, LLC., Raleigh NC
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Burnout syndrome is a widespread phenomenon that arises from chronic, unresolvable workplace stress that impacts quality of work and quality of life of the affected individual. It is characterized by physical and emotional exhaustion, decrease in performance, lethargy, cynicism, unhappiness and detachment from others and surroundings. Although there has been a large inflation in rates of burnout among several professions due to the current, unprecedented rates of competition and uncertainty in the global outlook, primary care MDs still remain one of the most vulnerable and particularly susceptible workforces. In fact, physician burnout rates have worsened since 2011 and presently, over half the physicians in the Unites States are suffering from symptoms of burnout1. Researchers over the past decade have focused on understanding the internal and external factors that contribute to burnout and have made significant strides in constructing interventions that can improve physicians’ quality of life. Studies and clinical trials aimed at preventing and treating primary care physician burnout are now arriving at the crossroads of a three-pronged approach involving knowledge, conversation and intervention at the professional and personal levels.
The causes of physician burnout are manifold and originate both from the individual’s surroundings and from within. The medical profession in the United States is a high-intensity environment that pushes physicians to be overworked and underappreciated. It promotes perfectionism, denial of personal vulnerability and requires delayed gratification throughout training and beyond. Medical practice has changed dramatically over the last ten years. It is now much more bureaucratic, regimented, and restrictive. A much greater emphasis is placed on following administrative requirements that has resulted in many physicians not being able to take their own patient notes during office visits, but rather use medical scribes or “professional patient note takers” They are required to complete countless insurance hospital, and governmental forms which are all time consuming. This has necessitated increased non-medical staff that require increased resources, physician management time, and costs. It is also important to consider that physicians experience a significantly higher-than-average frequency of distressing and emotionally painful experiences in the form of patient care that the average person does not experience. Few other professions have to make so many significant decisions that affect countless patients’ and their families’ well-being.
Immediate supervisors play an important role in caring for their employees’ well-being, absence of which can lead to unmet expectations on behalf of both entities. In many health care systems, physicians’ immediate supervisors are not medically trained, are focused primarily on business issues and therefore cannot properly relate to the unique stresses that physicians face. On the other hand, personality traits commonly seen in physicians that predispose them to experiencing burnout are feelings of guilt, compulsiveness to achieve perfect results and denial of mental and physical limitations. Many overworked physicians substitute their personal lives for successful careers; more often than not, they lack a support system in the form of family and friends that can help them maintain a healthy balance with their strenuous professional lives.
Forty two percent of physicians reported burnout in Medscape National Physician Burnout and Depression Report 2018 (Carol Peckman). Family physicians had the second highest rate with 47 percent burnout rate. The respondents claimed that the highest contributing factor is excess bureaucratic tasks. Other factors that confer susceptibility to burnout include but are not limited to physician gender, age, country of practice, financial status and family status. In 2015, the Association of American Medical Colleges reported that average graduating physician medical school debt was $183,000 (https://lendedu.com/blog/average-medical-school-debt/). This did not include undergraduate debt. Such a heavy debt burden fuels the flames of burnout, as does the constant threat of malpractice litigation. Female surgeons were significantly more prone to burnout and associated depressive-like symptoms arising from higher career conflicts, work-home balance conflicts and pressure to have children2. Studies characterizing physician burnout in Canada, UK, USA and the Middle East demonstrated a wide variability in scores among the three dimensions of burnout, possibly due to varying work environments1. Older physicians were less susceptible to experiencing burnout, as were married physicians.
Burnout is extremely deleterious to the personal and professional well-being of primary care physicians. Stress, decrease in job satisfaction and/or performance, rate of medical errors and desire or intent to leave the practice are common in those who are experiencing burnout. Physical symptoms can manifest as insomnia, muscle tension, headaches, and gastrointestinal problems. Additional effects of burnout and associated mental health neglect that have been observed in physicians and clinicians are depression, anxiety, sleep disturbances, fatigue, mental disorders, alcohol and substance abuse, marital dysfunction, premature retirement and perhaps most seriously, suicide. In spite of these serious consequences of burnout, stigmatizing physicians for seeking help and recovery options is prevalent to this day.
Physician burnout that leads to an increased physician turnover rate has tremendous economic costs3. A presentation by Stanford Medicine researcher Maryam Hamidi, Ph.D., at the American Conference on Physician Health in late 2017, showed that physician burnout costs their hospital at least $7.75M a year. Researchers at Stanford University, the National University of Singapore Business School and the American Medical Association evaluated the economic burden of physician burnout - they estimated the annual costs in the United States to be $3.4B of which 79% was attributed to the cost of physicians leaving the medical profession3,#. The negative impact of physician burnout on the well-being of an individual and the country’s medical economy makes it imperative to identify interventions for its large-scale prevention and treatment.
