Advertisement
Mayo Clinic Proceedings Home

In Reply—Physician Burnout: A Leading Indicator of Health Performance and “Head-Down” Mentality in Medical Education—I and II

      I agree with Drs Peck and Viswanath, that residents should be transitioning into their careers “invigorated and excited.” The fact that most physicians are experiencing burnout, and it is particularly high among residents, indicates a need for course correction. I concur with the logic that it is best to treat the root cause rather than its adverse effects. As I indicated in my editorial, the evidence suggests that the work and workplace stressors are the predominant drivers of physician burnout and the ensuing withdrawal from clinical practice, which frustrates our ability to provide the population with access to affordable high-quality patient-centered care.
      Stressors have been identified as lack of value-alignment with leadership, lack of control over workloads, working at a hectic pace in a chaotic inefficient atmosphere, and ineffective teamwork
      • Linzer M.
      • Poplau S.
      • Babbott S.
      • et al.
      Worklife and wellness in academic general internal medicine: results from a national survey.
      to manage time-consuming administrative and regulatory tasks,
      • Erickson S.M.
      • Rockwern B.
      • Koltov M.
      • McLean R.
      Medical Practice and Quality Committee of the American College of Physicians
      Putting patients first by reducing administrative tasks in health care: a position paper of the American College of Physicians.
      expanding requirements to accomplish more during shorter visits with patients who have more complex comorbidities, and restrictions to and reimbursements for goods and services.
      • Morley C.P.
      • Badolato D.J.
      • Hickner J.
      • Epling J.W.
      The impact of prior authorization requirements on primary care physicians' offices: report of two parallel network studies.
      The electronic health record has become omnipresent at patient encounters, altering workflow, prompting and tracking metrics, and linking stakeholders. Electronic health records compelled computerized physician order entry and increased clerical burdens,
      • 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.
      made clerical work possible 24-7, and became a common and formidable stressor.
      • Linzer M.
      • Poplau S.
      • Babbott S.
      • et al.
      Worklife and wellness in academic general internal medicine: results from a national survey.
      Physicians reported a lack of time for the more meaningful aspects of work—patient care, scholarship, administration.
      • Shanafelt T.D.
      • West C.P.
      • Sloan J.A.
      • et al.
      Career fit and burnout among academic faculty.
      They express discrepancies between what they expected of their careers and their actual work life. They reported stress tied to threat of liability, educational debt, and lack of work-life balance.
      • West C.P.
      • Shanafelt T.D.
      • Kolars J.C.
      Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents.
      The work itself entails managing illness and injury, preventing death and disability, easing suffering.
      I agree with Dr Kaushik and Einstein that “we cannot solve our problems with the same level thinking that created them.” The big questions are how to coordinate stakeholders to provide the population with reliable access to affordable high-quality patient-centered health care? What is and who defines quality and medical necessity (value) and how much autonomy can be afforded to patients and their physicians while dependent on payers and prices (2-3 times that of other industrialized countries)? How do we “bend the cost curve” down from 17.8% of the United States gross domestic product ($3.2 trillion per year)?
      • Martin A.B.
      • Hartman M.
      • Washington B.
      • Catlin A.
      National Health Expenditure Accounts Team
      National health spending: faster growth in 2015 as coverage expands and utilization increases.
      Physicians' decisions (made with patients) direct the flow of 80% of health care dollars,
      thus considered a lever by stakeholders. Physicians perceive a “lack of control” and “chaos.”
      • Linzer M.
      • Poplau S.
      • Babbott S.
      • et al.
      Worklife and wellness in academic general internal medicine: results from a national survey.
      Eighty-six percent of physicians felt that their perspectives were not taken into account in crafting health care legislation,
      The Physicians Foundation
      Health Reform and the Decline of Physician Private Practice. The Physicians Foundation website.
      which also accelerated the vertical integration of physicians into large hospital organizations as employees.
      • Kocher R.
