Discussion: physician-led wellness plan beating burnout.
United States are experiencing professional burnout. (1) Emergency medicine is one of the most affected specialties, with burnout rates as high as 70 percent. (1,2) Burnout is characterized by emotional exhaustion, compassion fatigue and a loss of a sense of personal accomplishment, and it has significant repercussions for both the individual provider and the health care organization. Burnout can decrease quality of care and patient satisfaction, and it may increase medical errors, malpractice risk, staff turnover, divorce, drug and alcohol addiction and suicide rates. (3)
The health care industry now recognizes this issue as critical. In 2016, U.S. Surgeon General Vivek Murthy said, "If health care providers aren't well, it's hard for them to heal the people for whom they are caring." (4) This concept has been echoed by many others, including physician coach Dike Drummond, MD, the CEO of TheHappyMD.com, who uses the analogy of an oxygen mask on an airplane to explain the importance of addressing physicians' needs before they can take care of their patients'. (5)
In 2008, the Institute for Healthcare Improvement adopted the Triple Aim of enhancing patient experience, improving population health and reducing costs as the model for improving health care in the United States. In 2014, authors Thomas Bodenheimer and Christine Sinsky suggested that it be expanded to the Quadruple Aim. Because burnout is associated with decreased quality of care and decreased patient satisfaction, it imperils the Triple Aim. Thus, a fourth component --improved clinician experience--must be addressed in order to make any significant improvements to the U.S. health care system. (6)
CAUSES OF PHYSICIAN BURNOUT
Psychologists Christina Maslach and Michael Leiter are among the original researchers on the subject of burnout, and they say it's largely a problem of the workplace, not the individual. They outline six major organizational causes: work overload, lack of control, insufficient reward, unfairness, breakdown of community, and value conflict (see Table 1). The risk of burnout increases when "the workplace does not recognize the human side of work." (7)
Echoing Maslach and Leiter, a recent Medscape.com survey cited "too many bureaucratic tasks" as the top physician-reported cause of burnout. (8) Other causes included "spending too many hours at work," "increasing computerization of practice," "income not high enough," and "feeling like just a cog in a wheel." Emergency physicians spend an increasing amount of time on electronic health records, maintenance of certification requirements, continuing medical education, licensures and mandated training modules (infection control, annual hospital training, Ebola readiness, sedation modules, central line modules, stroke CME, etc.).
One of the biggest changes to the modern physician's workplace is the EHR. Although it has benefits, (8) physicians now spend more time with computer screens than patients. (9) This translates to physicians spending less time with patients and more time documenting outside of their work hours. (10) Compounding the issue of increased documentation time is the pressure for time-based metrics. Physicians feel simultaneously pressured to see patients more quickly and use a documentation system that is more cumbersome. Physicians feel overworked, lacking in control of their medical practices, under-rewarded and a sense of unfairness regarding doing more work for less, and they perceive a value conflict between the profit motive and quality of care. Physicians and patients alike bemoan the intrusion of the computer into the doctor-patient relationship. (11)
Traditional medical training focuses on diagnosing and treating illness, but not on the leadership and business skills necessary to succeed in today's practice environment. A 2015 Mayo Clinic study concluded that "the leadership qualities of physician supervisors appear to impact the well-being and satisfaction of individual physicians." (12) Additionally, there is a boot camp aspect to training and a self-sacrificial style to physician culture that predisposes doctors to burnout. Physicians spend years learning to ignore their basic needs--sleep, exercise, healthy food and more. They also interact frequently with tragedy and are taught to suppress their emotional reactions, which can lead to a type of stress disorder known as "second-victim syndrome"--being traumatized by unanticipated adverse patient events.
ADDRESSING PHYSICIAN BURNOUT
Physicians are taught to put patients first, but lessons from other industries can inform us to change. As Drummond writes in his book, Stop Physician Burnout, successes in almost every other industry outside of health care are usually attributed to hiring good people and taking good care of them. (3)
For example, Danny Meyer, CEO of Union Square Hospitality Group and a successful restaurateur in New York, attributes his success in part to contradicting the "customer is always right" concept and always putting his employees first. (13) He invests heavily in his employees with comprehensive training, mentoring, leadership development programs and education. Meyer also offers competitive compensation, progressive compensation and extensive benefits, (14) which is rare in the restaurant industry.
