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Executive Leadership and Physician Well-being

Nine Organizational Strategies to Promote Engagement and Reduce Burnout
Published:November 18, 2016DOI:https://doi.org/10.1016/j.mayocp.2016.10.004

      Abstract

      These are challenging times for health care executives. The health care field is experiencing unprecedented changes that threaten the survival of many health care organizations. To successfully navigate these challenges, health care executives need committed and productive physicians working in collaboration with organization leaders. Unfortunately, national studies suggest that at least 50% of US physicians are experiencing professional burnout, indicating that most executives face this challenge with a disillusioned physician workforce. Burnout is a syndrome characterized by exhaustion, cynicism, and reduced effectiveness. Physician burnout has been shown to influence quality of care, patient safety, physician turnover, and patient satisfaction. Although burnout is a system issue, most institutions operate under the erroneous framework that burnout and professional satisfaction are solely the responsibility of the individual physician. Engagement is the positive antithesis of burnout and is characterized by vigor, dedication, and absorption in work. There is a strong business case for organizations to invest in efforts to reduce physician burnout and promote engagement. Herein, we summarize 9 organizational strategies to promote physician engagement and describe how we have operationalized some of these approaches at Mayo Clinic. Our experience demonstrates that deliberate, sustained, and comprehensive efforts by the organization to reduce burnout and promote engagement can make a difference. Many effective interventions are relatively inexpensive, and small investments can have a large impact. Leadership and sustained attention from the highest level of the organization are the keys to making progress.

      Abbreviations and Acronyms:

      CEO (chief executive officer), COMPASS (COlleagues Meeting to Promote And Sustain Satisfaction), EHR (electronic health record), JCAHO (Joint Commission on the Accreditation of Healthcare Organizations), SF-8/SF-12/SF-36 (8-/12-/36-Item Short Form Health Survey)

      The Challenge Facing Health Care Executives

      This is a challenging time for health care executives. Increasing price competition, narrowing of insurance networks, and a greater proportion of patients with noncommercial insurance (eg, Medicare, Medicaid) due to the Affordable Care Act have all resulted in declining reimbursements. In parallel, requirements for “meaningful use” of electronic health records have resulted in large capital expenditures and dramatically increased clerical burden for staff.
      • Shanafelt T.D.
      • Dyrbye L.N.
      • Sinsky C.
      • et al.
      Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction.

      Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties [published online September 6, 2016]. Ann Intern Med. http://dx.doi.org/10.7326/M16-0961.

      These financial challenges have, by and large, been addressed by increasing productivity expectations for physicians (ie, caring for more patients with the same amount of time/resources), efforts to improve efficiency, and expense reductions to decrease the cost of care delivered (doing more with less).
      Health care organizations are also facing a variety of other threats. Increased mergers and consolidation of competitors place contracting at risk and are a perpetual, existential threat to organizational survival.

      Evans M. Hospitals face closures as “a new day in healthcare” dawns. Modern Healthcare http://www.modernhealthcare.com/article/20150221/MAGAZINE/302219988. Published February 15, 2015. Accessed July 25, 2016.

      The implementation of new quality metrics and requirements for public reporting necessitates greater attention to measures of system safety and increased resources to count, track, and report these dimensions. The national shortage of nurses and physicians in many specialties makes it challenging to maintain adequate staffing.

      AAMC. Section II: Current status of the U.S. physician workforce. http://aamcdiversityfactsandfigures.org/section-ii-current-status-of-us-physician-workforce. Accessed September 2, 2015.

      US Department of Health and Human Services. The physician workforce: projections and research into current issues affecting supply and demand. http://bhpr.hrsa.gov/healthworkforce/reports/physwfissues.pdf. Published December 2008. Accessed April 15, 2015.

      Assessment of patient satisfaction and ubiquitous ratings of hospital “quality” creates incessant pressure to keep up with competitors in the technological “arms race” and to invest resources to maintain a state-of-the-art physical plant. Attacks from cyber criminals and nation states are a constant threat to information security as well as the trust of patients and the public.
      These myriad challenges often lead health care executives to focus on external threats. This can create a blind spot to equally important internal threats to organizational health. Successfully navigating the external challenges requires not only tremendous leadership but also committed and productive physicians working in partnership with leaders (who may or may not be physicians themselves). Executives need their physicians to be engaged, nimble, resilient, and invested in helping the organization improve quality, develop more efficient care delivery models, and enhance productivity.
      • Swensen S.
      • Kabcenell A.
      • Shanafelt T.
      Physician-organization collaboration reduces physician burnout and promotes engagement: the Mayo Clinic experience.
      Unfortunately, today's health care leaders face these challenges with an increasingly exhausted and disillusioned physician workforce. National studies indicate that at least 50% of US physicians are experiencing professional burnout.
      • Shanafelt T.D.
      • Boone S.
      • Tan L.
      • et al.
      Burnout and satisfaction with work-life balance among US physicians relative to the general US population.
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      Burnout is a syndrome characterized by exhaustion, cynicism, and reduced effectiveness.
      • Maslach C.
      • Jackson S.
      • Leiter M.
      Maslach Burnout Inventory Manual.
      Burnout in US physicians has increased during the past decade and is dramatically higher than that of US workers in other fields.
      • Shanafelt T.D.
      • Boone S.
      • Tan L.
      • et al.
      Burnout and satisfaction with work-life balance among US physicians relative to the general US population.
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      The rate of burnout among physicians varies by clinical discipline, with many of the specialties at the front line of access to care (eg, family medicine, general internal medicine, and emergency medicine) at highest risk.
      • Shanafelt T.D.
      • Boone S.
      • Tan L.
      • et al.
      Burnout and satisfaction with work-life balance among US physicians relative to the general US population.
      Although burnout can also affect nurses and other health care workers, the focus of this manuscript is the epidemic of burnout among US physicians.

