More than five years after her patient died, a physician is still haunted by her role in his final days.
Earlier this year, in an anonymous TED podcast, the physician told her story. Her patient — whom she called Mr. W — was screaming that he wanted to leave the hospital. Instead of using her usual empathy, compassion and well-honed communication skills to convince him to stay, the physician signed a “discharge against medical advice” order.
Mr. W died a few days later of a hemorrhage that the physician believes could have been diagnosed and treated if he had stayed in the hospital. In her podcast episode, titled “Dr. Burnout,” the physician said the best version of herself — one who was not burned out — would have acted differently.
She is not alone among physicians. In 2014, 54 percent of U.S. physicians surveyed reported at least one symptom of burnout, up from 45.5 percent in 2011, according to a Mayo Clinic study. A work-related syndrome, burnout is marked by emotional exhaustion, detachment from one’s thoughts or body (known as depersonalization) and feeling a lack of personal accomplishment.
While many physician organizations and health systems are trying to tackle physician burnout, surefire solutions are not yet known. One thing has become clear: This is not a problem that individual physicians or health care organizations can solve by themselves.
Mayo Clinic researchers, who have been examining physician burnout from many angles for more than a decade, put it this way in the Viewpoint section of the March 7 issue of The Journal of the American Medical Association: “Meaningful progress will require collaborative efforts by national bodies, health care organizations, leaders and individual physicians, as each is responsible for factors that contribute to the problem and must own their part of the solution. … Solving this problem will require cooperation at every level of the health care system.”
How did it get so bad?
Steven Strongwater, M.D., president and CEO of Atrius Health, agrees that addressing physician burnout requires a collaborative approach. “I personally believe that individual physicians are not able to tackle this,” says Strongwater, who heads an accountable care organization that includes 900 physicians in 36 locations serving 740,000 patients in eastern Massachusetts.
America’s physician burnout problem has many causes, but the regulatory and clerical burden associated with electronic health record technology makes everyone’s list. “I believe the electronic medical record is the tipping point,” Strongwater says.
The EHR movement, however, is not going to be whisked away just because it is a burden. Neither are other oft-cited causes of burnout, including reduced physician autonomy, the emphasis on productivity and the scrutiny of quality, cost and patient-satisfaction metrics.
That is why Jay Bhatt, D.O., senior vice president and chief medical officer for the American Hospital Association, thinks a national, multifaceted effort must be brought to bear on the problem. In addition to the personal toll that burnout takes on physicians — and, by extension, on their colleagues and loved ones — it has grave consequences for health care organizations and their patients.
“We know that the growing threat to clinician well-being directly impacts the quality of care that they deliver, as well as the health and effectiveness of organizations in which they practice,” Bhatt says.
One threat is increased physician turnover due to burnout. Atrius Health estimates that the cost of replacing a physician, including recruitment and training, runs between $500,000 and $1 million. “Turnover is really expensive,” Strongwater says. “Apart from the human impact, there’s a business case to be made that if you could reduce burnout, you would save money.”
In addition, a Stanford Medicine WellMD Center analysis showed that burned-out physicians were twice as likely to leave Stanford within two years as colleagues reporting low levels of burnout.
Even more disturbing is the effect that physician burnout has on patient care. A recently released National Academy of Medicine paper — which the AHA participated in developing — ties burnout to medical errors and patient incidents.
What’s to be done?
While burnout affects many providers, the causes vary widely across organizations and even departments or care teams. For instance, as described in a January article in Mayo Clinic Proceedings, the Mayo Clinic identified departments and divisions with high burnout rates compared with national benchmarks, as well as low satisfaction rates. But the drivers of burnout were different in each work unit, requiring different solutions.
“There's no one solution,” says the AHA’s Bhatt. “The practices and strategies that work are the ones that are contextually relevant to your environment and culture.”
Bhatt encourages health system leaders to consider using one of the physician wellness frameworks that have been developed in recent years. One example is the framework developed at Stanford’s WellMD Center, which focuses on improving efficiency of EHRs to ease physician workload and developing a culture of wellness and personal resilience. “Those are all areas [in which] to organize awareness, action and evaluation,” Bhatt says.
The AHA has made resilience and well-being one part of its physician inclusion agenda. And personal resilience is what “Dr. Burnout,” the physician who told her story on the TED podcast, is focusing on. By redefining what it means to be a “good doctor,” she has stopped pressuring herself to be immediately responsive to everyone’s demands for her attention. Her priority is on being a caring doctor for the patient she is seeing at the moment.
“You work your whole career to not hurt people, and then you watch it happen,” she said. “I watched this happen to other people, too. We have got to do something about this.”
Lola Butcher is a contributing writer to Trustee.
The tipping point of physician burnout
One of the nation’s top authorities on physician burnout, Colin West, M.D., co-director of the Mayo Clinic Department of Medicine Physician Well-Being Program, has published more than 40 papers on the topic.