Paul Spiegelman, founder and CEO of a successful patient-experience company, and Britt Berrett, president of Texas Health Presbyterian Hospital Dallas, elaborate on this concept for health care leaders in the book Patients Come Second: Leading Change by Changing the Way You Lead. They say "the best way to improve the patient experience is to build better engagement with their employees, who will then provide better service and care to patients. To put it another way: Patients come second." (15)
In response to the complex causes of physician burnout, a multifactorial approach to physician wellness is necessary to decrease exhaustion and improve happiness, thereby providing the best possible patient care. Since physician burnout is caused primarily by issues within the work environment and not the individual, an obvious course is for organizations to create programs that address it. But even the ideal job in medicine is stressful, so there is a role for resilience training as well. Resilience training is essentially "positive psychology"--teaching people to learn and grow from failure or trauma, rather than collapse. It is used in the military to help soldiers recover from trauma and minimize the development of post-traumatic stress disorder. (16) However, this can be off-putting to physicians if the work environment is not addressed first. As Jamie Riches, DO, astutely wrote after being offered resilience training in response to a fellow resident's suicide, "We were being given tools to obviate the natural human state of vulnerability." (17)
Leadership training is not routinely part of medical education, and that deficit can contribute to physician burnout. (12) Drummond suggests leadership training, coaching, regular feedback regarding leadership skills, education about physician burnout, and consideration of this when hiring. (18)
Further research is needed to discern which programs and interventions are most effective. A 2016 Lancet meta-analysis of interventions to prevent and reduce burnout found that "both individual-focused and structural or organizational interventions can reduce physician burnout." (19) However, no specific interventions have proved better than others, and the combination of individual and organizational interventions has not yet been studied.
Stanford Medicine developed the pioneering WellMD Center in 2015. Its mission is "to improve the health and professional fulfillment of physicians and the associated health of their patients, their students, and other members of the medical teams they lead." It has a comprehensive program that promotes a culture of wellness, efficiency of practice, and personal resilience. (20)
CREATING A PROGRAM
The New York-Presbyterian/Weill Cornell Medical College's emergency medicine division is an academic group of more than 50 board-certified emergency physicians. It staffs two emergency departments: Weill Cornell Medical Center Emergency Department, a 90,000-annual-visit quaternary-care facility in the upper east side of Manhattan, and Lower Manhattan Emergency Department, a 40,000-annual-visit community care facility.
To develop a collaborative approach, we established the Committee for Physician Wellness & Satisfaction. We used the term "wellness" because it is familiar and encompasses both physical and psychological health, and the term "satisfaction" to emphasize the fact that provider satisfaction is just as important as patient satisfaction, if not more so. Our mission acknowledges that happy physicians are the key to optimizing patient outcomes and satisfaction. It addresses the organizational causes of burnout identified by Maslach and Leiter, as well as the more physician-specific causes (see Table 1).
First, we surveyed physicians using the Maslach Burnout Inventory and Areas of Worklife Survey. Many physicians reported that simply being asked their opinions or how they feel about the workplace was therapeutic and brought a small sense of control back to their profession. We held a group discussion in our faculty meeting, giving physicians an opportunity to brainstorm solutions together and communicate directly with leadership.
We established a lecture series in our faculty meeting with a diverse range of topics related to physician well-being, job satisfaction and burnout prevention. We have covered such topics as mindfulness-based stress reduction, second-victim syndrome, dealing with malpractice cases, physician burnout and suicide. Also, we fill the gaps in medical education by teaching leadership skills and the business side of medicine. In addition, we have provided all physicians with copies of Drummond's Stop Physician Burnout so they will have a comprehensive resource and tools to address and lead the burnout prevention movement.
We have established a culture of engagement and response to attending input. For example, many physicians were unhappy that one clinical shift ended at 1:30 a.m., so it was changed to end at midnight. When faculty expressed exhaustion from working main emergency department shifts, we diversified our shifts to give attending physicians the option to work telemedicine shifts, which are a slower pace and require lesser acuity.