      Implications of Physician Burnout

      There is a moral and ethical imperative to address burnout in physicians. Physician burnout contributes to broken relationships, alcoholism, and physician suicide.
      • Shanafelt T.D.
      • Balch C.M.
      • Dyrbye L.N.
      • et al.
      Special report: suicidal ideation among American surgeons.
      • Balch C.M.
      • Oreskovich M.R.
      • Dyrbye L.N.
      • et al.
      Personal consequences of malpractice lawsuits on American surgeons.
      • Fridner A.
      • Belkic K.
      • Minucci D.
      • et al.
      Work environment and recent suicidal thoughts among male university hospital physicians in Sweden and Italy: the health and organization among university hospital physicians in Europe (HOUPE) study.
      • Oreskovich M.R.
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      • et al.
      The prevalence of substance use disorders in American physicians.
      • Shanafelt T.D.
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      • et al.
      The medical marriage: a national survey of the spouses/partners of US physicians.
      • Gabbard G.O.
      • Menninger R.W.
      The psychology of postponement in the medical marriage.
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      • Coyne L.
      Sources of conflict in the medical marriage.
      In addition to the moral-ethical argument, there is a strong professional and business case to reduce physician burnout and promote physician engagement. Studies indicate that physician burnout influences quality of care, patient safety, and patient satisfaction.
      • Firth-Cozens J.
      • Greenhalgh J.
      Doctors' perceptions of the links between stress and lowered clinical care.
      • Shanafelt T.D.
      • Bradley K.A.
      • Wipf J.E.
      • Back A.L.
      Burnout and self-reported patient care in an internal medicine residency program.
      • West C.P.
      • Huschka M.M.
      • Novotny P.J.
      • et al.
      Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study.
      • Williams E.S.
      • Manwell L.B.
      • Konrad T.R.
      • Linzer M.
      The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study.
      • West C.P.
      • Tan A.D.
      • Habermann T.M.
      • Sloan J.A.
      • Shanafelt T.D.
      Association of resident fatigue and distress with perceived medical errors.
      • Shanafelt T.D.
      • Balch C.M.
      • Bechamps G.
      • et al.
      Burnout and medical errors among American surgeons.
      • Linn L.S.
      • Brook R.H.
      • Clark V.A.
      • Davies A.R.
      • Fink A.
      • Kosecoff J.
      Physician and patient satisfaction as factors related to the organization of internal medicine group practices.
      • Haas J.S.
      • Cook E.F.
      • Puopolo A.L.
      • Burstin H.R.
      • Cleary P.D.
      • Brennan T.A.
      Is the professional satisfaction of general internists associated with patient satisfaction?.
      Physician distress has also been linked to physician prescribing habits, test ordering, the risk of malpractice suits, and whether or not patients adhere with physicians' medical recommendations (Figure 1).
      • Balch C.M.
      • Oreskovich M.R.
      • Dyrbye L.N.
      • et al.
      Personal consequences of malpractice lawsuits on American surgeons.
      • Melville A.
      Job satisfaction in general practice: implications for prescribing.
      • Grol R.
      • Mokkink H.
      • Smits A.
      • et al.
      Work satisfaction of general practitioners and the quality of patient care.
      • Jones J.W.
      • Barge B.N.
      • Steffy B.D.
      • Fay L.M.
      • Kunz L.K.
      • Wuebker L.J.
      Stress and medical malpractice: organizational risk assessment and intervention.
      • DiMatteo M.R.
      • Sherbourne C.D.
      • Hays R.D.
      • et al.
      Physicians' characteristics influence patients' adherence to medical treatment: results from the Medical Outcomes Study.
      Based on these relationships, it has been argued that physician distress is an important quality indicator for medical centers to monitor.
      • Wallace J.E.
      • Lemaire J.B.
      • Ghali W.A.
      Physician wellness: a missing quality indicator.
      Figure thumbnail gr1
      Figure 1Personal and professional repercussions of physician burnout.
      Burnout also has strong links to physician turnover and professional work effort.
      • Williams E.S.
      • Konrad T.R.
      • Linzer M.
      • et al.
      Physician, practice, and patient characteristics related to primary care physician physical and mental health: results from the Physician Worklife Study.
      • Williams E.S.
      • Konrad T.R.
      • Scheckler W.E.
      • et al.
      Understanding physicians' intentions to withdraw from practice: the role of job satisfaction, job stress, mental and physical health. 2001.
      • Shanafelt T.
      • Sloan J.
      • Satele D.
      • Balch C.
      Why do surgeons consider leaving practice?.
      • Dewa C.S.
      • Loong D.
      • Bonato S.
      • Thanh N.X.
      • Jacobs P.
      How does burnout affect physician productivity? a systematic literature review.
      • Shanafelt T.D.
      • Raymond M.
      • Kosty M.
      • et al.
      Satisfaction with work-life balance and the career and retirement plans of US oncologists.
      The costs of replacing a physician (recruitment, onboarding, and lost patient care revenue during recruitment, relocation, and ramp up) are estimated to be 2 to 3 times the physician's annual salary.
      • Misra-Hebert A.D.
      • Kay R.
      • Stoller J.K.
      A review of physician turnover: rates, causes, and consequences.
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      • Powe N.R.
      Estimates of costs of primary care physician turnover.
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      • Stoller J.K.
      The impact on revenue of physician turnover: an assessment model and experience in a large healthcare center.
      • Berger J.E.
      • Boyle Jr., R.L.
      How to avoid the high costs of physician turnover.
      Even if physicians do not leave, burnout can have a potentially large effect on productivity. In a prospective longitudinal study of approximately 2000 physicians at Mayo Clinic, each 1-point increase in burnout (on a 7-point scale) or 1-point decrease in satisfaction (on a 5-point scale) was associated with a 30% to 40% increase in the likelihood that physicians would reduce their professional work effort during the next 24 months based on independent correlation with payroll records.
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.

      A Shared Responsibility

      Given the professional repercussions of physician satisfaction and burnout, health care organizations have a vested interest in cultivating physician engagement. Engagement is the positive antithesis of burnout and is characterized by vigor, dedication, and absorption in work.
      • Shimazu A.
      • Schaufeli W.B.
      Work engagement: an emerging concept in occupational health psychology.
      • Maslach C.
      • Leiter M.P.
      Understanding the burnout experience: recent research and its implications for psychiatry.
      Any health care 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.
      • Williams E.S.
      • Konrad T.R.
      • Linzer M.
      • et al.
      Physician, practice, and patient characteristics related to primary care physician physical and mental health: results from the Physician Worklife Study.
      • Maslach C.
      • Leiter M.P.
      Understanding the burnout experience: recent research and its implications for psychiatry.
      Extensive evidence suggests that the organization and practice environment play critical roles in whether physicians remain engaged or burn out (Figure 2). Although a host of factors can contribute to burnout and engagement, these can largely be grouped into 7 dimensions: workload, efficiency, flexibility/control over work, work-life integration, alignment of individual and organizational values, social support/community at work, and the degree of meaning derived from work.
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
      • Shanafelt T.D.
      Enhancing meaning in work: a prescription for preventing physician burnout and promoting patient-centered care.
      • Konrad T.R.
      • Williams E.S.
      • Linzer M.
      • et al.
      SGIM Career Satisfaction Study Group
      Measuring physician job satisfaction in a changing workplace and a challenging environment.
      Each of these dimensions is influenced by individual, work unit, organizational, and national factors (Figure 3).
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
      Given this fact, reducing burnout and promoting engagement are the shared responsibility of individual physicians and health care organizations.
      • Williams E.S.
      • Konrad T.R.
      • Linzer M.
      • et al.
      Physician, practice, and patient characteristics related to primary care physician physical and mental health: results from the Physician Worklife Study.
      • Shanafelt T.D.
      • Sloan J.A.
      • Habermann T.M.
      The well-being of physicians.

      West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis [published online September 28, 2016]. Lancet. http://dx.doi.org/10.1016/S0140-6736(16)31279-X.

      Figure thumbnail gr2
      Figure 2Key drivers of burnout and engagement in physicians.
      Figure thumbnail gr3
      Figure 3Drivers of burnout and engagement with examples of individual, work unit, organization, and national factors that influence each driver. EHR = electronic health record; JCAHO = Joint Commission on the Accreditation of Healthcare Organizations.
      Adapted from Mayo Clin Proc.
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
      Mistakenly,
      • Scheurer D.
      • McKean S.
      • Miller J.
      • Wetterneck T.
      U.S. physician satisfaction: a systematic review.
      • Demerouti E.
      • Bakker A.B.
      • Nachreiner F.
      • Schaufeli W.B.
      The job demands–resources model of burnout.
      most hospitals, medical centers, and practice groups operate under the framework that burnout and professional satisfaction are solely the responsibility of the individual physician. This frequently results in organizations pursuing a narrow list of “solutions” that are unlikely to result in meaningful progress (eg, stress management workshops and individual training in mindfulness/resilience). Such strategies neglect the organizational factors that are the primary drivers of physician burnout and are correctly viewed with skepticism by physicians as an insincere effort by the organization to address the problem. Casting the issue as a personal problem can also lead individual physicians to pursue solutions that are personally beneficial but detrimental to the organization and society, such as reducing professional work effort or pursuing a concierge practice model. The fact that more than 50% of US physicians are now burned out underscores the need for a system-level strategy.
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      • Shanafelt T.D.
      • Sloan J.A.
      • Habermann T.M.
      The well-being of physicians.
      • Bodenheimer T.
      • Sinsky C.
      From triple to quadruple aim: care of the patient requires care of the provider.
      • Spinelli W.M.
      The phantom limb of the triple aim.
      Herein we focus on organization-level strategies to reduce burnout and promote engagement.

      Nine Organizational Strategies to Promote Physician Well-being

      Although the framework of shared responsibility and the need for system-level solutions have begun to be recognized, 2 pervasive myths have been barriers to organizations taking effective action. The first is the belief that the steps necessary to cultivate physician well-being will conflict with other organizational objectives. The second is the assumption that all effective interventions to reduce burnout will be cost prohibitive. The reality is that an engaged physician workforce is requisite to achieving institutional objectives, that small investments can have a large impact, and that many effective interventions are cost neutral. Herein, we summarize 9 organizational strategies to promote physician well-being and highlight how we have operationalized some of these approaches at Mayo Clinic. We do not consider these principles to be exhaustive or definitive. Rather, they represent tangible organizational actions that are supported by evidence and experience.