      • Sahni N.R.
      Hospitals' race to employ physicians—the logic behind a money-losing proposition.
      Now, the “quadruple aim” recognizes physicians' well-being as a reflection of their perspectives on system performance and quality care for patients.
      • Bodenheimer T.
      • Sinsky C.
      From triple to quadruple aim: care of the patient requires care of the provider.
      Pioneering health care organizations have recognized the value of engaging physicians' perspectives
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      and are discovering it can generate innovation and efficiency
      • Asch D.A.
      • Terwiesch C.
      • Mahoney K.B.
      • Rosin R.
      Insourcing health care innovation.
      and higher-quality care at lower costs with better satisfaction scores for patients and physicians.
      • Swensen S.
      • Kabcenell A.
      • Shanafelt T.
      Physician-organization collaboration reduces physician burnout and promotes engagement: the Mayo Clinic experience.
      • Oostra R.D.
      Physician leadership: a central strategy to transforming healthcare.
      Physicians' satisfaction is closely tied to their sense of agency to produce high-quality patient-centered care, in collaboration with the clinical team, colleagues, and leadership.
      • Friedberg M.W.
      • Chen P.G.
      • Van Busum K.R.
      • et al.
      Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy.
      • Barr D.A.
      The effects of organizational structure on primary care outcomes under managed care.
      Physician partnership also facilitates the organizations' priorities.
      • Barr D.A.
      The effects of organizational structure on primary care outcomes under managed care.
      • Eisenberg J.M.
      • Williams S.V.
      Cost containment and changing physicians' practice behavior: can the fox learn to guard the chicken coop?.
      Vanguard organizations are creating a culture of wellness (mission-aligned leadership, teamwork, collegiality, for meaning in work), managing the bureaucratic machine away from the clinical arena, partnering with clinicians to improve workplace efficiency to support clinical work, and facilitating work-life balance and personal resiliency.
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      • 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.
      • Engel G.V.
      The effect of bureaucracy on the professional autonomy of the physician.
      • Bohman B.
      • Dyrbye L.
      • Sinsky C.A.
      • et al.
      Physician well-being: the reciprocity of practice efficiency, culture of wellness, and personal resilience.
      Such organizations measure and monitor the well-being of the physician workforce via wellness metrics, the withdrawing behaviors or their adverse effects, or the presence of stressors via surveys such as Mark Linzer's Mini Z survey.
      Dr Kaushik's letter makes the important point that when burnout is pervasive in the workforce, organizational change can be difficult, and self-care and personal resiliency is required. While systematic reviews and meta-analysis find that organization-directed interventions are more effective than individual-directed interventions to remedy burnout,
      • West C.P.
      • Dyrbye L.N.
      • Erwin P.J.
      • Shanafelt T.D.
      Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis.
      • Panagioti M.
      • Panagopoulou E.
      • Bower P.
      • et al.
      Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis.
      it is understood that these interventions have reciprocal influences, and both are necessary to improve individual well-being and organizational performance.
      • Bohman B.
      • Dyrbye L.
      • Sinsky C.A.
      • et al.
      Physician well-being: the reciprocity of practice efficiency, culture of wellness, and personal resilience.
      Therefore, leaders and individuals both benefit from encouraging proactive self-care and personal resiliency while organizational stressors are addressed.
      For example, my colleagues and I collaborated with Dr. Seligman's Positive Psychology Center at the University of Pennsylvania to provide physician-oriented resiliency tools and an optimistic mind-set to prevent languishing in psychological distress, and skills to bounce back and grow in adversity. Whole-hearted participation hinged on trust that the organization was also sincerely resolving stressors. Based on Seligman's PERMA model, a thriving workforce may feel inspiration and pride, deeply interested and involved, valued and supported, a sense of service and purpose larger than themselves, internally motivated toward mastery, and vitality. Beyond the absence of burnout and withdrawing behaviors, there is a physician workforce eager to engage in clinical work and creative problem solving.