To address the issues of workload and excessive data entry, we have hired medical scribes to serve as assistants to the physicians. Their main role is to document patient encounters, but they also track down ancillary medical data, facilitate communication between staff members and the physician, alert physicians when test results are posted, and act as an in-person dictation system. While data on ED throughput with scribes is mixed--likely because of factors outside of the physician's control, such as time to radiologic and laboratory studies--scribes have been shown to improve patient satisfaction, provider satisfaction and revenue capture. (21,22,23) Physicians spend less time documenting and more time with patients. (24)
We established a system of 20- to 30-minute breaks on every shift. Established attending physicians cover at our academic site, and physicians are not assigned new patients at our community site. The feedback has been positive and, consistent with literature from other fields, physicians report increased productivity after a brief recharge. There Is little research on the impact of physician breaks, but, in one study, surgeons who were given a five-minute break every half-hour during complex laparoscopic surgery were shown to have reduced psychological stress without impacting performance or prolonging the operation. (25) We also completed an extensive renovation of our ED physician offices to create a more-serene space for physicians to take their breaks, complete with a massage chair and espresso machine.
At our community site, we began a project called the Attending Offloading Project and surveyed all of our attending physicians for ideas on how to minimize clerical work and improve ED workflow. Simple changes, such as having registered nurses print work notes and registration clerks enter pharmacy information into the EHR, are small but effective. These workflow solutions, from the providers themselves, have an appreciable impact on the physician's overburdened day.
To improve our sense of community, in addition to faculty group discussions, we have established a program of wellness events funded and supported by the department, including dinners, happy hours and a staff cruise around the city, and family events to include those most important to the health and well-being of our colleagues.
Lastly, we have started a peer-support program for physicians dealing with malpractice cases, medical errors or bad outcomes. These events can be isolating, so we provide physicians with an outlet to discuss their feelings with a colleague in confidence. Physicians are given a list of phone numbers of designated peer supporters that they can contact, and we also contact them when we hear about a difficult case or other concerning issue.
We intend to compare one-year inventory scores as an objective measure of the efficacy of our faculty wellness program. There was an increase in the department's total staff engagement index compared to 2016. While this likely has many factors, anecdotal reports suggest a significant correlation to wellness initiatives. For logistical reasons, we designed our program for attending physicians. However, it has had a significant impact on all clinical staff. Residents and PAs all take breaks now, and both have been included in some departmental outings.
The major barriers to developing a physician wellness program are the investments of time and money. Early buy-in from administrative leaders is crucial; they must understand the benefits of staff performance and retention and the long-term impact these outcomes will have on patient care. (26)
Our program is an ongoing physician-led project. Early colleague feedback has been promising; anecdotally, these interventions are having a positive impact. We recognize there is no quick fix to this complex issue and that we have chosen a challenging yet incredibly rewarding profession. Our rapidly changing health care system should draw on the wisdom of other successful industries and recognize that the well-being of clinicians is as important as the well-being of our patients. These ideas must be collaborative and come from physicians themselves. As David Rock wrote in 2009, in Strategy and Business, "People rarely support initiatives they had no part in designing." (27) When physicians are happy and engaged with their work, the greatest beneficiaries will be their patients.
The authors are physicians in the emergency medicine division at New York-Presbyterian/Weill Cornell Medicine. firstname.lastname@example.org
(1.) Shanafelt TD, Hasan 0, Dyrbye LN, et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population. Mayo Clin Proc. 2015; 90(12):1600-13.
(2.) Medscape Lifestyle Report, medscape.com/features/slideshow/lifestyle/2016/ public/overview. Published Jan. 13, 2016. Accessed Dec. 4, 2016.
(3.) Drummond D. Stop Physician Burnout: What to Do When Working Harder Isn't Working. 2014.
(4.) Surgeon General Concerned About Physician Burnout. MedPage Today. medpagetoday.com/publichealthpolicy/generalprofessionalissues/57280. Published April 10, 2016. Accessed Dec. 4, 2016.
(5.) Drummond D. Compassion Fatigue Is a Call to Action. The Huffington Post. Dec. 10, 2012. huffingtonpost.com/dike-drummond/compassionfatigue_b_2267964.html. Accessed Dec. 4, 2016.
(6.) Bodenheimer T and Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014; 12(6): 573-6.
(7.) Maslach C and Leiter M. The truth about burnout: How organizations cause personal stress and what to do about it. San Francisco, CA: Jossey-Bass; 1997.
(8.) Institute of Medicine, Committee on Patient Safety and Health Information Technology. Key capabilities of an electronic health record system. Washington, DC: National Academies Press; 2003.
(9.) Hill RG Jr, Sears LM and Melanson SW. 4000 clicks: a productivity analysis of electronic medical records in a community hospital ED. Am J Emerg Med. 2013; 11:1591-4.