      Strategy 1: Acknowledge and Assess the Problem

      Acknowledging the problem of burnout and demonstrating that the organization cares about the well-being of its physicians is a necessary first step toward making progress. We have been impressed by how much our staff appreciate open and candid dialogue directly with the chief executive officer (CEO) about the challenge of being a physician in today's world. It is important that these discussions are not rushed and are repeated more often than one initially imagines would be necessary. Depending on the size of the organization, a variety of formats is typically necessary to reach the staff. At Mayo Clinic, we have incorporated town halls, radio broadcasts, letters, and video interviews along with face-to-face meetings involving clinical divisions, work units, and small groups as formats for the CEO to reach the staff. Naming the issue and being willing to listen demonstrates that the problem is recognized at the highest level of the organization and creates the necessary trust for physicians and leaders to work in partnership to make progress.
      Once the problem is acknowledged, it is necessary to measure physician well-being as a routine institutional performance metric.
      • Wallace J.E.
      • Lemaire J.B.
      • Ghali W.A.
      Physician wellness: a missing quality indicator.
      • Spinelli W.M.
      The phantom limb of the triple aim.
      • Linzer M.
      • Levine R.
      • Meltzer D.
      • Poplau S.
      • Warde C.
      • West C.P.
      10 bold steps to prevent burnout in general internal medicine.
      Organizations measure the things that they believe are critical to achieving their mission. All medical organizations routinely assess patient volume, payer mix, quality/safety, patient satisfaction, and financial performance (cost, net operating income, etc). Overwhelming evidence indicates that physician well-being is equally important to the health and long-term viability of the organization, and, thus, it should be measured.
      There are a variety of dimensions of physician well-being worthy of assessment, including: burnout, engagement, professional fulfillment/satisfaction, fatigue, emotional health/stress, and various dimensions of well-being/quality of life (Table). Organizations should select and assess several of these dimensions at regular intervals. Ideally, standardized instruments shown to correlate with outcomes of interest (eg, safety, quality, productivity, and turnover) should be used.
      • Maslach C.
      • Jackson S.
      • Leiter M.
      Maslach Burnout Inventory Manual.
      • Williams E.S.
      • Konrad T.R.
      • Scheckler W.E.
      • et al.
      Understanding physicians' intentions to withdraw from practice: the role of job satisfaction, job stress, mental and physical health. 2001.
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
      • West C.P.
      • Dyrbye L.N.
      • Sloan J.A.
      • Shanafelt T.D.
      Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals.
      • West C.P.
      • Dyrbye L.N.
      • Satele D.V.
      • Sloan J.A.
      • Shanafelt T.D.
      Concurrent validity of single-item measures of emotional exhaustion and depersonalization in burnout assessment.
      • Dyrbye L.N.
      • Satele D.
      • Sloan J.
      • Shanafelt T.D.
      Utility of a brief screening tool to identify physicians in distress.
      • Dyrbye L.N.
      • Satele D.
      • Shanafelt T.
      Ability of a 9-item well-being index to identify distress and stratify quality of life in US workers.
      Using instruments with national benchmark data can also help provide context for interpreting results.
      • Shanafelt T.D.
      • Boone S.
      • Tan L.
      • et al.
      Burnout and satisfaction with work-life balance among US physicians relative to the general US population.
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      • Maslach C.
      • Jackson S.
      • Leiter M.
      Maslach Burnout Inventory Manual.
      • Williams E.S.
      • Konrad T.R.
      • Linzer M.
      • et al.
      SGIM Career Satisfaction Study Group
      Refining the measurement of physician job satisfaction: results from the Physician Worklife Survey.
      • Dyrbye L.N.
      • Satele D.
      • Sloan J.
      • Shanafelt T.D.
      Utility of a brief screening tool to identify physicians in distress.
      • Dyrbye L.N.
      • Satele D.
      • Shanafelt T.
      Ability of a 9-item well-being index to identify distress and stratify quality of life in US workers.
      Tools that are applicable to other health professionals (eg, nurses) and other job types also allows comprehensive assessment of the organization rather than assessment of physician alone. At Mayo Clinic, we first began measuring the professional satisfaction of physicians (as well as our 60,000 other employees) in 1998, and we began systematically measuring burnout using standardized instruments in 2010. We also regularly measure engagement and satisfaction with work-life integration. Historically, we assessed these dimensions every 24 months, but we switched to annual assessment in 2016. We benchmark these measures against national data
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      and use the information as a barometer of organizational health. The results are reported directly to the Mayo Clinic Board of Governors and Board of Trustees along with other key organizational performance metrics.
      TableCandidate Dimensions of Well-being for Organizations to Assess
      DimensionPotential standardized instruments to assessNo. of questionsNational benchmarks for US physiciansComparisons with the general populationRelevant to other health care workers
      Can be used in nurses and other health care professionals (eg, applied at the medical center, hospital, or system level).
      Shown to correlate with relevant outcomes
      Relevant outcomes include quality of care, patient satisfaction, turnover, professional work effort, and suicide.
      Select references
      Achievement/professional fulfillment
      • MeaningPhysician Job Satisfaction Scale5 or 36Yes
      Most recently 1999.
      --NoYes
      • Williams E.S.
      • Manwell L.B.
      • Konrad T.R.
      • Linzer M.
      The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study.
      • Williams E.S.
      • Konrad T.R.
      • Scheckler W.E.
      • et al.
      Understanding physicians' intentions to withdraw from practice: the role of job satisfaction, job stress, mental and physical health. 2001.
      • Konrad T.R.
      • Williams E.S.
      • Linzer M.
      • et al.
      SGIM Career Satisfaction Study Group
      Measuring physician job satisfaction in a changing workplace and a challenging environment.
      • Williams E.S.
      • Konrad T.R.
      • Linzer M.
      • et al.
      SGIM Career Satisfaction Study Group
      Refining the measurement of physician job satisfaction: results from the Physician Worklife Survey.
      • Professional satisfactionEmpowerment at Work Scale12----Yes--
      • Spreitzer G.
      Psychological empowerment in the workplace: dimensions, measurement, and validation.
      • Spreitzer G.M.
      • McCall M.W.
      • Mahoney J.D.
      Early identification of international executive potential.
      Burnout
      • ExhaustionMaslach Burnout Inventory2 or 22YesYesYesYes
      • Shanafelt T.D.
      • Boone S.
      • Tan L.
      • et al.
      Burnout and satisfaction with work-life balance among US physicians relative to the general US population.
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      • Maslach C.
      • Jackson S.
      • Leiter M.
      Maslach Burnout Inventory Manual.
      • Shanafelt T.D.
      • Balch C.M.
      • Dyrbye L.N.
      • et al.
      Special report: suicidal ideation among American surgeons.
      • Shanafelt T.D.
      • Balch C.M.
      • Bechamps G.
      • et al.
      Burnout and medical errors among American surgeons.
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
      • West C.P.
      • Dyrbye L.N.
      • Sloan J.A.
      • Shanafelt T.D.
      Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals.
      • West C.P.
      • Dyrbye L.N.
      • Satele D.V.
      • Sloan J.A.
      • Shanafelt T.D.
      Concurrent validity of single-item measures of emotional exhaustion and depersonalization in burnout assessment.
      • CynicismOldenburg Burnout Inventory16----Yes--
      • Demerouti E.
      • Bakker A.B.
      • Nachreiner F.
      • Schaufeli W.B.
      The job demands–resources model of burnout.
      • Demerouti E.
      • Bakker A.B.
      • Vardakou I.
      • Kantas A.
      The convergent validity of two burnout instruments: a multitrait-multimethod analysis.
      • Inefficacy
      Engagement
      • VigorUtrecht Work Engagement Scale9----Yes--
      • Schaufeli W.B.
      • Bakker A.B.
      • Salanova M.
      The measurement of work engagement with a short questionnaire: a cross-national study.
      • Dedication
      • Absorption
      Fatigue
      • EnergyBrief Fatigue Index9----Yes--
      • Mendoza T.R.
      • Wang X.S.
      • Cleeland C.S.
      • et al.
      The rapid assessment of fatigue severity in cancer patients: use of the Brief Fatigue Inventory.
      • SleepEpworth Sleepiness Scale8----Yes--
      • Johns M.W.
      A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale.
      Stress
      • Work stressPerceived Stress Scale10--YesYes--
      • Cohen S.
      • Kamarck T.
      • Mermelstein R.
      A global measure of perceived stress.
      • Cohen S.
      • Williamson G.
      Perceived stress in a probability sample of the United States.
      • Anxiety
      Quality of Life
      • PhysicalShort Form Health Survey (SF)-8/SF-12/SF-368 or 12 or 36--YesYes--
      • Ware Jr., J.
      • Kosinski M.
      • Keller S.D.
      A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity.
      • McHorney C.A.
      • Ware Jr., J.E.
      • Raczek A.E.
      The MOS 36-Item Short-Form Health Survey (SF-36), II: psychometric and clinical tests of validity in measuring physical and mental health constructs.
      • MentalLinear Analogue Self-Assessment Scales1-10----Yes--
      • Singh J.A.
      • Satele D.
      • Pattabasavaiah S.
      • Buckner J.C.
      • Sloan J.A.
      Normative data and clinically significant effect sizes for single-item numerical linear analogue self-assessment (LASA) scales.
      • Emotional
      • Social
      • Financial
      • Overall
      Composite well-being measures
      • Achievement/professional fulfillmentWell-being Index/Physician Well-being Index
      Evaluates dimensions of meaning in work, burnout, stress, work-life integration, fatigue, mental/emotional quality of life, and physical quality of life.
      9Yes
      Most recently 2014.
      YesYesYes
      • Dyrbye L.N.
      • Satele D.
      • Sloan J.
      • Shanafelt T.D.
      Utility of a brief screening tool to identify physicians in distress.
      • Dyrbye L.N.
      • Satele D.
      • Shanafelt T.
      Ability of a 9-item well-being index to identify distress and stratify quality of life in US workers.
      • Shanafelt T.D.
      • Kaups K.L.
      • Nelson H.
      • et al.
      An interactive individualized intervention to promote behavioral change to increase personal well-being in US surgeons.
      • BurnoutMini-Z
      Evaluates dimensions of professional satisfaction, burnout, and stress.
      16----No--
      • Linzer M.
      • Poplau S.
      • Babbott S.
      • et al.
      Worklife and wellness in academic general internal medicine: results from a national survey.
      • Work-life integration
      • Stress
      • Fatigue
      a Can be used in nurses and other health care professionals (eg, applied at the medical center, hospital, or system level).
      b Relevant outcomes include quality of care, patient satisfaction, turnover, professional work effort, and suicide.
      c Most recently 1999.
      d Evaluates dimensions of meaning in work, burnout, stress, work-life integration, fatigue, mental/emotional quality of life, and physical quality of life.
      e Most recently 2014.
      f Evaluates dimensions of professional satisfaction, burnout, and stress.
      Although anonymous at the level of the individual, results are aggregated at the work unit level (eg, division/department) to allow executive leadership to focus attention and resources where they are most needed. Assessing these dimensions also allows us to evaluate their relationship with other key measures of organizational performance (financial metrics, safety/quality, physician turnover, and patient satisfaction).
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.

