By Guest Author on Jul 9, 2018 2:37:15 PM
Alleviating Burnout Among Physicians & Clinicians
She will never forget that decision or that patient. In an anonymous TED podcast, a physician recounted the day burnout got the best of her. Emotionally exhausted after too many grueling shifts at a teaching hospital and not enough attention to her own needs, “I had stopped seeing patients as people. They were diseases, lab values and test results,” she says.
She was going through the motions when she entered the room of a belligerent patient who was screaming that he wanted to go home. Instead of trying to calm him and talk him into staying, she discharged him against medical advice and her better judgment.
Two days later, she learned that the patient was back in the hospital and dying from a hemorrhage. Though she had warned him of the consequences of leaving the hospital, she felt responsible for his setback.
“I knew that a better version of myself could have prevented all of this from happening,” she says. “I didn’t exactly make a mistake. I didn’t ignore a vital sign or forget to order a medication. I just didn’t try very hard.”
She wondered what was wrong with her: Why hadn’t she cared more about this patient? Why was she feeling so cynical and detached? Grappling with the reality of what had just happened forced her to see how detrimental her burnout had become—not just to herself but also to her patients.
“As doctors, we are never convinced we have a duty to care for ourselves, but we also never really believe our problems can cause any harm to our patients,” she says.
Marked by emotional exhaustion, depersonalization and a diminishing sense of accomplishment, burnout is a silent epidemic growing among physicians, nurses and other healthcare workers. It’s a syndrome resulting from a stress-fueled healthcare system with mounting workloads and increasing responsibilities from regulatory pressures and evolving payment and care delivery models. The condition is twice as common among physicians as professionals in other fields, according to a 2017 National Academy of Medicine (NAM) discussion paper.
More than half of all U.S. physicians surveyed in 2014 by the Mayo Clinic reported at least one symptom of burnout—an increase of 9 percent from a study three years earlier. Doctors specializing in the frontlines of care, particularly those in emergency, family and internal medicine, are most likely to suffer from burnout.
“They’re the ones who are coordinating so many dimensions of care, interfacing with multiple providers, prescribing and renewing a larger volume of medications, interacting with patients on electronic portals and fielding the volume of phone calls,” Tait Shanafelt, M.D., Stanford Medicine’s chief physician wellness officer and former Mayo Clinic researcher, says in an interview with the New England Journal of Medicine (NEJM).
Burnout has many repercussions for providers, from decreased productivity, low morale and dissatisfied patients to oversights in care, medical errors and malpractice suits. It’s become so debilitating for clinicians that many are cutting back their hours or leaving the profession altogether for less stressful jobs inside and outside of the medical field. For those who decide to stay in the profession, burnout can even be deadly. Studies show a higher suicide rate in physicians and link higher rates of substance abuse, depression and anxiety among clinicians. A 2015 Mayo Clinic study revealed that more than 7 percent of nearly 7,000 doctors had considered taking their own lives in the past 12 months, compared with 4 percent of professionals in other fields. Approximately 400 doctors a year commit suicide. Nurses may also have a higher suicide risk than most people, according to a discussion paper published by NAM, though no formal studies exist to determine the extent to which they are affected.
Recognizing the Signs and Sources
Clinicians react differently to burnout. Some may feel lethargic, forgetful or irritable, while others may become increasingly anxious, apathetic and depressed. But most who struggle with burnout share a common symptom: a loss of the joy they once found in practicing medicine.
Although physicians agree that the lack of appreciation, growing demands from patients and the high-stakes environment in which they work can contribute to burnout, much of their stress is rooted in the changing healthcare landscape. Not only must they struggle with serving an aging patient population with higher rates of chronic disease, but they are also pressed to provide better, more efficient care to patients at lower costs and with fewer resources. One of the biggest sources of frustration for physicians is what many consider cumbersome electronic health records (EHRs), which they must use to fulfill regulatory mandates for documenting the quality of patient care.
“EHRs have expanded the workday and created a number of frustrating inefficiencies related to documentation and order entry,” Shanafelt told the NEJM. “In many ways, they have turned physicians into data entry clerks.”
Stats on Burnout
55 percent: Female physicians burnout scale
45 percent: Male physicians burnout scale
Pre-approval requirements from health insurers for services, as well as quality metrics built into the Affordable Care Act, have also added more clerical duties for doctors. To keep up, primary care physicians are spending more than half of their day performing data entry and other administrative tasks, according to a 2017 study by the American Medical Association (AMA) and the University of Wisconsin, published in the Annals of Family Medicine.
Remote, 24/7 access to EHRs has increased productivity expectations in many hospitals and clinics, enabling doctors to see the same number of patients—if not more—during the day while bringing documentation home to finish at night. The average physician spends up to 30 hours a month updating patient records after hours, with EHR use peaking at 10 a.m. and 10 p.m. on the weekends.
Doctors are also concerned about not getting enough time with patients. For every hour they spend seeing patients, they must spend two hours on the computer, the AMA study found. Even in the exam room, doctors may interact with the computer as much as they do with patients and care team members. This trend has begun to “erode the human interaction that is at the heart of healing and serves as a tremendous source of meaning for both patients and physicians,” Shanafelt says.
