Banishing Burnout in Healthcare Settings

REGARDLESS OF THE profession, most people have likely experienced occupational burnout at some point in their careers. The syndrome, typically characterized by feelings of emotional exhaustion, increased apathy and fatigue, may also cause individuals to become short-tempered or irritable. In some instances, attention to detail may lag. Obviously, whether a person is an office manager, teacher or mechanic, these symptoms can be problematic and negatively impact job performance. But, if the person is a practicing physician, nurse or other healthcare provider, burnout syndrome can impact the quality of care provided and even patient safety.

So just how widespread is the problem in the healthcare sector? In late 2015, a study conducted by the Mayo Clinic, in partnership with the American Medical Association (AMA), found more than half of American physicians had at least one sign of burnout, a nearly 10 percent increase from prior study results conducted three years earlier.¹ In fact, a recent report written by a panel of prominent healthcare CEOs and presented at a 2017 AMA summit asserts burnout is becoming a “national public health crisis.”² In addressing some of the root causes, the paper states doctors and nurses alike are working longer shifts, caring for more patients and completing more documentation for those patients. “The spike in reported burnout is directly attributable to loss of control over work, increased performance measurement (quality, cost, patient experience), the increasing complexity of medical care, the implementation of electronic health records [EHRs] and profound inefficiencies in the practice environment, all of which have altered workflows and patient interactions,” the report says. “The result is that many previously well-adjusted and engaged physicians have been stressed to the point of burnout, prompting them to retire early, reduce the time they devote to clinical work, or leave the profession altogether.”²

Diagnosing Burnout and Identifying Root Causes

In the healthcare setting, burnout is a concern with far-reaching ramifications. The syndrome can lead to reductions in focus, effort, empathy and bedside manner, which in turn may result in misdiagnoses, medical errors, suboptimal care and increased medical malpractice risk. Having an accurate means of diagnosis for this widespread problem is essential if practitioners are to receive the support and care they need.

Recognized as the leading measure of burnout among healthcare professionals, the Maslach Burnout Inventory³ was created in 1981 by Christina Maslach, professor emerita of psychology at the University of California at Berkeley. The tool consists of 22 questions rated on a frequency and intensity scale, and is considered a go-to resource that identifies three levels or “scales” of burnout:

• Emotional exhaustion measures feelings of being emotionally overextended and exhausted by one’s work.
• Depersonalization measures an unfeeling and impersonal response toward patients.
• Personal accomplishment measures feelings of competence and successful achievement in one’s work.

According to Maslach, “Burnout is a negative state of physical, emotional and mental exhaustion that is the end result of a gradual process of disillusionment. It is typically found among highly motivated individuals who work over long periods of time in situations that are emotionally demanding.”

Changes in medicine resulting from healthcare reform have also introduced workplace pressures that threaten to further destroy the health and morale of America’s healthcare providers. In the Medscape Physician Lifestyle Report 2015, physicians were asked to rank causes of burnout in order of significance.⁴ Respondents cited:

• Excessive bureaucratic tasks
• Long hours at work
• Insufficient income
• Increasing computerization of practice
• Ramifications of the Affordable Care Act

Ann Whitehead, vice president of risk management and patient safety for CAPAssurance, notes, “Healthcare reform has dramatically changed the way medicine is delivered, and we’re all in the process of transformation. Physicians are now asked and required to do much more to keep their practices going. Whereas in the past, physicians would call us with basic risk-management questions, it is now not uncommon to field calls with questions on a wide range of compliance and regulatory issues — MU2, ICD-10, HIPAA, EHR, reimbursement issues, telehealth, CDS and many more. It is inevitable that this increase in responsibilities would detract from time spent with patients and career fulfillment.”⁴

Some say the very culture of the medical field is also a culprit when it comes to burnout, citing an educational system and profession that have long rewarded self-denial, perseverance and expert performance in the face of enormous pressure. In assessing the problem, leading healthcare executives now say the way medicine is practiced in the United States is to blame, fueled in part by growing clerical demands that have doctors spending two hours on the computer for every one hour they spend seeing patients.⁵

According to Anthony Montgomery, MD, organizational psychologist and expert in physician burnout, the educational system is largely responsible for perpetuating burnout by neglecting to cultivate an essential set of skills in its learners. Dr. Montgomery explains that medical education is almost exclusively aimed at perfecting students’ clinical and technical abilities — with little to no attention given to the development of the social, leadership and teamwork skills desperately needed to successfully interact with patients and colleagues.⁵

Addressing Issues at the Organizational Level

In other professions, dealing with burnout can be handled with a variety of physical and mental health interventions. But, when it comes to the medical field, experts say the solutions are not so simple. “This really isn’t just about exercise and getting enough sleep and having a life outside the hospital,” says Tait Shanafelt, MD, a former Mayo Clinic researcher. “It has at least as much or more to do with the environment in which these folks are practicing.”⁵

In a recent study, researchers conducted a meta-analysis evaluating existing randomized clinical trials and before-and-after studies of physician burnout interventions. Specifically, they assessed the effectiveness of two types of burnout interventions:

• Physician-directed, or approaches that target individuals, such as mindfulness or cognitive behavioral techniques to improve coping, communication and competence; and
• Organization-directed, or approaches that focus on improving the workplace environment, such as changes in scheduling, workload, practice operation and decision-making.