      Strategy 2: Harness the Power of Leadership

      Although the importance of leadership for organizational success is obvious, its direct effect on the professional satisfaction of individual physicians is underappreciated. Recent evidence suggests that the leadership behaviors of the physician supervisor play a critical role in the well-being of the physicians they lead.
      • Williams E.S.
      • Manwell L.B.
      • Konrad T.R.
      • Linzer M.
      The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study.
      • Shanafelt T.D.
      • Gorringe G.
      • Menaker R.
      • et al.
      Impact of organizational leadership on physician burnout and satisfaction.
      A 2013 study of more than 2800 physicians at Mayo Clinic found that each 1-point increase in the leadership score (60-point scale) of a physician's immediate supervisor (division/department chair) was associated with a 3.3% decrease in the likelihood of burnout (P < .001) and a 9.0% increase in satisfaction (P < .001) for individual physicians after adjusting for age, sex, and specialty.
      • Shanafelt T.D.
      • Gorringe G.
      • Menaker R.
      • et al.
      Impact of organizational leadership on physician burnout and satisfaction.
      After adjusting for other factors, 11% of the variation in burnout and 47% of the variation in satisfaction between work units was explained by the aggregate leadership rating of the work unit supervisor as assessed by their physician reports.
      Harnessing the power of effective leadership to promote individual and organizational health requires several steps. First, the right leaders must be selected. This selection should focus on identifying individuals with the ability to listen to, engage, develop, and lead physicians.
      • Stoller J.K.
      Commentary: recommendations and remaining questions for health care leadership training programs.
      Second, these individuals must themselves be developed, prepared, and equipped for their leadership role.
      • Arroliga A.C.
      • Huber C.
      • Myers J.D.
      • Dieckert J.P.
      • Wesson D.
      Leadership in health care for the 21st century: challenges and opportunities.
      • Stoller J.K.
      Help wanted: developing clinician leaders.
      Several experts have characterized the core competencies for physician leaders,
      • Stoller J.K.
      Commentary: recommendations and remaining questions for health care leadership training programs.
      • Lobas J.G.
      Leadership in academic medicine: capabilities and conditions for organizational success.
      • Schwartz R.W.
      • Pogge C.
      Physician leadership: essential skills in a changing environment.
      • Trastek V.F.
      • Hamilton N.W.
      • Niles E.E.
      Leadership models in health care: a case for servant leadership.
      • Menaker R.
      Leadership strategies in healthcare.
      • Egener B.
      • McDonald W.
      • Rosof B.
      • Gullen D.
      Perspective: organizational professionalism: relevant competencies and behaviors.
      and progressive institutions have developed formal strategies to identify, develop, and equip physician leaders.
      • Stoller J.K.
      Commentary: recommendations and remaining questions for health care leadership training programs.
      • Lobas J.G.
      Leadership in academic medicine: capabilities and conditions for organizational success.
      • Schwartz R.W.
      • Pogge C.
      Physician leadership: essential skills in a changing environment.
      • Stoller J.K.
      • Berkowitz E.
      • Bailin P.L.
      Physician management and leadership education at the Cleveland Clinic Foundation: program impact and experience over 14 years.
      • Lee T.H.
      Turning doctors into leaders.
      • Schwartz R.W.
      • Pogge C.R.
      • Gillis S.A.
      • Holsinger J.W.
      Programs for the development of physician leaders: a curricular process in its infancy.
      • Tangalos E.G.
      • Blomberg R.A.
      • Hicks S.S.
      • Bender C.E.
      Mayo leadership programs for physicians.
      Third, the performance of leaders should be regularly assessed by the individuals they lead. Although this seems intuitive, the leaders of many health care organizations are assessed solely based on whether they deliver on organizational performance targets. We believe that leaders must be assessed based on whether they achieve such targets as well as the way in which they do so (as evaluated by the people they are leading). Our physicians now evaluate the leadership behaviors of their immediate supervisors annually using the scale in the Supplemental Table which has been shown to correlate with burnout and satisfaction within the work-unit (available online at http://www.mayoclinicproceedings.org). This information is used for leaders' yearly performance review with executive management.
      To be effective, leaders must also recognize the unique talents of the individual physicians on their team and know what motivates them.
      • Horowitz C.R.
      • Suchman A.L.
      • Branch Jr., W.T.
      • Frankel R.M.
      What do doctors find meaningful about their work?.
      Evidence suggests that physicians who spend at least 20% of their professional effort focused on the dimension of work they find most meaningful are at dramatically lower risk for burnout.
      • Shanafelt T.D.
      • West C.P.
      • Sloan J.A.
      • et al.
      Career fit and burnout among academic faculty.
      Although each 1% reduction below this threshold increases the risk of burnout, there is a ceiling effect to this benefit at 20% (eg, spending 50% of your time in the most meaningful area is associated with similar rates of burnout as 20%).
      • Shanafelt T.D.
      • West C.P.
      • Sloan J.A.
      • et al.
      Career fit and burnout among academic faculty.
      This suggests that physicians will spend 80% of their time doing what leadership needs them to do provided that they are spending at least 20% of their time in the professional activity that motivates them. This activity could involve caring for specific types of patients (eg, the underserved) or patients with a given health condition (eg, becoming a disease expert) or activities such as patient education, quality improvement work, community outreach, mentorship, teaching students/residents, or leadership/administration. To harness this principle, leaders must know what that 20% activity is for each of their physicians so that they can facilitate professional development in that dimension and identify opportunities that may allow the individual to increase the time they devote to this activity. In our experience, few leaders seek such information. Furthermore, we find that few physicians can articulate in a granular way which professional activity is most meaningful to them when first asked. This represents a missed opportunity for individual physicians and leaders to work together to foster engagement, professional development, and professional fulfillment.
      Organizations must also have the courage to make leadership changes when necessary. In most organizations, a leader who consistently underperforms on financial metrics will be removed from leadership. In the same way, leaders who continue to receive low leadership behavior scores from those they lead despite appropriate support, coaching, and mentorship may be ill-suited to lead physicians, and a leadership change may be required.