In their efforts to juggle regulatory and administrative tasks with caring for more patients in less time, doctors often put themselves on the back burner. Three out of four primary care physicians say their heavy workloads prevent them from getting enough sleep or exercise, according to a 2017 MDVIP Physician Health Survey.
Two out of three say work stress negatively impacts their personal lives, making them feel like they’re on a treadmill that keeps speeding up.
The most diligent and caring clinicians can develop compassion fatigue when burdensome tasks and time constraints converge with a lack of flexibility or support at work, a neglect of personal needs and the suffering or loss of patients.
They may have a harder time coping with the pressures around them or connecting with patients like they once did—though many never let on they are struggling.
When it comes to burnout, “doctors are masters of disguise,” says Pamela Wible, a family physician and author who has studied the mental effects of burnout on physicians. “Even fun-loving docs who crack jokes and make patients smile all day may be suffering in silence.”
Burnout can even make physicians question their own competence. Mayo Clinic researchers found that higher levels of burnout in surgeons made them more likely to report major medical errors. Many physicians are hesitant to ask for help coping in a field where demanding shifts, sleep deprivation and personal sacrifices are the norm. Nearly 40 percent of physicians told Mayo Clinic researchers they were reluctant to seek psychological or psychiatric treatment for fear of jeopardizing their medical license.
What Burnout Costs Providers
As crippling as burnout can be for doctors and clinicians, patients are the ones who suffer the most when it goes unchecked. Recent studies show that being under the care of a burned-out physician or clinical team raises the risk of healthcare-associated infections, medical errors and adverse outcomes. Burnout is also driving up rates of unnecessary testing and hospital readmissions, researchers say, leaving providers vulnerable to lackluster HCAHPS scores, declining reimbursements and higher costs.
As many organizations endeavor to balance increased patient care demands with tight budgets, low morale and clinician shortages, providers are starting to recognize the impact of burnout.
In a recent joint study by the Mayo Clinic, the AMA and Stanford University, nearly 1 in 5 doctors say they intend to reduce their clinical hours over the next year, while 1 in 50 plan to leave medicine within the next two years. If even a third of these doctors follow through on their intentions, the nation could lose a physician pool equivalent to the graduating classes of 19 medical schools.
According to estimates from Atrius Health, the largest independent physician-led healthcare organization in the Northeast, every time a doctor quits, the cost of recruiting and training his or her replacement can range from $500,000 to $1 million.
And, the Blue Ridge Academic Health Group estimates that burnout costs the nation around $150 billion a year in physician turnover, lost productivity from early retirements and medical errors.
Tackling the issue head on
Several university medical centers have been successful at easing burnout by establishing physician wellness networks that offer resources for helping doctors and medical interns adopt healthier habits and get more exercise, rest and balance in their lives. Boston Medical Center’s Wellness Program helps clinicians cope with work and personal problems and promotes health and wellness. (See its resources here.) Stanford University Medical Center has piloted a program providing ER doctors with meals, housecleaning and babysitting services in exchange for long hours. At its Institute for Patient Safety and Quality, Johns Hopkins is working with hospitals to create confidential “psychological first aid” programs intended to provide caregivers with the emotional support they need on difficult days without feeling stigmatized.
Other hospitals are doing more to spread the burden of heavier patient loads and administrative tasks across clinical teams. Cleveland Clinic recently hired more nurse practitioners to handle routine tasks for physicians, such as coordinating patient care, managing order entry, and answering patient questions and calls.
Other facilities are hiring medical assistants to assist doctors with note-taking and documentation during visits and bringing clinical teams together more often to reduce reliance on email and EHRs.
HealthTrust Workforce Solutions helps healthcare systems address clinician shortages that lead to burnout, says the group’s first chief nursing officer, Shaun McCamant, MSN, RN. “From my work on the frontlines, I’ve seen how patient acuity is higher now and so many patients need complex care. The ability of HealthTrust Workforce Solutions to recruit and hire the right staff at the right time can really help on the tough days to assist with the gaps.”
Experts say that changes from stakeholders across the healthcare industry will be necessary since burnout is a systemic issue. To meet that challenge, the AMA has launched a national initiative to raise awareness and promote wellness and resilience among physicians, partnering with more than 130 groups composed of providers, payers, researchers, health tech firms, government agencies and patient advocacy groups. The collaborative has launched an online hub of research, toolkits and resources that leaders can use to tackle the issue.
Burnout is often the earliest indicator of a healthcare system prone to errors and dysfunction, so hospitals must continuously monitor the well-being of their staff and act to reduce sources of stress that contribute to burnout before it impacts patient care. Often the most empathic and contentious physicians are the ones at highest risk for burnout, researchers note.
For the doctor who shared her story on the TED podcast, redefining what it means to be a “good doctor” and being mindful of her own resilience, as well as that of her patients, has helped her keep burnout at bay.
“There is power in talking about burnout,” she says. “Like any disease—once you name it, you can begin to see it, understand it, prevent it and maybe fix it.”