      Reivich K, Saltzberg Levick J, eds. Yale Medicine–University of Pennsylvania Resilience and Well-being Program for Yale Physicians course book. Yale Medicine–University of Pennsylvania Resilience and Well-being Program for Yale Physicians; October 20-22 and November 11-12, 2017; New Haven, CT.

      Resident physicians should feel excited and invigorated transitioning into their careers because I suspect we are witnessing a renaissance in physician work life. Now that the National Academy of Medicine and others have made physician well-being a top priority, there is an air of inevitability. Yet, there is much work to do. I agree with Drs Peck and Viswanath that physicians-in-training should receive support to develop a wellness practice and build personal resilience as soon as medical school. Dr Kaushik suggests a “tool bag of self-care.” Normalizing wellness allows anyone to comfortably access peer support and necessary care and sets a good example for the patients we counsel. Change can be stressful, yet ripe with opportunity. Stay well. There is reason for hope.

      References

        • Linzer M.
        • Poplau S.
        • Babbott S.
        • et al.
        Worklife and wellness in academic general internal medicine: results from a national survey.
        J Gen Intern Med. 2016; 31: 1004-1010
        • Erickson S.M.
        • Rockwern B.
        • Koltov M.
        • McLean R.
        • Medical Practice and Quality Committee of the American College of Physicians
        Putting patients first by reducing administrative tasks in health care: a position paper of the American College of Physicians.
        Ann Intern Med. 2017; 166: 659-661
        • Morley C.P.
        • Badolato D.J.
        • Hickner J.
        • Epling J.W.
        The impact of prior authorization requirements on primary care physicians' offices: report of two parallel network studies.
        J Am Board Fam Med. 2013; 26: 93-95
        • 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.
        Mayo Clin Proc. 2016; 91: 836-848
        • Shanafelt T.D.
        • West C.P.
        • Sloan J.A.
        • et al.
        Career fit and burnout among academic faculty.
        Arch Intern Med. 2009; 169: 990-995
        • O'Rourke M.
        Doctors tell all—and it's bad.
        (The Atlantic website) (Published November 2014. Accessed April 10, 2017)
        • West C.P.
        • Shanafelt T.D.
        • Kolars J.C.
        Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents.
        JAMA. 2011; 306: 952-960
        • Martin A.B.
        • Hartman M.
        • Washington B.
        • Catlin A.
        • National Health Expenditure Accounts Team
        National health spending: faster growth in 2015 as coverage expands and utilization increases.
        Health Aff (Millwood). 2017; 36: 166-176
      1. Crosson F.J. Tollen L.A. Partners in Health: How Physicians and Hospitals Can Be Accountable Together. Jossey-Bass, San Francisco, CA2010
        • The Physicians Foundation
        Health Reform and the Decline of Physician Private Practice. The Physicians Foundation website.
        (Published 2010. Accessed August 4, 2016)
        • Kocher R.
        • Sahni N.R.
        Hospitals' race to employ physicians—the logic behind a money-losing proposition.
        N Engl J Med. 2011; 364: 1790-1793
        • Bodenheimer T.
        • Sinsky C.
        From triple to quadruple aim: care of the patient requires care of the provider.
        Ann Fam Med. 2014; 12: 573-576
        • Sinsky C.
        • Shanafelt T.
        • Murphy M.L.
        • et al.
        Creating the organizational foundation for the Joy in Medicine.
        (American Medical Association website) (Published October 2017. Accessed November 19, 2017)
        • Shanafelt T.D.
        • Noseworthy J.H.
        Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
        Mayo Clin Proc. 2017; 92: 129-146
        • Asch D.A.
        • Terwiesch C.
        • Mahoney K.B.
        • Rosin R.
        Insourcing health care innovation.
        N Engl J Med. 2014; 370: 1775-1777
        • Swensen S.
        • Kabcenell A.
        • Shanafelt T.
        Physician-organization collaboration reduces physician burnout and promotes engagement: the Mayo Clinic experience.
        J Healthc Manag. 2016; 61: 105-127
        • Oostra R.D.
        Physician leadership: a central strategy to transforming healthcare.
        Front Health Serv Manage. 2016; 32: 15-26
        • Friedberg M.W.
        • Chen P.G.
        • Van Busum K.R.
        • et al.
        Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy.
        (RAND Corporation website) (Published 2013. Accessed August 8 2016)
        • Barr D.A.
        The effects of organizational structure on primary care outcomes under managed care.
        Ann Intern Med. 1995; 122: 353-359
        • Eisenberg J.M.
        • Williams S.V.
        Cost containment and changing physicians' practice behavior: can the fox learn to guard the chicken coop?.
        JAMA. 1981; 246: 2195-2201
        • 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.
        Health Care Manage Rev. 2010; 35: 105-115
        • Engel G.V.
        The effect of bureaucracy on the professional autonomy of the physician.
        J Health Soc Behav. 1969; 10: 30-41
        • Bohman B.
        • Dyrbye L.
        • Sinsky C.A.
        • et al.
        Physician well-being: the reciprocity of practice efficiency, culture of wellness, and personal resilience.
        (NEJM Catalyst website) (Published April 26, 2017. Accessed April 30, 2017)
        • West C.P.
        • Dyrbye L.N.
        • Erwin P.J.
        • Shanafelt T.D.
        Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis.
        Lancet. 2016; 388: 2272-2281
        • Panagioti M.
        • Panagopoulou E.
        • Bower P.
        • et al.
        Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis.
        JAMA Intern Med. 2017; 177: 195-205
      2. Reivich K, Saltzberg Levick J, eds. Yale Medicine–University of Pennsylvania Resilience and Well-being Program for Yale Physicians course book. Yale Medicine–University of Pennsylvania Resilience and Well-being Program for Yale Physicians; October 20-22 and November 11-12, 2017; New Haven, CT.

      Linked Article