30 Jan Beating Physician Burnout Requires a Systems-level Hard Reset. Here Are 6 Steps Forward
The way Christine Cassel, M.D., recalls her residency might make you cringe. Back then, 35 years ago, there was no limit on work hours. She and her peers labored all night and then kept at it the next day, several times each week. “Nobody thought anything about it,” she says. Intense pressure placed on women in a male-dominated program further fueled the grueling stress of the program.
“I know what burnout feels like because I’ve experienced it,” notes Cassel, who works for University of California, San Francisco’s medical school and co-chairs the National Academy of Medicine (NAM) committee that wrote last fall’s much-discussed report on systems approaches to clinician burnout.
Now, 42% of doctors say that they, too, feel the effects of physician burnout, according to Medscape’s 2020 report on the crisis. So, what causes this longstanding problem and how can we fix it?
Cassel points to one shift that has wrought havoc in physician lives: mounting administrative burden. “We were able to spend time when we made rounds, and you actually went into patients’ rooms and sat with them, examined them, and talked with them,” she says. “Now, everybody sits outside and plugs everything into the computer, and maybe we’ll drop in for a courtesy call.”
Put simply, medicine has become dehumanized. Interactions between doctor and patient—the reason why most physicians hustled through med school—aren’t what they ought to be. A recent literature review finds that for every hour doctors spend in the exam room, they work one to two hours on documentation. Given the demoralizing nature of medicine today, it’s little wonder we’re facing physician burnout and suicide crises.
But the forces that shaped modern medicine didn’t stem from physicians. Rather, this transformation has roots in external change—from state and federal governments, touching care quality and patient safety, technology, and reimbursements—and internal change—from healthcare organizations and their business decisions. Although healthcare leaders were right to upgrade a system built on handwritten notes and highly variable care, physicians are left to deal with the unforeseen or unheeded consequences.
Most prominent in the NAM report on systems approaches to clinician burnout are several high-impact recommendations for reducing it, which assign responsibility to health systems, governments, and vendors. But one overarching theme defines the report—and how we must approach burnout: This isn’t the fault or responsibility of any one physician. The system is broken, so we need to fix the system.
Redesigning Clinical Systems to Fight Burnout
The moral value of physician well-being is clear, but morals don’t always incite action in business and governance. So, what else should drive healthcare leaders to act? “The well-being of your clinical workforce affects the quality of care that your patients are receiving and the bottom line of your health system,” Cassel says. Physician burnout costs between $2.6 billion and $6.3 billion per year, according to a recent study. That number varies from $3,700 to $11,000 per physician—meaning every health system feels the burn.
But healthcare leaders can do something about it. If you’re to leave with any topline takeaway from the NAM report, it should be this: “taking action to address burnout requires a bold vision for redesigning clinical systems.”
One-off programs won’t suffice.
Calls for individual resilience won’t suffice.
Wellness programs that fail to accommodate hectic physician schedules won’t suffice.
Nothing that treats the symptoms of clinician burnout without addressing the root cause of this public health crisis will achieve physician well-being at scale. That means many people, in various roles and levels of power, must start prioritizing this goal if we are to enact real change.
The 300-plus-page NAM report provides a roadmap for leaders in healthcare, politics, and technology organizations. NAM also published a handy list of recommendations (PDF) to prompt intelligent action. Anyone who’s serious about combatting physician burnout should read the full report and its recommendations for greater detail, but here are a few major action items.
- Healthcare organizations must create positive work environments across the enterprise. This requires rigorous design and implementation of new programs, buy-in from leadership, and accountability, with ongoing evaluation and modification. NAM calls for the establishment of a new executive position to oversee these efforts. And healthcare organizations need to adopt principles that set the path toward meaningful and balanced lives for physicians and clinicians.
- Healthcare organizations and technology vendors need to work with physicians to develop tech that clinicians find helpful, not hurtful. This need is most obvious in electronic health records. Heather Lavoie, president of health data company Geneia, a financial supporter of the Sharp Index Scholarship, adds that the relationship between hospital and vendor can’t end after implementation. “Make sure they’re securing face time with physicians in a practice and hospital setting to see exactly how they are using the system,” she says. “And it’s not a one-time thing, right? It’s an iterative process.”
