From Health Affairs
By: John Noseworthy, James Madara, Delos Cosgrove, Mitchell Edgeworth, Ed Ellison, Sarah Krevans, Paul Rothman, Kevin Sowers, Steven Strongwater, David Torchiana, Dean Harrison
The Quadruple Aim recognizes that a healthy, energized, engaged, and resilient physician workforce is essential to achieving national health goals of higher quality, more affordable care and better health for the populations we serve. Yet in a recentstudy of U.S. physicians, more than half reported experiencing at least one symptom of burnout—a substantial increase over previous years—indicating that burnout among physicians is becoming a national health crisis. Leadership is needed to address the root causes of this problem and reposition the health care workforce for the future. The authors of this paper—the CEOs of our respective institutions—are committing to do just that.
Reasons For Physician Burnout
Burnout is an experience of emotional exhaustion, depersonalization, and feelings of low achievement and decreased effectiveness. Although the focus of this blog is physicians, burnout is also a serious problem for nurses and other health care workers. National studies indicate that burnout is more common in physicians than U.S. workers in other fields and that the gap between physician burnout and other workers’ experience is increasing. This difference is not because of physician shortcomings. The physician selection process is rigorous and eliminates those unable or unwilling to accept this lifestyle. Most physicians are altruistic and committed to their profession. They are taught to address complex problems and to embrace challenges, including grueling training, ongoing night call, and long work hours.
The spike in reported burnout is directly attributable to loss of control over work, increased performance measurement (quality, cost, patient experience), the increasing complexity of medical care, the implementation of electronic health records (EHRs), and profound inefficiencies in the practice environment, all of which have altered work flows and patient interactions. The result is that many previously well-adjusted and engaged physicians have been stressed to the point of burnout, prompting them to retire early, reduce the time they devote to clinical work, or leave the profession altogether.
Why Burnout Matters
The consequences of physician burnout are significant, and threaten our U.S. health care system, including patient safety, quality of care, and health care costs. Costs are impacted by burnout in direct ways (e.g. turnover, early retirement, less than full time work) and indirect ways (e.g. poor quality , including medication and other errors, unnecessary testing and referrals, greater malpractice risk, and possibly higher hospital admissions/readmissions). Prospective longitudinal studies from the Mayo Clinic demonstrate that for every 1-point increase in burnout score, there is a 43 percent increase in likelihood a physician will reduce clinical effort in the following 24 months. The experience from Atrius Health suggests that replacing a physician who retires early or leaves to pursue other career opportunities can cost between $500,000 and $1 million due to recruitment, training, and lost revenue during this time. All of this is in addition to the significant toll, sometimes with tragic consequences, that burnout exacts on physicians and their loved ones.
The high level of burnout among physicians should be considered an early warning signof dysfunction in our health care system. Professional satisfaction for physicians is primarily driven by the ability to provide high-quality care to patients in an efficient manner. Dissatisfaction is driven by factors that impede this effort, including administrative and regulatory burdens, limitations of current technology, an inefficient practice environment, excessive clerical work, and conflicting payer requirements. High levels of physician burnout can thus be seen as an indicator of poor performance by the underlying system and environment.
The Role Of Technology In Driving Burnout
One of the key contributors to burnout involves the aforementioned EHRs. While they have the potential to make a major contribution to patient safety and enhanced coordination of care, EHRs have also radically altered and disrupted established workflows and patient interactions, become a source of interruptions and distraction and are verytime intensive.
While EHRs are evolving in a meaningful way in some institutions, the pace of enhancement must accelerate across the board. Health care delivery organizations, organized medicine, payers and other interested parties need to work with EHR vendors to improve their product offerings, which could reduce EHRs burden on physicians.
Leadership’s Role In Responding To Burnout
Executive attention to the issue of burnout in physicians and other health professionals is paramount to make the changes necessary to improve the health care environment. To further this objective, the CEOs of 10 leading health care delivery organizations held a summit meeting at the American Medical Association (AMA) headquarters in Chicago in September 2016. We reviewed the compelling data on the extent of physician burnout and the consequences for health care delivery systems. After reviewing this data and sharing the experiences of our organizations, we unanimously concluded that physician burnout is a pressing issue of national importance for patients and the health care delivery system.
As leaders, we must recognize burnout in physicians and other health care workers as a serious problem and respond vigorously. This is especially true if we want to maximize the effectiveness, productivity, and longevity of clinicians. More than words are needed. Leaders of health care delivery organizations must embrace physician well-being as a critical factor in the long-term clinical and financial success of our organizations. We must make both the prevention of burnout and the restoration of the joy of a career in medicine core priorities, and address this issue with the same urgent methods we would use to solve any other important business problem: commit to measurement, develop strategy and tactics, and allocate the resources necessary to achieve success. Boards should hold CEOs accountable to implement these approaches to address physician burnout.
The leadership characteristics of a physician’s immediate supervisor also matter. Each 1-point increase (on a 5-point scale) in the leadership score of a physician’s immediate supervisor decreases the odds of burnout by 3.3 percent and increases the likelihood of satisfaction by 9 percent. Successful leaders hold career development conversations with their physicians, inspire and empower their physicians to do their job well, and recognize the physician for a job well done.
CEO Commitment And Call To Action
There was clear consensus among all present at the AMA summit that addressing the issue of burnout is a matter of absolute urgency. We candidly acknowledge that we don’t have all the answers, or know for certain what the most impactful interventionsare, but we are beginning to learn and progress is being made in some areas. Throughout the course of our meeting, we shared effective interventions and successful practices from our own institutions. We acknowledged that not all of the issues we explored were equally weighted in all institutions, and that each CEO needs to examine—and address—the specific issues that contribute to burnout in their respective organization. At the end of the summit, we committed to continue educating ourselves and to take action.
Specifically, we committed to:
Regularly measure the well-being of our physician workforce at our institutions using one of several standardized, benchmarked instruments.
Where possible, include measures of physician well-being in our institutional performance dashboards along with financial and other performance metrics.
Evaluate and track the institutional costs of physician turnover, early retirement, and reductions in clinical effort.
Emphasize the importance of leadership skill development for physicians and managers leading physicians throughout our organization.
Understand and address more fully the clerical burden and inappropriate allocation of work to physicians that is contributing to professional burnout.
Support collaborative, team-based models of care where physician expertise is maximally utilized for patient benefit, with tasks that do not require the unique training of a physician delegated to other skilled team members.
Encourage government/regulators to address the increasing regulatory burden that is driving inefficiency, redundancy, and waste in health care and to proactively monitor and address new unnecessary and/or redundant regulations.
Encourage and support the AMA and other national organizations to work with regulators and technology vendors to align technology and policy with advanced models of team-based care and to reduce the burden of the EHR on all users.
Encourage and support the AMA and other national organizations in developing further initiatives to make progress in this area by compiling and sharing best practices from institutions that have successfully begun to address burnout, profiling case studies of effective well-being programs, efficient and satisfying changes in task distribution, and outlining a set of principles for achieving the well-being of health professionals.
Continue to educate our fellow CEOs as well as other stakeholders in the health care ecosystem about the importance of reducing burnout and improving the well-being of physicians as well as other health care professionals.
Support and use organizational research at our centers to determine the most effective policies and interventions to improve professional well-being among our physicians and other health care professionals.
We believe that our patients deserve care from a compassionate, competent, engaged, and resilient health professional workforce. We are committed to working together as CEOs as well as with other stakeholders within the health care ecosystem to make progress in this critical arena. We invite you to join us.