      Strategy 3: Develop and Implement Targeted Interventions

      Although the drivers of burnout have been defined (Figure 2), the specific way in which they manifest and which dimension is dominant varies by specialty and work unit. For example, inefficiency in the practice environment (including clerical burden) is a universal driver of dissatisfaction and burnout, but how it manifests and the specific factors that create inefficiency vary widely among surgical, primary care, radiology, and pathology work units (and among organizations).
      • Mizumoto R.
      • Cristaudo A.T.
      • Hendahewa R.
      A surgeon-led model to improve operating theatre change-over time and overall efficiency: a randomised controlled trial.
      • Saha P.
      • Pinjani A.
      • Al-Shabibi N.
      • Madari S.
      • Ruston J.
      • Magos A.
      Why we are wasting time in the operating theatre?.
      • Kamat A.S.
      • Parker A.
      Effect of perioperative inefficiency on neurosurgical theatre efficacy: a 15-year analysis.
      • Shipman S.A.
      • Sinsky C.A.
      Expanding primary care capacity by reducing waste and improving the efficiency of care.
      • Dyrbye L.N.
      • West C.P.
      • Burriss T.C.
      • Shanafelt T.D.
      Providing primary care in the United States: the work no one sees.
      • Epling J.W.
      • Mader E.M.
      • Morley C.P.
      Practice characteristics and prior authorization costs: secondary analysis of data collected by SALT-Net in 9 central New York primary care practices.
      • Hillman B.J.
      • Pandya B.J.
      Radiologists' burden of inefficiency using conventional imaging workstations.
      Although general principles can be established (eg, we aim to minimize clerical burden and maximize physician efficiency), this variability makes it challenging for executive leaders to effectively address burnout at the enterprise level. Many of the challenges and solutions are local.
      • Sinsky C.A.
      • Willard-Grace R.
      • Schutzbank A.M.
      • Sinsky T.A.
      • Margolius D.
      • Bodenheimer T.
      In search of joy in practice: a report of 23 high-functioning primary care practices.
      Using the framework of the existing organizational structure in combination with strategy 1 (assessment) and strategy 2 (leadership) can overcome this dilemma.
      • Swensen S.
      • Kabcenell A.
      • Shanafelt T.
      Physician-organization collaboration reduces physician burnout and promotes engagement: the Mayo Clinic experience.
      Information on the prevalence of burnout, engagement, and satisfaction at the division/department level (strategy 1) allows senior leaders to identify “high-opportunity work units.” At Mayo Clinic, rather than identifying high-opportunity work units using relative criteria (eg, the lowest-scoring 10% of work units on well-being–related metrics at our institution), we categorize units as high-opportunity based on external benchmarks.
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      For example, in 2013 we designated divisions/departments with burnout rates higher than the national average
      • Shanafelt T.D.
      • Boone S.
      • Tan L.
      • et al.
      Burnout and satisfaction with work-life balance among US physicians relative to the general US population.
      and satisfaction below the 50th percentile relative to other US organizations as high-opportunity work units.
      • Swensen S.
      • Kabcenell A.
      • Shanafelt T.
      Physician-organization collaboration reduces physician burnout and promotes engagement: the Mayo Clinic experience.
      Once identified, we systematically engaged these units to identify local factors that could be rapidly altered to improve physician burnout and satisfaction.
      • Swensen S.
      • Kabcenell A.
      • Shanafelt T.
      Physician-organization collaboration reduces physician burnout and promotes engagement: the Mayo Clinic experience.
      This interaction was based on the principle of participatory management, collaborative action planning, and understanding how the drivers of burnout were manifest locally. The framework of the intervention is described in Figure 4. This process can also be used to drive improvement in work units that do not meet the criteria of being a high-opportunity unit. The process is structured to transition away from generalities regarding burnout, focus on the specific issue(s) in the local work unit, and identify, develop, and implement an initial intervention. This approach helps transform physicians' mindset from that of a victim in a broken system to an engaged and empowered partner working constructively with leaders to shape their own future.
      Figure thumbnail gr4
      Figure 4A stepwise process for targeted work unit interventions. aThis process can also be applied to other units that do not meet the high-opportunity criteria, and, in such cases, it may be possible for some steps performed by the consulting team to be performed by work unit leaders. EHR = electronic health record.
      Among the 7 Mayo Clinic work units with analyzable data that went through this process after the 2013 survey, all 7 had an improvement in burnout (median change 11% absolute reduction in burnout; range 4%-46% reduction), and 5 also had an improvement in satisfaction (median change 8% absolute improvement).
      • Swensen S.
      • Kabcenell A.
      • Shanafelt T.
      Physician-organization collaboration reduces physician burnout and promotes engagement: the Mayo Clinic experience.
      Notably, at the conclusion of the intervention, 6 of these 7 work units no longer met the criteria initially used to identify high-opportunity work units.
      Because our criteria to identify high-opportunity units are based on external benchmarks, it is theoretically possible to have no work units qualify as high opportunity. This characteristic avoids the possibility that a unit moves out of the high-opportunity category simply because other units got worse. We have used these qualities to set measurable institutional objectives. Given its vital importance to organizational health, one of us (J.H.N.) has incorporated goals related to these parameters into the annual CEO performance scorecard evaluated by the Mayo Clinic Board of Trustees. Specifically, this goal is to have at least 50% of high-opportunity work units improve to the extent that they no longer qualify as high-opportunity units within 12 months. Achieving this goal means that a division/department that is down will not be down for long. Using an objective external benchmark also makes it possible for the organization to try to drive down the total number of high-opportunity work units in an iterative manner over time (eg, reduce the number of high-opportunity work units by 10% every 12 months). These are strategic metrics that can be measured as a target to evaluate the performance of senior management.

      Strategy 4: Cultivate Community at Work

      Physicians deal with unique challenges (eg, medical errors, malpractice suits) and have a professional identity and role that is distinct from other disciplines.
      • Balch C.M.
      • Oreskovich M.R.
      • Dyrbye L.N.
      • et al.
      Personal consequences of malpractice lawsuits on American surgeons.
      • Meier D.E.
      • Back A.L.
      • Morrison R.S.
      The inner life of physicians and care of the seriously ill.
      • Christensen J.F.
      • Levinson W.
      • Dunn P.M.
      The heart of darkness: the impact of perceived mistakes on physicians.
      • Waterman A.D.
      • Garbutt J.
      • Hazel E.
      • et al.
      The emotional impact of medical errors on practicing physicians in the United States and Canada.
      Peer support has always been critical to helping physicians navigate these professional challenges. This support can be formal
      • Hu Y.Y.
      • Fix M.L.
      • Hevelone N.D.
      • et al.
      Physicians' needs in coping with emotional stressors: the case for peer support.
      • Shapiro J.
      • Galowitz P.
      Peer support for clinicians: a programmatic approach.
      or informal
      • Wallace J.E.
      • Lemaire J.
      On physician well being: you'll get by with a little help from your friends.
      and encompasses a wide range of activities, including celebrating achievements (eg, personal and professional milestones), supporting one another through challenging experiences (eg, loss of a patient, medical errors, a malpractice suit), and sharing ideas on how to navigate the ups and downs of a career in medicine.
      • Balch C.M.
      • Oreskovich M.R.
      • Dyrbye L.N.
      • et al.
      Personal consequences of malpractice lawsuits on American surgeons.
      • Shanafelt T.D.
      • Balch C.M.
      • Bechamps G.
      • et al.
      Burnout and medical errors among American surgeons.
      • Meier D.E.
      • Back A.L.
      • Morrison R.S.
      The inner life of physicians and care of the seriously ill.
      • Christensen J.F.
      • Levinson W.
      • Dunn P.M.
      The heart of darkness: the impact of perceived mistakes on physicians.
      • Waterman A.D.
      • Garbutt J.
      • Hazel E.
      • et al.
      The emotional impact of medical errors on practicing physicians in the United States and Canada.
      • Pratt S.D.
      • Jachna B.R.
      Care of the clinician after an adverse event.
      • Jena A.B.
      • Seabury S.
      • Lakdawalla D.
      • Chandra A.
      Malpractice risk according to physician specialty.
      • Blendon R.J.
      • DesRoches C.M.
      • Brodie M.
      • et al.
      Views of practicing physicians and the public on medical errors.
      Historically, such interactions happened somewhat organically during the course of discussing interesting/challenging cases or spending time together in the physicians' lounge. In our experience, these interactions have been an unintended casualty of increasing productivity expectations, documentation requirements, and clerical burden. Well-intentioned efforts to create a more egalitarian environment have also led many organizations to eliminate formal spaces for physicians to interact (eg, physicians' lounge or dining room) without recognizing the important role that this dedicated space played in fostering interpersonal connections among physicians. Collectively, these changes have led to an erosion of peer support and a greater sense of isolation for many physicians.
      Deliberate organizational strategies are needed to counter the forces eroding connection with colleagues.
      • Novack D.H.
      • Suchman A.L.
      • Clark W.
      • Epstein R.M.
      • Najberg E.
      • Kaplan C.
      Working Group on Promoting Physician Personal Awareness
      Calibrating the physician: personal awareness and effective patient care.
      Around the same time that many institutions were eliminating their physicians' lounge (eg, 2001), we introduced a dedicated meeting area with free fruit and beverages, computer stations, lunch tables, and limited food for purchase for the 2000 physicians, scientists, and senior administrators at our Rochester campus as part of an ongoing building project. The space so rapidly became an incubator for peer interaction and comradery that within 3 years we remodeled existing space to create similar rooms at a second location in Rochester as well as on our Florida and Arizona campuses.
      We have also experimented with other ways to promote community at work. In 2012, a randomized trial at Mayo Clinic found that providing physicians with 1 hour of protected time every other week to meet with a small group of colleagues and discuss topics related to the experience of physicianhood improved meaning in work and reduced burnout.
      • West C.P.
      • Dyrbye L.N.
      • Rabatin J.T.
      • et al.
      Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.
      A follow-up trial evaluated a revised format to make these COMPASS (COlleagues Meeting to Promote And Sustain Satisfaction) groups more cost-effective and scalable. Participating physicians signed up with a group of 6 to 7 colleagues, shared a meal together at a restaurant in town once every 2 weeks, and spent the first 20 minutes of that gathering discussing a question that explored the virtues and challenges of being a physician.
      • West C.P.
      • Dyrbye L.N.
      • Satele D.
      • Shanafelt T.D.
      A randomized controlled trial evaluating the effect of COMPASS (COlleagues Meeting to Promote and Sustain Satisfaction) small group sessions on physician well-being, meaning, and job satisfaction.
      Funds to cover the cost of the meal were provided by Mayo Clinic. The randomized trial again found that these meetings with colleagues led to an improvement in both meaning in work and burnout for participants.
      • West C.P.
      • Dyrbye L.N.
      • Satele D.
      • Shanafelt T.D.
      A randomized controlled trial evaluating the effect of COMPASS (COlleagues Meeting to Promote and Sustain Satisfaction) small group sessions on physician well-being, meaning, and job satisfaction.
      Based on this evidence, Mayo Clinic made COMPASS groups available to all 3755 Mayo Clinic physicians and scientists across our organization in October 2015. More than 1100 of our physicians and scientists joined a group in the first 10 months.

