At the conclusion of this activity, participants will be able to:
- Describe current drivers of physician burnout in the healthcare environment
- Describe at least one strategy for improving personal resilience
- Describe at least one strategy that can create a culture of wellness in the healthcare workplace
- Describe a strategy for improving practice efficiency
Physician wellness is a topic that has received increasing attention in recent years.
It has always been important, of course, for physicians to care for themselves so that they can best care for others. But a recent report of burnout in more than half of the physicians in the United States1 has brought the topic of physician wellness to the forefront.
The term “burnout” was first coined in the 1970s. The most recent large-scale studies, each looking at about 7,000 physicians across the United States, found an average of about 45 percent of physicians had at least one symptom of burnout in 2011, which increased to 54 percent in 2014.1
Burned-out physicians mean burned-out care. Burnout has been associated with more medical errors as perceived by physicians, less careful prescribing habits and less satisfying doctor–patient relationships.2-5 In addition, burnout can lead to more turnover of physicians in practices, hospitals or organizations and physicians going part-time or retiring early—which is costly to organizations and disrupts the continuity of care for patients.2, 6 Burnout can lead to depression, and it is an independent risk factor for physicians thinking about suicide.2, 7
The aviation industry has paid attention to the wellness of its pilots for the safety of passengers; in medicine, we are behind in that regard. But we are catching up.
Burnout as a work-related syndrome
Burnout is not a mental health diagnosis—it is a work-related syndrome that can be explained in three parts that can exist to varying degrees in an individual person.
The first part is emotional exhaustion—feeling depleted, like you have nothing left to give.
The second part is depersonalization—going through the motions at work, being so robotic that you view patients as just another problem to solve, rather than seeing them as people. Depersonalization can also mean feeling cynical about and removed from the work you do.
The third part is a decreased sense of personal accomplishment—no matter how well you may be doing or how many accomplishments you may have, you just don’t feel good enough or worthwhile.8
Various factors drive these elements of physician burnout, including individual coping style and circumstances. However, the extensive number of physicians reporting burnout has led experts to look at organizational factors in the work environment and within the healthcare system9 as the main drivers of the current burnout epidemic.
Physicians report administrative burden is the top work environment factor contributing to burnout. For example, physicians have been faced with increased demands for documentation for reimbursement, quality management monitoring and certification maintenance.10 Electronic health records (EHRs) are designed to support comprehensive documentation, but are not necessarily designed to be user friendly.11 It has been recently estimated that for each hour of patient care, there are two additional hours of related administrative work. This is time-consuming, leading physicians to log in from home at the end of the day to complete charts and other administrative requirements. Time on the computer during the medical visit itself can also erode meaningful face-to-face quality time that physicians spend with their patients.10
To reduce physician burnout, it is clear that organizational factors at work and within the healthcare system must be addressed.9 Some factors, such as documentation requirements for reimbursement, need to be attended at the national level. For example, the Centers for Medicare and Medicaid Services is working to simplify the evaluation and management coding system to reduce provider burden.12 National professional organizations, too, are weighing in as this process evolves.13 Some medical specialty boards are simplifying requirements for Maintenance of Certification.14
Three domains of professional fulfillment
As these larger systemic changes take place, physicians can proactively work to maintain personal wellness and promote professional fulfillment within their local work environment. One methodical approach for supporting physician wellness is to address the following three domains of professional fulfillment: personal resilience, culture of wellness and efficiency of practice.15
Approaches for improving personal resilience—the ability to thrive despite adversity—can be divided into three categories: self-care, self-awareness and work–life integration.
Self-care includes the basic, but necessary, elements of exercise, good nutrition and adequate sleep. It also includes activities that offset the body’s stress response, such as relaxation techniques, mindfulness meditation, breathing techniques, disciplines such as yoga or tai-chi, or any activity or hobby that has that effect for an individual. In particular, mindfulness meditation has been shown to be effective in physicians.16
Self-awareness is multifaceted. Aspects include awareness of one’s personality traits and feelings and knowledge of what is most meaningful at work. Common traits in physicians include a heightened sense of responsibility, a tendency to doubt and be critical, and a tendency to feel guilty.17 Although these traits are helpful and important in medicine, they can be draining if they are taken to an extreme. For example, one wants a physician to be critical of the literature and double-check test results, but being overly self-critical can be demoralizing. A physician needs to be mindful and aware of these traits and maintain a healthy balance.