He and two Mayo Clinic colleagues summarized what they have learned in the Viewpoint section of the March 2017 issue of The Journal of the American Medical Association.
What prompted you and your colleagues to write the Viewpoint piece?
West: Historically, there’s been a tendency to place the responsibility of solutions [for burnout] at the feet of individual physicians. Certainly, individual physicians need to have positive coping strategies and deal with stressful situations in a way that is appropriate. But that verges on a blame-the-victim mentality because we have come to understand that so much of the root of physician stress lies in our health care system and in our organizations.
One purpose of that paper was to briefly summarize a decade's worth of work from our group and others around the world, but then [that] led into: 'OK, what groups need to take responsibility for the solutions?' It was intended to help people who are responsible for higher-level leadership directions to recognize that this is a shared responsibility and they need to be stepping up to the plate.
One of the things that we are trying to emphasize is that addressing physician burnout is not a matter of 'Can we afford to do this?' Because [given] all the negative impacts of physician burnout, this is something we can't afford not to do.
Physician burnout has been discussed for many years now. What is the trigger prompting so many health system leaders to step to the forefront at this time?
West: Until as recently as maybe two years ago, I think the majority of organizations in medicine had sort of a rudimentary understanding of what the issues around physician burnout were. The cumulative effect of the literature has been such that it finally reached that tipping point where it became something that could not be ignored.
In 2015, we published a paper — we partnered with the AMA to identify the national rates of burnout and their change from 2011 to 2014 — that showed that, in those three years, the burnout rate across every specialty of medicine had worsened, on average, by 10 absolute percentage points. That was the first time, at least in national documentation, that the burnout rate was more than 50 percent. That served as a little bit of a focal point for the cumulative weight of evidence.
How will the National Academy of Medicine’s initiative to promote clinician well-being and combat burnout make a difference?
West: What we expect to come out of the NAM initiative is an elevation of that sense of responsibility from leaders in medicine around the country and around the world. They are saying: 'You know what? We do have a responsibility to improve the environments within which our physicians are practicing.'
This is not a selfish thing for physicians. This is actually in service of optimal patient care because we know that when physicians are gaining more meaning in their work, are more satisfied in their work and are less burned out, they are better able to meet the needs of our health care system and our patients.
Getting a large national group of leaders together to realize that they are not alone in this is hugely impactful in changing the direction nationally. Until now, if you are the leader of a health care organization, you may be wondering, 'How committed to this should I really be? I'm not sure that I'm ready to be the first adopter of major changes like this.'
But when you get a major group together as the National Academy of Medicine is doing, people start to realize, 'I'm not the first adopter. This is actually a wave, and I need to be part of this wave or I'm going to be left behind.'
All 10 health system executives who gathered for an American Medical Association summit on physician burnout last fall already recognized that the problem was taking a toll on their organizations. By the time they left the meeting, they had identified physician burnout as a national public health crisis and agreed to take ownership of the problem.
“Leadership is needed to address the root causes of this problem and reposition the health care workforce for the future,” the CEOs wrote in a Health Affairs blog post.
The CEOs represented the Mayo Clinic, Cleveland Clinic, Vanderbilt University Medical Center Hospital & Clinics, Kaiser Permanente, Sutter Health, Johns Hopkins Medicine, Duke Health, Atrius Health, Partners HealthCare and Northwestern Memorial HealthCare.
“We candidly acknowledge that we don’t have all the answers, or know for certain what the most impactful interventions are, but we are beginning to learn, and progress is being made in some areas,” they wrote.
To that end, they committed to 11 actions:
- Regularly measure the well-being of physicians at their institutions using a standardized instrument.
- Include measures of physician well-being in their institutional performance dashboards.
- Track the institutional costs of physician turnover, early retirement and reductions in clinical effort.
- Emphasize the importance of leadership skill development for physicians and their managers.
- Address the clerical burden and inappropriate allocation of work to physicians, acknowledging its contribution to professional burnout.
- Support team-based models of care.
- Encourage government regulators to address the burden of unnecessary and/or redundant regulations.
- Support the AMA and other national organizations to push regulators and technology vendors to reduce the burden of electronic health record systems on all users.
- Share anti-burnout best practices.
- Educate CEOs and other stakeholders about the importance of reducing burnout among physicians and other health care professionals.
- Conduct research to determine the most effective policies and interventions to improve the well-being of the health care workforce.
Other national efforts are also taking place. For one, the National Academy of Medicine launched an “action collaborative” in December to promote clinician well-being and resilience. More than 35 professional organizations, including the American Hospital Association, health systems and payers, have signed on as sponsors.
In addition, this summer, the AHA joined with the AMA, the American Nurses Association, the Association of American Medical Colleges, the Mayo Clinic and the Agency for Healthcare Research and Quality to develop a discussion paper on burnout among health care professionals.