      Strategy 5: Use Rewards and Incentives Wisely

      People can be motivated by rewards. To harness this principle, many health care organizations have linked physicians' financial compensation to productivity.
      • Conrad D.A.
      • Sales A.
      • Liang S.Y.
      • et al.
      The impact of financial incentives on physician productivity in medical groups.
      In some settings, physicians' income is entirely based on productivity, and in others it is structured as a base salary with a productivity bonus.
      • Robinson J.C.
      • Shortell S.M.
      • Li R.
      • Casalino L.P.
      • Rundall T.
      The alignment and blending of payment incentives within physician organizations.
      • Lewandowski S.
      • O'Connor P.J.
      • Solberg L.I.
      • Lais T.
      • Hroscikoski M.
      • Sperl-Hillen J.M.
      Increasing primary care physician productivity: a case study.
      • Khullar D.
      • Kocher R.
      • Conway P.
      • Rajkumar R.
      How 10 leading health systems pay their doctors.
      Physicians are not salespeople. Although some variation in productivity (eg, patient volumes and relative value unit generation) can be attributed to physicians' experience, efficiency, and skill, such variation is relatively narrow. Physicians in an equally efficient practice environment primarily increase productivity or revenue generation in 3 ways: (1) shortening the time spent per patient, (2) ordering more tests/procedures, or (3) working longer. The first 2 approaches may erode quality of care, and the third approach increases the risk of physician burnout and may, therefore, be self-defeating in the long run. Consistent with this notion, evidence suggests that productivity-based compensation increases the risk of physician burnout.
      • Shanafelt T.D.
      • Balch C.M.
      • Bechamps G.
      • et al.
      Burnout and medical errors among American surgeons.
      • Shanafelt T.D.
      • Gradishar W.J.
      • Kosty M.
      • et al.
      Burnout and career satisfaction among US oncologists.
      To mitigate the potential negative effects of productivity-based pay, some medical centers have incorporated other dimensions (eg, patient satisfaction and quality measures) as part of the productivity-based pay formula.
      • Khullar D.
      • Kocher R.
      • Conway P.
      • Rajkumar R.
      How 10 leading health systems pay their doctors.
      • Rodriguez H.P.
      • von Glahn T.
      • Elliott M.N.
      • Rogers W.H.
      • Safran D.G.
      The effect of performance-based financial incentives on improving patient care experiences: a statewide evaluation.
      • Glickman S.W.
      • Peterson E.D.
      Innovative health reform models: pay-for-performance initiatives.
      • Williams C.H.
      • Leatherman S.
      • Christianson J.B.
      • Sutherland K.
      Paying for quality: understanding and assessing physician pay-for-performance initiatives.
      • Gavagan T.F.
      • Du H.
      • Saver B.G.
      • et al.
      Effect of financial incentives on improvement in medical quality indicators for primary care.
      Although incentivizing quality rather than only productivity/volume may better align with the mission of health care, the effectiveness of financial incentives in improving quality is far less clear,
      • Rosenthal M.B.
      • Frank R.G.
      What is the empirical basis for paying for quality in health care?.
      • Berwick D.M.
      The toxicity of pay for performance.
      • Jenkins D.G.
      • Mitra A.
      • Gupta N.
      • Shaw J.D.
      Are financial incentives related to performance? a meta-analytic review of empircal research.
      • Scott A.
      • Sivey P.
      • Ait Ouakrim D.
      • et al.
      The effect of financial incentives on the quality of health care provided by primary care physicians.
      • Petersen L.A.
      • Woodard L.D.
      • Urech T.
      • Daw C.
      • Sookanan S.
      Does pay-for-performance improve the quality of health care?.
      can have unintended consequences,
      • Rosenthal M.B.
      • Frank R.G.
      What is the empirical basis for paying for quality in health care?.
      • Petersen L.A.
      • Woodard L.D.
      • Urech T.
      • Daw C.
      • Sookanan S.
      Does pay-for-performance improve the quality of health care?.
      • Wynia M.K.
      • Cummins D.S.
      • VanGeest J.B.
      • Wilson I.B.
      Physician manipulation of reimbursement rules for patients: between a rock and a hard place.
      • Hannan E.L.
      • Siu A.L.
      • Kumar D.
      • Racz M.
      • Pryor D.B.
      • Chassin M.R.
      Assessment of coronary artery bypass graft surgery performance in New York: is there a bias against taking high-risk patients?.
      and does not address the third potential problem of productivity-based physician pay: the incentive to overwork. Physicians may be particularly vulnerable to overwork due to high levels of education debt, their desire to “do everything for their patients,” unhealthy role modeling by colleagues, and normalization of extreme work hours during the training process. Salaried compensation models are a way to overcome this issue.
      • Khullar D.
      • Kocher R.
      • Conway P.
      • Rajkumar R.
      How 10 leading health systems pay their doctors.
      Other innovative centers have begun to incorporate dimensions of self-care and well-being as part of the formula to calculate productivity-based pay, which may provide a safeguard to counter the incentive to overwork.
      A final dimension of productivity-based compensation to consider is what “carrot” is used as a reward.
      • Rosenthal M.B.
      • Frank R.G.
      What is the empirical basis for paying for quality in health care?.
      • Berwick D.M.
      The toxicity of pay for performance.
      Rewards such as greater flexibility (which can facilitate work-life integration) or protected time to pursue personally meaningful aspects of work (eg, quality improvement work, community outreach, research, education, or mentorship) may allow more productive physicians to shape their work to create personal and professional fulfillment. In contrast, using a simple financial incentive may be less effective
      • Gavagan T.F.
      • Du H.
      • Saver B.G.
      • et al.
      Effect of financial incentives on improvement in medical quality indicators for primary care.
      • Rosenthal M.B.
      • Frank R.G.
      What is the empirical basis for paying for quality in health care?.
      • Berwick D.M.
      The toxicity of pay for performance.
      and encourage overwork that erodes meaning and fuels burnout. Ultimately, there is no right or wrong model of compensation. It is important, however, to recognize the potential risks of each model, deliberately consider how they will be mitigated, and structure compensation in a way that facilitates individual and organizational health over the long-term.