(10.) Boonstra A and Broekhuls M. Barriers to the acceptance of electronic medical records by physicians from systematic review to taxonomy and Interventions. BMC Health Serv Res. 2010;10:1-17.
(11.) Girgis L. The War on Doctors and Destruction of Healthcare. Physician's Weekly. 28 May 2015. physiciansweekly.com/the-war-on-doctors-destruction-of-healthcare. Accessed Dec. 4, 2016.
(12.) Shanafelt TD. Impact of Organizational Leadership on Physician Burnout and Satisfaction. Mayo Clin Proc. 2015; 90(4):432-440.
(13.) Cutrone C. Danny Meyer to 'Treps: Put Your Employees First, Customers Will Follow. Inc. Jan. 28, 2014. inc.com/carolyn-cutrone/danny-meyer-speaks-atinc-business-owners-council.html. Accessed Dec. 4, 2016.
(14.) Careers. Union Square Hospitality Group, ushgnyc.com/why-work-with-us/. Accessed April 26, 2017.
(15.) Splegelman P and Berrett B. Patients Come Second: Leading Change by Changing the Way You Lead. New York, NY: Inc. 2013.
(16.) Seligman M. Building Resilience. Harv Bus Rev. 2011. hbr.org/2011/04/ building-resilience
(17.) Riches J. What Is Resilience? NEJM. July 15, 2016. resident360.nejm.org/ contentjtems/what-is-resilience. Accessed Dec. 4, 2016.
(18.) Physician Leadership can cause Physician Burnout. TheHappyMD.com. thehappymd.com/blog/physician-leadership-is-a-cause-of-physician-burnout. Accessed April 26, 2017.
(19.) West CP, Dyrbye LN, Erwin PJ and Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016; 388(10057):2272-2281.
(20.) Stanford Medicine WellMD. wellmd.stanford.edu. Accessed April 26, 2017.
(21.) Bastani A, Shaqiri B, Palomba K, Bananno D and Anderson W. An ED scribe program is able to improve throughput time and patient satisfaction. Am J Emerg Med. 2014; 32:399-402.
(22.) Arya R, Salovich D, Ohman-Strickland P and Merlin M. Impact of Scribes on Performance Indicators in the Emergency Department. Acad Emerg Med. 2010; 17(5):490-4.
(23.) Heaton HA, Castaneda-Guarderas A, Trotter ER, Erwin PJ and Bellolio MF. Effect of scribes on patient throughput, revenue, and patient and provider satisfaction: a systematic review and meta-analysis. Am J Emerg Med. 2016; 34(10):2018-2028.
(24.) Hess J, Wallenstein J and Ackerman J, et al. Scribe impacts on provider experience, operations, and teaching in an academic emergency medicine practice. West J Emerg Med. 2015; 16(5):602-10.
(25.) Engelmann C, Schneider M, Kirschbaum C, et al. Effects of intraoperative breaks on mental and somatic operator fatigue: a randomized clinical trial. Surg Endose 2011; 25(4):1245-50.
(26.) Brod HC, Lemeshow S, Binkley P. Determinants of Faculty Departure in an Academic Medical Center: A Time to Event Analysis. Am J Med. 2017; 4: 488-493.
(27.) Rock, D. Managing with the Brain in Mind. Strategy & Business. Aug. 27, 2009. strategy-business.com/artide/09306?gko=5df7f. Accessed
Dec. 4, 2016.
Renu Mital, MD
Rahul Sharma, MD, MBA, CPE, FACEP
Peter Steel, MD
Lucy Willis, MD
Caption: FIGURE 1: "The Missing Aim"
Caption: FIGURE 2: Elements of the Wellness & Satisfaction Program
TABLE 1: CAUSES OF PHYSICIAN BURNOUT ORGANIZATIONAL * Work overload * Lack of control * Insufficient reward * Unfairness * Breakdown of community * Value conflict PHYSICIAN-SPECIFIC * Bureaucratic tasks * Medical malpractice * Limitations of career development training * EMR documentation duties * "Second-victim syndrome" * Third-party involvement in medical decisions
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|Title Annotation:||HEALTH CARE ORGANIZATIONS|
|Author:||Willis, Lucy; Mitai, Renu; Steel, Peter; Sharma, Rahul|
|Publication:||Physician Leadership Journal|
|Date:||Sep 1, 2017|
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