The study’s takeaway was that while physician-directed interventions held merit, when it comes to actually beating and preventing physician burnout altogether, organization-directed interventions have a greater positive influence. “The first step to overcoming burnout at the organization level is to listen and understand the root causes. Then, offer institutional support, which can take many forms, including optimizing physician workflows, reducing EHR burdens and increasing physician time on direct patient care. These organization-directed interventions will have a greater effect on burnout among your physicians,” says the study.⁶

Last July, the National Academy of Medicine called on researchers to identify specific organizational interventions intended to ease burnout; and, in the meantime, many hospitals and even health insurers have stepped in to do their part.⁵

In 2017, Cleveland Clinic increased the number of nurse practitioners and other highly trained providers by 25 percent to handle more routine tasks for its 3,600 physicians. It also hired eight pharmacists to assist with prescription refills.

Atrius Health, Massachusetts’ largest independent physicians group, is addressing administrative “overload” by diverting email traffic away from doctors to other staffers and simplifying medical records. The goal, it says, is to cut 1.5 million “mouse clicks” per year.

Insurer UnitedHealth Group, which operates physician practices for more than 20,000 doctors through its Optum subsidiary, launched a program to help doctors quickly determine whether drugs are covered by a patient’s insurance plan during the patient visit. It is also running a pilot program for Medicare plans in eight states to shrink the number of procedures that require prior authorization.

A Career in Crisis

While burnout is said to be affecting all segments of the medical profession, certain areas of specialty seem to be more at risk. In 2015, AMA and Mayo Clinic conducted a survey⁷ of 6,880 doctors to assess the occurrence of burnout. The top five specialties with the highest rates of burnout were providers who practiced:

1. Emergency medicine
2. Urology
3. Physical medicine and rehabilitation
4. Family medicine
5. Radiology

Additional studies indicated, in some instances, practitioners were not only questioning their chosen area of expertise, but their entire career path. The Physicians Foundation 2016 Physicians Survey⁸ revealed:

• 63 percent of its respondents had negative feelings about practicing medicine;
• 49 percent experienced feelings of burnout; and
• 49 percent would not recommend a career in medicine.

While much of the responsibility for addressing burnout is focused on organizational change, this can take time. In the interim, mental health professionals familiar with the problem say healthcare workers must become proactive about recognizing the symptoms of burnout and seek immediate support when needed. Jodi De Luca, PhD, a clinical psychologist at Boulder Community Hospital Emergency Department in Colorado, encourages practitioners to take advantage of the company’s employee assistance program.⁷ “Many healthcare organizations offer resources for employees that include free services such as short-term counseling sessions for personal and/or work-related issues such as alcohol and substance abuse; grief and bereavement counseling; individual, couples and/or family counseling sessions; treatment for psychological disorders; assessments; referrals to specialists; and much more,” she says. “The healthcare industry is very active in educating employees about the signs and consequences of burnout. Support from managers, supervisors and fellow colleagues is essential in addressing the identification, prevention and treatment of burnout.”

Still others assert prevention is key. Mark Linzer, MD, director of the division of general internal medicine at Hennepin County Medical Center in Minneapolis, has studied physician burnout since 1996. He understands why many physicians eventually feel exhausted practicing medicine, but believes the problem is avoidable. 9 “Burnout doesn’t have to be highly expensive to fix,” Dr. Linzer says. “The problem is that no one is listening. People always want to say that physician wellness and performance measures will cost a lot of money, but preventing burnout can actually save money in the long run on recruiting and training new practice staff.”

Dr. Linzer cites at least seven warning signs of burnout, including a chaotic work environment, a disagreement between personal and organizational values, and a poor work/life balance. “Spending quality time with loved ones helps physicians perform better,” he explains. “When they can’t do those things, it’s all they think about during the day, and the patient suffers.”

Moving the Needle Toward Wellness

While the medical profession is just starting to grapple with the epidemic problem of burnout, hope is on the horizon with new and innovative approaches to overall wellness. “I think most healthcare leaders now realize this is a threat to their organization, but there is also uncertainty that they can do anything effective to address it,” notes Dr. Shanafelt. “They say, ‘It’s a national epidemic, what can we do?’”

To address this question, Dr. Shanafelt is part of a pioneering program at Stanford Medicine where he now serves as its chief wellness officer. Stanford is the first U.S. academic medical center to create such a position, and Dr. Shanafelt hopes to build a model program other medical centers will emulate. 10 Currently, Stanford’s WellMD Center offers programs that include peer support, stress reduction and guidance on how to cultivate compassion and resilience. The center also aims to relieve some of the burdens on physicians through organization-level changes such as increased efficiencies and simplified workplace systems. “My experience has shown that an individual organization that is committed to this at the highest level of leadership and that invests in well-designed interventions can move the needle and run counter to the national trend of physician distress and burnout,” he says.¹⁰