      Strategy 6: Align Values and Strengthen Culture

      Most health care organizations have an altruistic mission statement that centers on serving patients and providing them the best possible medical care. An organization's culture, values, and principles in large part determine whether it will achieve its mission. It is critical for organizations to (1) be mindful of factors that influence culture, (2) assess ways to keep values fresh, and (3) periodically take stock of whether actions and values are aligned.
      Mayo Clinic has a long-standing value proposition that “the needs of the patient come first” as well as a mature organizational culture that supports this value.
      • Berry L.L.
      • Seltman K.D.
      The enduring culture of Mayo Clinic.
      This culture is, in part, built on principles such as physician leadership, salaried physicians, physician-administrator partnership, a multidisciplinary approach to team-based care, “term limits” for all leaders (including the CEO), and organizational policies that cultivate long tenure and low turnover.
      To facilitate honest self-appraisal, we ask our people to evaluate how well we live out our values through our all-staff survey. Although the commitment of our staff to the organization on this survey has been unwavering during the past 20 years, other aspects of this feedback are not always flattering. At the time of our 2011 staff survey, we received feedback from our physicians that they perceived erosion in the commitment of Mayo Clinic to its staff. In response, the Mayo Clinic Board of Governors commissioned a task force of physicians and scientists to identify where we had gotten off course.
      During an 18-month interval, this task force engaged our physicians, scientists, and senior leaders in a dialogue designed to articulate our shared values and affirm that we were working toward a common goal. The task force initially used this input to create a working document that identified the 11 key components of our shared commitment, indicated why each component was important to both physicians and the organization, and gave examples of how these characteristics shaped our culture. This document was then refined based on surveys and focus groups with physicians from across the entire organization. All Mayo Clinic physicians and scientists were then given the opportunity to review the final document and provide feedback on whether it captured what mattered most to them about the organization and to indicate the dimensions where we were not living up to our ideals. The approximately 2000 physicians and scientists who responded overwhelmingly endorsed (>95%) that the document captured the key components of the relationship between Mayo Clinic and our physicians and scientists. They also provided feedback indicating the 3 dimensions most needing improvement to better live up to our aspirations. The final document was subsequently endorsed by the Mayo Clinic Board of Governors, who also received the feedback on which dimensions were most in need of improvement. This process of value alignment helped affirm that 1) the organization and physicians are partners working toward a common goal, 2) provided candid feedback on where we needed to improve, and 3) created an enduring document that articulates the principles that form the foundation of the partnership between Mayo Clinic and its physicians (Supplemental Figure, available online at http://www.mayoclinicproceedings.org). This document is now used for recruitment and onboarding, as a recurring touchstone for communications, to identify areas needing improvement, and as a source of principles to guide organizational decision making.

      Strategy 7: Promote Flexibility and Work-Life Integration

      A host of organizational policies are linked to the drivers of burnout and can have a profound effect on physician well-being. Given their broad impact, the intended and unintended consequences of these policies must be thoughtfully considered and periodically reevaluated. Two aspects particularly important to physician well-being are policies related to flexibility and work-life integration.
      • Shanafelt T.D.
      • West C.P.
      • Poland G.A.
      • LaRusso N.F.
      • Menaker R.
      • Bahn R.S.
      Principles to promote physician satisfaction and work-life balance.
      Physicians are nearly twice as likely to be dissatisfied with work-life integration as US workers in other fields. This problem is likely, in part, explained by differences in work hours. Approximately 45% of physicians work more than 60 hours per week compared with less than 10% of US workers in other fields.
      • Shanafelt T.D.
      • Boone S.
      • Tan L.
      • et al.
      Burnout and satisfaction with work-life balance among US physicians relative to the general US population.
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      The high work hours expected of a full-time position in medicine make it difficult for physicians to integrate their personal and professional lives. These challenges may be even more problematic for women physicians due to different cultural and societal expectations.
      • Shanafelt T.D.
      • Boone S.
      • Tan L.
      • et al.
      Burnout and satisfaction with work-life balance among US physicians relative to the general US population.
      • Dyrbye L.N.
      • Freischlag J.
      • Kaups K.L.
      • et al.
      Work-home conflicts have a substantial impact on career decisions that affect the adequacy of the surgical workforce.
      • Dyrbye L.N.
      • Shanafelt T.D.
      • Balch C.M.
      • Satele D.
      • Sloan J.
      • Freischlag J.
      Relationship between work-home conflicts and burnout among American surgeons: a comparison by sex.
      • Dyrbye L.N.
      • West C.P.
      • Satele D.
      • Sloan J.A.
      • Shanafelt T.D.
      Work/home conflict and burnout among academic internal medicine physicians.
      Providing physicians with the option to adjust professional work effort (with a commensurate reduction in compensation) allows them to tailor their work hours to meet both personal and professional obligations.
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
      • Murray A.
      • Safran D.G.
      • Rogers W.H.
      • Inui T.
      • Chang H.
      • Montgomery J.E.
      Part-time physicians: physician workload and patient-based assessments of primary care performance.
      • Mechaber H.F.
      • Levine R.B.
      • Manwell L.B.
      • et al.
      Part-time physicians…prevalent, connected, and satisfied.
      • McMurray J.E.
      • Heiligers P.J.
      • Shugerman R.P.
      • et al.
      Part-time medical practice: where is it headed?.
      • Levine R.B.
      • Harrison R.A.
      • Mechaber H.F.
      • Phillips C.
      • Gallagher T.H.
      Professional characteristics and job satisfaction among SGIM members: a comparison of part-time and full-time physician members.
      • Parkerton P.H.
      • Wagner E.H.
      • Smith D.G.
      • Straley H.L.
      Effect of part-time practice on patient outcomes.
      • Panattoni L.
      • Stone A.
      • Chung S.
      • Tai-Seale M.
      Patients report better satisfaction with part-time primary care physicians, despite less continuity of care and access.
      Evidence suggests that reducing professional work hours can help individual physicians recover from burnout.
      • Shanafelt T.D.
      • Sinsky C.
      • Dyrbye L.N.
      • West C.P.
      Potential impact of burnout on the U.S. physician workforce.
      Depending on the specialty and the size of the organization, it may not always be possible for a physician to work less than full time. Nonetheless, organizations should seek to make this option available to the greatest extent possible. Given the large anticipated physician workforce shortage over the next 10 years,

      AAMC. Section II: Current status of the U.S. physician workforce. http://aamcdiversityfactsandfigures.org/section-ii-current-status-of-us-physician-workforce. Accessed September 2, 2015.

      US Department of Health and Human Services. The physician workforce: projections and research into current issues affecting supply and demand. http://bhpr.hrsa.gov/healthworkforce/reports/physwfissues.pdf. Published December 2008. Accessed April 15, 2015.

      providing the option to work less than full time may become an increasingly important strategy for recruitment and retention.
      Perhaps even more important, organizations should seek to provide physicians greater flexibility in when and how they work.
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
      • Shanafelt T.D.
      • West C.P.
      • Poland G.A.
      • LaRusso N.F.
      • Menaker R.
      • Bahn R.S.
      Principles to promote physician satisfaction and work-life balance.
      Allowing physicians to start the work day earlier/later or to work longer hours on certain days of the week and shorter hours on others may allow individual physicians to meet personal responsibilities without having to reduce total work effort. This is typically preferable to the organization than having a part-time physician and can represent a win-win for both the individual and the organization. Declarative statements (eg “we have to staff the clinic on Friday” and “it is too complicated to match the work schedule of support staff”) are frequently used as pretexts to close down discussion rather than being legitimate barriers. These needs can typically be easily accommodated in an equitable manner if explored and discussed as a team.
      Institutions should also comprehensively examine the structure of their vacation benefits, coverage for life events (eg, birth of a child, illness/death in family), approach to scheduling, and strategy for coverage of nights and weekends. Compensation practices that disincentivize using vacation time are shortsighted and should be eliminated.