Noticing one’s feelings is another component of self-awareness. Physicians are taught to remain calm and objective in the face of chaos; they are exposed to tragedy and joy in people’s lives, and often go from one high-stress situation to another, without time to notice what they feel or to process the emotional impact. Being aware of these feelings and seeking a venue in which to share them is a healthy way to maintain resilience. Mindfulness need not be achieved only during formal mindfulness meditation, but can be done informally in simple moments of awareness during day-to-day experiences. A second or two to appreciate the patient in front of us, a few slow breaths taken before the next meeting or patient session, or a moment to think about a grateful patient can be helpful and remind us of what is most meaningful at work.
Work–life integration can be challenging. One approach is to have a schedule that integrates personal and work activities so that family and personal matters are not simply getting leftover time after work. For example, formally scheduling family or hobby activities on one’s calendar may prevent a physician from putting them on hold until the workload improves. When possible, paying for assistance with household chores can help make the time at home more focused on relationships or on more meaningful home activities (keeping in mind that a chore for one person can be fun for another).
Culture of wellness
Physicians are typically viewed as leaders, and thus, they can normalize and model wellness behaviors with their colleagues, co-workers or clinical team members. At the organizational level, support for wellness should include regular measurement of well-being and work fulfillment.18 A culture of wellness should be more than hosting wellness fairs. It is about how the organization or the practice is run and the values that the leadership projects.
The leadership in an organization should be encouraged to support provider wellness efforts for many reasons. Implementing strategies for improving provider wellness can help the organization save money, improve the quality of care provided to patients, improve morale and maintain satisfied providers. Additionally, a sincere commitment to addressing wellness can foster trust between administrators and providers.
A number of activities can create a culture of wellness. These include regular meetings in which team members have a voice to improve the work environment, recognition of successes, meetings with time for people to share meaningful personal or professional successes, peer support or formal mentoring and gatherings for affinity groups (e.g., women, minorities, physicians with particular clinical or research interests). Providing the opportunity for judgment-free discussion groups in which physicians of all backgrounds can freely share and reflect about work experiences have also been shown to reduce burnout19 and can give a powerful message that wellness is supported in the work environment.15
Physicians who are employers or supervisors can promote a culture of wellness. This can be done through sensitive planning of staff/physician deployment by being mindful to help employees spend at least 20 percent of their time on activities that are meaningful and are a good fit for them20 while balancing the needs of the practice or organization. Flexible scheduling for those who need it, as well as direct and compassionate feedback about areas that need improvement, also contributes to wellness.
Efficiency of practice
Working in an efficient clinical practice with well-organized work flows and team members who work well together and perform at the top of their license is certainly more satisfying than practicing in a chaotic, uncoordinated clinical environment. This domain of wellness often appears more difficult to attain to many physicians who do not feel they have control over their practice setting or over wellness issues impacted by the larger, national healthcare system.
A recommended approach is to hold a meeting or focus group with the clinical team about the work flow, giving every team member a chance to provide ideas for improvement. Then the team can select one achievable change to improve the work flow or the functioning of the practice. The team should then meet again to review outcomes.18 This is a quality assurance process, or plando-study-act cycle, that focuses on practice efficiency centered on the wellness and satisfaction of the providers and clinical team members. The American Medical Association has a website called STEPS Forward21 that provides information (and continuing medical education credits) about physician well-being. This site offers several practice initiatives that can help a physician save time and improve efficiency, such as implementing an expanded rooming protocol or pre-visit laboratory tests or even managing the EHR in-box. These approaches and others have been used successfully in clinical practices to improve providers’ joy in practice.22
The wellness of physicians is an essential part of providing excellent quality care to patients. Wellness initiatives include developing important resilience strategies that physicians can do for themselves, as well as participating in organizational interventions that promote a culture of wellness and an efficient, more satisfying clinical practice. Physicians can join in all these initiatives to attain, improve and maintain their resilience and wellness.
Chantal Brazeau, MD, is Professor of Family Medicine and Psychiatry and Assistant Dean for Faculty Vitality at Rutgers New Jersey Medical School, Newark, New Jersey.