- Reducing administrative burden is critical to physician well-being, but healthcare can’t get the job done without hard work from state and federal policymakers, regulators, professional boards, and payers. They need to examine how existing laws affect clinical jobs and patient care quality, safety, and cost, according to NAM. Strive for human-centered design and regular review. As Cassel notes, in the age of telemedicine, it’s alarming that physicians need to maintain so many licenses across state lines. It’s time to align licensing rules, which will eliminate painstaking, repetitive work. Payers need to work with healthcare organizations to smooth documentation processes.
- End stigma. Embrace support and recovery. State boards, health system credentialing bodies, and disability and malpractice insurers need to quit prying into clinicians’ health. Otherwise, they should ask only about current health “impairments,” not past mental health diagnoses, NAM writes. Physician well-being requires data transparency, training, and legal protections that empower individuals to seek help.
- Medical schools must step up for their students by cultivating an atmosphere that elevates well-being. Again, this vision calls for commitment from executives. Med students and educators need a system in which their workloads, rewards, and incentives are optimized for better living. Resources need to be easily accessible by those who are experiencing burnout and other mental health conditions.
- The feds need to fund research. NAM wants to see a coordinated effort to spotlight factors that contribute to burnout in medicine, the condition’s effects, and system-level interventions. Healthcare organizations need to get behind this industrywide examination through public-private partnerships.
Battling Physician Burnout at the Health System Level
Several years ago, the leaders of a large medical group in the Southwest decided they had to begin measuring and improving physician satisfaction. The undertaking wouldn’t be easy, but it would reward their employees, patients, and bottom line. The CEO recently shared their findings with Lavoie, as part of Geneia’s 2019 national Physician Misery Index survey, highlighting the crucial role that system-level forces play in physician well-being.
Barriers to physician satisfaction orbited around four major areas:
- Technology and workflow, especially via electronic health records, coding, and documentation
- Lack of control over patient scheduling
- Rewards and recognition from physicians
- Communication and community
The organization created a team comprising physicians, nurse practitioners, physician assistants, and a human resources administrator, Lavoie says. The clinicians advocated for initiatives that could boost well-being, while the administrator got busy breaking down walls to bolster implementation. Meanwhile, the medical practice created the role of wellness champion, who spent a quarter of their workday on advancing well-being.
First, the team opted to change office language. Instead of fighting “burnout,” they began striving for “well-being.” The practice launched a home-for-supper program to cut punishing work hours in favor of family time. Leaders found a connection between patient satisfaction and physician satisfaction, which drove the practice to place more energy into building a positive patient experience. A larger wellness program, built on the understanding that physician and clinician work experiences differ from other employees, tied the bow on this campaign.
“There’s always the fear that if we implement some program, we’re going to have an adverse effect on physician productivity,” Lavoie says. “And we have to get away from that.”
The medical practice ultimately achieved greater physician satisfaction scores, which signaled physicians were happier and healthier. Key to the program’s success was its systems-level approach in which physicians received trust, decision-making power, and executive support.
Enough of the Burnout Resilience Narrative
If we continue to view physician burnout through the lens of the individual, we will continue to fail our doctors, and they will continue to suffer for it.
In one sense, the NAM report offers a potent repudiation of wellness islands—meaning the occasional yoga class or painting party, available to all, pursued by few, and integrated into no larger organizational campaign. By dedicating years of research to systems-level approaches, NAM’s actions scream that these wellness islands aren’t enough. In fact, the first thing that Cassel said after signing on to co-author the report was that the document could not focus on doctors and nurses doing yoga. Although these smaller initiatives serve a certain need, they don’t address healthcare’s foundational flaws.
“It’s not about doctors and nurses making fewer mistakes,” she says. “It’s about setting up a system that helps them prevent mistakes from happening.” By issuing a set of comprehensive, wide-ranging recommendations, NAM’s taking a crack at just that. But it’s up to leaders across healthcare to turn knowledge into real change.
— Jack Murtha. Connect with him on Twitter.
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