Organizations may experience physician burnout without being able to see it, which can threaten their success and patient safety.
For healthcare leaders who look at their bottom line and think they do not need to deal with physician burnout, statistics beg to differ. Burnout is a problem for clinicians at all levels — but as a group, physicians are suffering from an epidemic. From 2011 to 2014 alone, their burnout rate skyrocketed from 45 to 55 percent on average, says Laurie Drill-Mellum, MD, MPH, Chief Medical Officer of MMIC. The effects are corrosive, impacting everyone within the physician’s sphere of influence, from leaders to coworkers to patients.
Earlier this year, researchers at Stanford University School of Medicine concluded that physicians suffering from burnout were twice as likely to commit a medical error, while The New England Journal of Medicine (NEJM) reported that physicians with burnout symptoms were twice as likely to leave their organization.
According to an analysis cited by the American Medical Association (AMA), losing a single physician to turnover costs organizations between $500,000 and $1 million. Combine that statistic with an ongoing physician shortage, and healthcare leaders cannot afford to ignore burnout, even if they are profitable now.
“Some problems will go away without attending to them, like a mosquito bite that itches,” Dr. Drill-Mellum says. “One day that will go away, whether you put medicine on it or not. This problem will not go away unless it’s attended to.”
“We don’t walk around in any environment as if in insulated tubes. We all influence each other. … What happens with one group of clinicians could drive feelings and affect others in their work environment.”
— Laurie Drill-Mellum, MD, MPH, Chief Medical Officer of MMIC
Why Burnout Happens
Leaders must understand burnout to combat it. The first thing Dr. Drill-Mellum stresses is that burnout does not begin with the physician.
“Physicians are very resilient to go through what they go through — premed studies, medical school, residency — so this is not an individual problem,” she says. “It’s a systemic problem.”
Melanie (Mel) Sullivan, EdD, Chief People Officer for Constellation, notes that a physician’s work is inherently stressful, but changes in the business and regulation of medicine have resulted in what she references as “stress on steroids.”
For example, long workdays have been compounded by EHRs, which have physicians spending nearly two additional hours documenting for every hour of face-to-face clinical interaction, according to a study in the Annals of Internal Medicine. The study estimates that half of a physician’s workday is spent inputting information for EHRs. Additionally, 37 percent of time spent with a patient in an exam room is reserved for that same task.
In 2015, adoption of the ICD-10 classification system increased the number of diagnostic codes physicians use from 14,000 to 68,000. A year later, only 5 to 6 percent of respondents to a Physicians Foundation Survey said the new system improved their organizations’ efficiency, revenues or patient care.
Changes like these not only prevent physicians from working up to their level of training, but also disconnect them from what drew them to medicine in the first place.
“Doctors go to medical school to learn how to take care of people,” Dr. Drill-Mellum says. “They did not go to medical school to document on a chart so [treatment] could be billed more efficiently.”
Physicians have also become uneasy arbiters between insurance companies and patients.
“Health care has become much more transactional,” Dr. Drill-Mellum says. “It’s less about the relationship. Trust has decreased. Now people wonder, ‘Are you not ordering this particular lab or test for me because you’re trying to minimize expenses? Do you really have my best interest in mind?’ As a physician, that’s kind of offensive.”
She notes that while dermatology does not have the highest burnout rate, it had one of the highest rate increases between 2011 and 2014. Having interviewed many dermatologists, she attributes the increase to the amount of time they spend dealing with prescription insurance issues.
Another stressor is the constant pressure to never make an error, especially one that could have severe or even fatal consequences for patients and lifelong personal and legal repercussions for physicians. On average, physicians spend 11 percent of their career under the cloud of a lawsuit, Dr. Drill-Mellum says, and the higher their training, the greater their risk of being sued.
Meanwhile, corporate acquisition of private practices has deprived physicians of personal gratification, which is often a bigger motivator than money. A surgeon may no longer be allowed to offer a professional courtesy, for example, or may never even be thanked by a patient for a job well done.
That trend toward corporatization shows no sign of slowing. In 2015 alone, there were more than $400 billion in mergers and some 100 consolidations among hospitals and health systems, according to the Physicians Foundation Survey.
Arnold Relman, MD, the late editor of the NEJM, predicted that burnout would increase with the corporatization of medicine, and that has happened.
How Burnout Feels
Occasionally a physician’s workplace antics attract media attention. Sullivan recalls the “egregious” behavior of a Minnesota surgeon whose repeated outbursts resulted in serial suspensions of hospital privileges. Disruptive physician behavior could indicate burnout in that case, she says.
But most burnout is more nuanced. Even if the physician might not see it, those around him or her probably do.
The pioneering Maslach Burnout Inventory, published in 1981, identifies job burnout by three main characteristics: emotional exhaustion, depersonalization and sense of low personal accomplishment. Dr. Drill-Mellum says all three lead to decreased effectiveness at work.
Emotional exhaustion is usually observable, she says. Sufferers “can’t take on one more task, one more problem … they lose the energy to care, and that leads to feelings of cynicism and skepticism.”
Depersonalization can become a coping mechanism, an unconscious choice to view the patient as a body part or disease rather than a whole person; this happens to patients seeking care as well as physicians, who can also feel depersonalized in their work environments when treated as someone who produces revenue rather than a highly trained, expert clinician.