      Strategy 8: Provide Resources to Promote Resilience and Self-care

      Although the primary focus for organizations should be to optimize the practice environment and create a healthy organizational culture, they should also provide resources that make it easier for physicians to implement individual strategies to prevent burnout, deal with distress, and promote well-being.
      • Shanafelt T.D.
      • Sloan J.A.
      • Habermann T.M.
      The well-being of physicians.
      • Spinelli W.M.
      The phantom limb of the triple aim.
      • Linzer M.
      • Baier Manwell L.
      • Mundt M.
      • et al.
      Organizational climate, stress, and error in primary care: the MEMO study.
      • Quill T.E.
      • Williamson P.R.
      Healthy approaches to physician stress.
      • Back A.L.
      • Steinhauser K.E.
      • Kamal A.H.
      • Jackson V.A.
      Building resilience for palliative care clinicians: an approach to burnout prevention based on individual skills and workplace factors.
      Unfortunately, most medical centers have made such individual offerings the centerpiece of their strategy. When individually focused offerings are not coupled with sincere efforts to address the system-based issues contributing to burnout, this approach is typically met with skepticism and resistance by physicians (“they are implying I am the problem”). In this context, the response to well-intentioned “resilience training” is frequently a cynical one (“you only want to make me more resilient so you can further increase my workload”). For this reason, it is important that such individual offerings are part of a broader strategy that demonstrates that the organization is also doing its part to address issues in the system and environment.
      Providing individual physicians with tools for self-calibration, resources to promote self-care, and training in skills that promote resilience are 3 tangible ways that organizations can help individuals care for themselves. The available data indicate that individual physicians do not accurately calibrate their personal level of well-being/distress and suggest that providing them objective information on how their well-being compares with that of physicians nationally helps promote behavior change.
      • Shanafelt T.D.
      • Kaups K.L.
      • Nelson H.
      • et al.
      An interactive individualized intervention to promote behavioral change to increase personal well-being in US surgeons.
      Linking such tools for self-calibration to resources may help physicians take action. Such resources should be comprehensive and address work-life integration, exercise/fitness, sleep habits, diet, personal financial health, relationships, hobbies, and preventive medical care.
      • Shanafelt T.D.
      • Sloan J.A.
      • Habermann T.M.
      The well-being of physicians.
      • Linzer M.
      • Levine R.
      • Meltzer D.
      • Poplau S.
      • Warde C.
      • West C.P.
      10 bold steps to prevent burnout in general internal medicine.
      • Quill T.E.
      • Williamson P.R.
      Healthy approaches to physician stress.
      • Shanafelt T.D.
      • Oreskovich M.R.
      • Dyrbye L.N.
      • et al.
      Avoiding burnout: the personal health habits and wellness practices of US surgeons.
      • Gross C.P.
      • Mead L.A.
      • Ford D.E.
      • Klag M.J.
      Physician, heal thyself? regular source of care and use of preventive health services among physicians.
      • Hlubocky F.J.
      • Back A.L.
      • Shanafelt T.D.
      Addressing burnout in oncology: why cancer care clinicians are at risk, what individuals can do, and how organizations can respond.
      Physicians who take better care of their own health have been found to provide more optimal counseling and screening practices to their patients; this suggests that encouraging these behaviors in physicians may have a double benefit.
      • Lewis C.E.
      • Clancy C.
      • Leake B.
      • Schwartz J.S.
      The counseling practices of internists.
      • Frank E.
      • Rothenberg R.
      • Lewis C.
      • Belodoff B.F.
      Correlates of physicians' prevention-related practices: findings from the Women Physicians' Health Study.
      • Frank E.
      • Segura C.
      • Shen H.
      • Oberg E.
      Predictors of Canadian physicians' prevention counseling practices.
      Skills training in tasks related to resilience, positive psychology exercises, mindfulness, narrative medicine, and approaches to work-life integration should be offered.
      • Novack D.H.
      • Suchman A.L.
      • Clark W.
      • Epstein R.M.
      • Najberg E.
      • Kaplan C.
      Working Group on Promoting Physician Personal Awareness
      Calibrating the physician: personal awareness and effective patient care.
      • Back A.L.
      • Steinhauser K.E.
      • Kamal A.H.
      • Jackson V.A.
      Building resilience for palliative care clinicians: an approach to burnout prevention based on individual skills and workplace factors.
      • Epstein R.M.
      Mindful practice.
      • Krasner M.S.
      • Epstein R.M.
      • Beckman H.
      • et al.
      Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians.
      • Charon R.
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      Strategy 9: Facilitate and Fund Organizational Science

      Instituting operational efforts to reduce burnout and promote physician engagement will be the primary objective for most medical centers. Vanguard institutions, however, have the additional responsibility of developing the evidence-based strategies that these other centers will implement. The Mayo Clinic Program on Physician Well-being, founded in 2007, was launched precisely to provide such evidence. Many of the approaches outlined in strategies 1 through 8 are derived from the scientific efforts of this program during the past decade. These efforts have included developing new metrics, establishing national benchmarks, implementing practice analytics, and conducting intervention studies and randomized trials, which have resulted in approximately 100 peer-reviewed publications. Other leading institutions, such as the Stanford University School of Medicine/Medical Center, have recently made a major institutional investment in launching a similar program, and it is time for other premier institutions to follow suit. As opposed to employee assistance programs or offices/committees on physician wellness that provide support to physicians already experiencing distress, the focus of such programs is the creation of new knowledge and evidence on how to reduce burnout and promote engagement in physicians through organizational science. 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.

      The Mayo Clinic Experience

      Our experience at Mayo Clinic demonstrates that deliberate, sustained, and comprehensive efforts by the organization to reduce burnout and promote engagement can make a difference. Between 2011 and 2013, the rates of burnout among our physicians went from lower than average to similar to that of physicians nationally.
      • Shanafelt T.D.
      • Boone S.
      • Tan L.
      • et al.
      Burnout and satisfaction with work-life balance among US physicians relative to the general US population.
      In response to this increase, a host of changes were pursued, including several of the strategies articulated herein (Figure 5). In the following 2 years, the absolute burnout rate of our physicians decreased by 7%, despite an 11% rise in the absolute rate of burnout in physicians nationally using identical metrics.
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      This reduction in physician burnout at Mayo Clinic was achieved while simultaneously reducing the rates of burnout in our nonphysician employees and despite having to implement a variety of other changes to improve efficiency, decrease costs, and increase productivity during the same interval. Although we are gratified that the rate of physician burnout at Mayo Clinic is currently approximately two-thirds the rate nationally (32.9% vs 48.8%),
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      burnout still affects approximately one-third of our physicians. We have more work to do.
      Figure thumbnail gr5
      Figure 5Organizational strategies to reduce burnout and promote physician engagement. aOften will focus on improving efficiency and reducing clerical burden but should focus on whichever driver dimension () deemed most important by members of the work unit ().

      Conclusion

      Addressing the problem of physician burnout is the shared responsibility of individual physicians and the organizations in which they work. Having an engaged physician workforce is critical for health care organizations to meet institutional objectives and achieve their mission. Given the strong links to quality of care, patient safety, and patient satisfaction, there is a strong business case for organizations to reduce physician burnout and promote physician engagement. Although some factors driving burnout are larger than the organization, organizational-level efforts can have a profound effect on physician well-being. Herein, we have outlined 9 organizational strategies to reduce burnout and promote engagement along with examples of how these strategies have been operationalized at Mayo Clinic. Many effective interventions are relatively inexpensive, and small investments can have a large impact. Although the specific way each of these 9 strategies is operationalized must be adapted to fit the organization, we believe that the dimensions themselves have broad applicability. Leadership and attention from the highest level of the organization are the keys to making progress.

      Supplemental Online Material

      Supplemental Online Material

      Supplemental material can be found online at http://www.mayoclinicproceedings.org. Supplemental material attached to journal articles has not been edited, and the authors take responsibility for the accuracy of all data.

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          On the basis of the conclusion that more than 50% of US physicians suffer from burnout, Melnick and Powsner1 and Shanafelt and Noseworthy2 underlined the importance of taking systemic action to reduce the risk of the syndrome by improving conditions under which physicians work. To effectively deal with the issue of job stress, we think that a critical step is to understand burnout as a depressive condition.
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      • Defining Physician Burnout, and Differentiating Between Burnout and Depression—II
        Mayo Clinic ProceedingsVol. 92Issue 9
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          Shanafelt and Noseworthy1 in a recent study are to be commended for continuing to raise awareness of physician job stress, but their reliance on fractions of questions from what they indicate to be “potentially standardized instruments” to categorize burnout is unfortunate. Among these, the popular Maslach Burnout Inventory (MBI)2 is a proprietary test, and its use in the table titled “Candidate Dimensions of Well-being for Organizations to Access” is flawed. Not only are the ‘cutoff’ scores proposed by the developers of the MBI wholly arbitrary and devoid of any clinical referent,2 the inventory's user manual also warns that “neither the coding nor the original numerical scores should be used for diagnostic purposes.”2 Nonetheless, several authors have attempted to take the complexity of physician burnout syndrome down to even single-item measures validated against the MBI3 and/or to comment on qualitative differences that describe a “sense of calling”4 in making physician assessments.
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        Mayo Clinic ProceedingsVol. 95Issue 4
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          This monthly feature highlights three articles in the current print and online issue of Mayo Clinic Proceedings. These articles are also featured on the Mayo Clinic Proceedings’ YouTube Channel ( https://youtu.be/9tRffX_lo2Q ).
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