Understanding the causes of burnout has been instrumental in devising ways to intervene. An important tool to quantitatively assess an individual's experience of burnout is the Maslach Burnout Inventory (MBI), originally published by Christina Maslach and colleagues in 1981. The MBI has separate scales to evaluate each major attribute associated with burnout: emotional exhaustion, depersonalization and low sense of personal accomplishment. Significant landmarks have been achieved by research groups that conducted trials in hospitals using the MBI to not only assess physician burnout, but also to find effective interventions to improve their quality of life. A MEMO (minimizing error, maximizing outcome) study conducted between 2001 and 2005 established that adverse work conditions like time pressure and pace, chaotic hospital/clinic environments and unfavorable organizational culture contributed to stress, intent to leave the practice and other burnout symptoms in primary care physicians4. A HWP or Healthy Work Place study published more recently in 2014 designed interventions to improve communication, create changes in physician workflow and targeted quality improvement projects on clinicians’ concerns that decreased burnout and dissatisfaction and improved retention of clinicians in the study5. Other groups have documented the positive impact of professional coaching, positive psychology, mindfulness and organization-level interventions (including facilitated small-group curriculum and self-determination training) on keeping primary care physicians’ stress and burnout at bay6,7. These studies arrive at common focal points in burnout intervention: communication is key and emotional and organizational support is vital to physician well-being.
One proposed method of preventing physician burnout is a Clinical Physician Scientist Program (CPSP). This program is aimed at restoring and re-enforcing the scientific enthusiasm, creativity, and mental stimulation that physicians have, especially those in clinical practice-heavy primary care. It emphasizes how individual physician observation and creative involvement is important and can have an important influence.
The program uses podcasts, webinars, and videoconferences to educate and communicate with the participants. The formation of a CPSP network is designed to reduce isolation and to enhance physician skills, medical interests and fascination. To prevent burnout, it turns their minds from solely mundane tasks to refreshing scientific exploration and accomplishment. Such a program would consist of the following elements, fashioned to promote scientific growth in the context of group communication. It emphasizes elements of scientific discovery in practice that might normally go unnoticed or unapplied. The program as designed recreates some of the most tried and true elements of graduate medical education in the practice setting to enhance creative thinking and group involvement. Facilitated by physicians who are experienced in practice, academia and industry, its elements are:
· Establishment of a Clinical Physician Scientist Program
o Core Program I: Eliciting Constructive Creativity
§ Writing and publishing Case Histories and Case Series
· How to more accurately read and interpret the medical literature
· The identification of significant medical cases for publication
§ Creating posters for medical conferences
§ Conducting (non-product) in-office clinical studies
§ The basics for conducting product clinical trials
o Core Program II: Fostering Enhanced Knowledge Sharing and Professional Growth
o Monthly/Quarterly Journal Club
§ Discuss relevant clinical articles
o Monthly/Quarterly Case History Discussion
o Monthly/Quarterly Clinical Research Discussion
While such a program requires that physicians invest some time, it is designed to reinvigorate them and help make them more productive in their routine daily activities. It works in concert with steps now being taken by health care systems such as the Southern California Permanente Medical Group. Its program, called “Complete Care” recognizes the intolerable time burden being placed on Primary Care Providers and counters this with a four-part program. The program coordinates sharing of some primary care activity with specialists, delegation of time consuming tasks to nurse clinicians and other licensed non-physicians, leveraging information technology to streamline scheduling and testing and finally standardizing care practices to make physician time more efficients8. The combination of healthcare system-wide workload and workstyle changes with focused attention on the growth of the individual physician is a promising plan to control physician burnout. The latter may be particularly important for those physicians in solo or small practices in rural environments but the approach is applicable to all physicians. Being a physician should be one of the most gratifying, stimulating, self- actualization careers one could ever hope to undertake. A new awareness of the causes and prevention of burnout will hopefully restore these features of medical practice. While there is probably not one cure for physician burnout, the use of the CPSP may be one helpful tool. Future studies are being planned to demonstrate the benefit of this program. The use of a CPSP may also stimulate scientific thinking, and help provide physicians with better tools to apply the medical literature for better patient care.
1 Kumar, S. Burnout and Doctors: Prevalence, Prevention and Intervention. Healthcare (Basel) 4, doi:10.3390/healthcare4030037 (2016).
2 Dyrbye, L. N. & Shanafelt, T. D. Physician burnout: a potential threat to successful health care reform. JAMA 305, 2009-2010, doi:10.1001/jama.2011.652 (2011).
3 Shanafelt, T., Goh, J. & Sinsky, C. The Business Case for Investing in Physician Well-being. JAMA Intern Med 177, 1826-1832, doi:10.1001/jamainternmed.2017.4340 (2017).
4 An, P. G. et al. Burden of difficult encounters in primary care: data from the minimizing error, maximizing outcomes study. Arch Intern Med 169, 410-414, doi:10.1001/archinternmed.2008.549 (2009).
5 Linzer, M. et al. A Cluster Randomized Trial of Interventions to Improve Work Conditions and Clinician Burnout in Primary Care: Results from the Healthy Work Place (HWP) Study. J Gen Intern Med 30, 1105-1111, doi:10.1007/s11606-015-3235-4 (2015).
6 Gazelle, G., Liebschutz, J. M. & Riess, H. Physician burnout: coaching a way out. J Gen Intern Med 30, 508-513, doi:10.1007/s11606-014-3144-y (2015).
7 Siedsma, M. & Emlet, L. Physician burnout: can we make a difference together? Crit Care 19, 273, doi:10.1186/s13054-015-0990-x (2015).
8 Arabadjis, S., Sullivan, E., How one California medical group is decreasing physician burnout, Harvard Business Review, June 7, 20
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