“It can be pretty wounding for physicians because this is in direct conflict with what drew them to the profession of medicine in the first place, that is, caring for people. Sadly, the experience for patients is one of feeling devalued or invisible,” Dr. Drill-Mellum says. “Needless to say, putting two people together who are feeling depersonalized and maybe exhausted — and hoping for a good interaction — is wishful thinking.”
The first two signs of burnout often appear in medical students, when exhaustion leads to depersonalization. The lack of purpose sets in over time, leading to decreased effort and output.
As physicians continue in their practice, some will be at higher risk for burnout than others. And if current trends persist, more than half of medical students will eventually be overwhelmed by a perfect storm of internal, external and regulatory pressures. This, unfortunately, causes everyone around them from leaders to patients to be swept up in the storm, too.
The Ripple Effect
Ripples from burnout spread beyond whomever is on the receiving end of one person’s emotional outbursts or ennui. A disruptive or disengaged physician can have a demoralizing impact on the overall organization, Sullivan says, and if the problem continues unchecked, patients can get lost in the middle.
It makes sense that burnout has been linked to worse patient outcomes, such as decreased satisfaction and compliance. When a physician seems annoyed or disinterested, patients and clinical staff are less likely to follow up with questions or problems, and that impacts the culture of safety, according to Dr. Drill-Mellum.
And that safety risk is measurable. Sullivan points to the recent JAMA Internal Medicine study, which concluded that physicians with a symptom of burnout were more likely to report having made a major medical error in the past three months. Daniel Tawfik, MD, instructor in pediatric critical care medicine at Stanford University, found that physicians were twice as likely to make a medical error if they were experiencing burnout.
“If you’re a patient, you don’t know if the physician is burned out,” Sullivan says. “But what if they are, and you’re the patient who suffers from a mistake?”
Because the causes of burnout are systemic, the solutions must be, too.
Some components of burnout need to be addressed individually early on, perhaps even in medical school. However, making changes on an organizational level is more potent and successful when attempting to alter the current atmosphere. Engagement and prevention, earlier rather than later, is key.
“Change must begin at the top,” Dr. Drill-Mellum says. “Leaders must recognize that there’s a problem and be motivated to address it, devoting tools and resources and an accountability piece as well.”
She suggests they borrow from Stanford University’s model of organizational support, which focuses on improving workplace culture and efficiency and building/supporting individual resilience and wellness.
The best improvement strategies include observation, measurement and feedback. Observation could include tracking unsolicited patient complaints, which have been linked to higher malpractice risk and worse surgical outcomes, according to research published in JAMA Surgery.
It could also mean simply paying closer attention to what people are saying as well as who’s saying it, Dr. Drill-Mellum suggests. After 10 years of experience managing complaints from patients and coworkers, she’s learned that an atypical complaint pattern usually means something is wrong.
Measurement might involve monitoring how often physicians access EHRs during their off hours, and administering physician surveys like the Mini Z, a popular 11-item self-assessment available at STEPSForward.org. Stanford University’s new Professional Fulfillment Index could also be helpful, Sullivan says. She suggests publishing the results organizationally on a “burnout scorecard” to drive honest discussion about any problems.
“That transparency and authenticity just help tear down the walls brick by brick, allowing more of those conversations about ‘How can we work on this together?’” she says. “Because it’s not physicians who are going to solve it by themselves, and it’s not executives and leaders who are going to solve it by themselves. It has to be everyone working together — and the best way to do that is to bring the problem forward.”
“By inviting feedback from clinicians affected by burnout, leaders can generate viable, compassionate solutions,” Dr. Drill-Mellum adds. “That’s the way to engage on the front line of care. That’s the way to hear and learn from doctors, as well as improve with them.”
“Even the simplest strategies, like choosing to use more positive language in the workplace, can help create a more supportive organizational culture,” Sullivan says. “All those things make a difference when you start to do the additive approach.”
“You can make a difference by refocusing and deliberately talking about how to find joy, day to day. Sharing stories across organizations can help, too. There are both tangible and intangible ways to make an impact.”
— Melanie (Mel) Sullivan, EdD, Chief People Officer for Constellation
With the Association of American Medical Colleges projecting a shortage of up to 90,400 physicians by 2025, more healthcare organizations are starting to get proactive about burnout.
The AMA has helped lead the charge with its STEPS Forward module, which includes a calculator that evaluates an organization’s risk of physician burnout and turnover, including potential return on investment in programs that decrease turnover.
Sullivan says she suspects most specialties now offer tools to support physician wellness and reduce burnout. Leadership also seems more willing to administer physician burnout or well-being surveys, and physicians seem more willing to answer them honestly. While not every physician experiences burnout, it’s a big enough issue to demand an organizational solution, Sullivan says.
“We have a lot to figure out in terms of leveraging people’s skills and expertise and engaging their hearts in a better way than we’re doing currently,” Dr. Drill-Mellum says. “The institutions that figure that out will be the ones that survive.”
MMIC is a member of Constellation, a collective of MPL insurance and partner companies offering solutions that are good for care teams and business. To learn more about the services MMIC provides to physicians, hospitals and health systems, visit MMICgroup.com.