Martin Stillman, MD, JD, is a physician, lawyer and a mediator who has a particular interest in mediating conflict within healthcare and understanding and minimizing physician burnout. He is a practicing internist at Hennepin County Medical Center in Minneapolis, Minnesota, where he also serves as the Mediation and Conflict Resolution Officer, an Assistant Chief for the Department of Medicine and Assistant Director of the Institute of Professional Worklife. Additionally, he is an Associate Professor of Medicine at the University of Minnesota Medical School and teaches about medical error, medical malpractice, disclosure of unexpected patient outcomes and the risk management aspects of physician-patient relations and communication. Recently, Dr. Stillman responded to questions posed by Catherine Williams and Janet Puro on the topic of physician burnout and its impact on medical liability risk.
MDAdvisor: As a physician who also has a law degree, how did you become interested in the topic of physician burnout?
Stillman: I have had an interest in the intersection of medicine and the law for a long time, and more recently, this has included mediation. In my role as Mediation and Conflict Resolution Officer at my hospital, I work to reduce and mediate conflict between providers or groups of providers so that they can move forward in a productive way and ultimately, deliver safer patient care. In this work, physician burnout had been an issue that continued to come up, and I developed an interest in educating others about burnout and burnout reduction.
MDAdvisor: How do you define physician burnout?
Stillman: Physician burnout is usually the result of some sort of prolonged stress that leads to a number of significant implications. This can include higher rates of depression, fatigue and anxiety. In some physicians who are burned out, there is a higher rate of substance abuse, increased incidents of sleep disturbances, broken relationships and even increased rates of suicide. Physician burnout can also appear as a loss of interest in and enthusiasm for work as well as increased frustration and emotional exhaustion. All of this in turn can lead to decreased empathy for patients, as well as a decreased sense of personal worth and professional accomplishment.
MDAdvisor: In your experience, what is the magnitude of physician burnout, and how does it differ from burnout experienced in other types of careers?
Stillman: One thing we know is that burnout among U.S. physicians continues to be on the rise and is higher than in other career areas. A major study in 2014, led by Dr. Tait Shanafelt out of the Mayo Clinic in Rochester, Minnesota, looked at physician burnout compared to the general population. In that study, 49 percent of doctors were burned out, compared to 28 percent of the general U.S. working population. Thus, burnout was actually 75 percent higher in doctors. Additionally, the rates of emotional exhaustion were roughly 43 percent for physicians, compared to 25 percent in the general population, and 36 percent of the doctors were satisfied with their work-life balance compared to 61 percent in the general U.S. working population. That study begins to get at the magnitude of the issue and the increase we are seeing in physician burnout. Additionally, this same study looked at physician burnout comparing data from 2011 to the findings in 2014. Physician burnout had increased in every specialty measured. This study begins to get at the magnitude of the issue and the increase we are seeing in physician burnout.
MDAdvisor: Which physicians are most at risk for burnout?
Stillman: In general, some of the front-line specialties, such as emergency medicine, family medicine, internal medicine and pediatrics, have a higher occurrence of burnout. The data also support the conclusion that mid-career physicians appear to be at increased risk, compared to physicians in the early and late stages of their careers. We also know that women appear to be affected by burnout more than men. But I say these generalizations with some warning. Part of the problem with calling out a few areas or specialties is that it may suggest these are the only areas that have burnout, where other specialties don’t. That is simply not the case. Sometimes, the measurements show that the difference in physician burnout between specialties is minimal. So the concern I have in naming a few specialties as the hardest hit is that it can detract from the global issue of burnout affecting many if not all areas of practice.
MDAdvisor: How is burnout measured?
Stillman: When researchers look to measure burnout, they rely primarily on three well-accepted self-assessment tools. One is the Mini Z Burnout Survey. The second is the Maslach Burnout Inventory, and the third is the Professional Fulfillment Index (Physician Wellness Survey). These tools vary in length, with some being more in-depth than others. Sometimes, there is an advantage to using a shorter survey that is easier to fill out, which may result in higher participation when you’re looking at a large department or hospital. At the same time, sometimes it is more helpful to collect the in-depth information that a longer survey allows. Currently, a study is underway that is trying to evaluate how a score on one self-assessment tool compares to the scores on the others, which will be helpful.
MDAdvisor: How does physician burnout impact the risk of medical errors, and ultimately, patient care?
Stillman: This is a question that is currently and understandably receiving much attention, and to some extent, debate. Many studies look at the impact of burnout on patients retrospectively, where physicians are asked to rate their level of burnout after an error occurs. When these metrics have been used, multiple studies have suggested that there is a correlation between increased burnout and increased levels of patient errors. Some feel that when you have a retrospective self-reporting method for medical errors, it is not necessarily a true measure of errors that may or may not have occurred. But despite some of the concerns of retrospective analysis, I believe that when concerns are raised about physician burnout, legitimate patient safety flags are raised.
There have been other studies in which researchers looked at levels of burnout in inpatient nurses as a predictor of patient satisfaction. The results showed that as nurse burnout increased, patient satisfaction decreased. This tells us a lot about liability risk. Although the studies didn’t look specifically at medical errors, risk managers know that, in general, unsatisfied patients are a higher liability risk when substandard care becomes an issue. And as I noted, physicians with burnout have higher rates of depression, fatigue, anxiety and substance abuse, as well as less empathy for patients. When all of this is in play, it is reasonable to recognize that there is a real medical liability risk associated with burnout with respect to providing appropriate standards of care in a manner that’s well-received by patients.
MDAdvisor: What are some strategies or best recommendations to decrease physician burnout?
Stillman: It is difficult to identify one global answer for reducing burnout because the solution really depends on what is driving the burnout in a particular practice, clinic or hospital. You need to take the time to evaluate and identify the drivers of stress in your particular setting. For example, if taking too much work home is a big driver of burnout and electronic health records are taking a good deal of the physician’s time, then scribes may be of benefit. At the same time, we have seen that scribes alone don’t just take the burnout away. For example, if a clinic practice still feels chaotic, and there is not good values alignment with clinic leadership, stress and burnout will likely remain.
Sometimes, finding a break in the middle of a clinic session, like a designated time for catch-up, can be helpful. In the hospital setting, it is helpful to identify issues with the physicians’ support systems that are impacting a physician’s time, control and stress level, such as social work, pharmacy, physical therapy support, etc.
Additionally, when people have at least 10 percent of their work time devoted to a work activity they feel particularly passionate about, it can have a protective impact against burnout. That doesn’t mean the physician is going to get 10 percent of his or her time off. Rather, if someone has a particular area of interest within which they like to practice, fostering that passion even one half day per week can make a substantial difference in reducing physician burnout.
MDAdvisor: Do you have an example of a successful workflow strategy that helped reduce physicians’ stress?
Stillman: I have one example that I like to share because it was pretty straightforward. There was a clinic where new patients were being scheduled at the end of the day. Some of the patients were relatively straightforward, and of course, some were not. When new patients presented who needed more time, it disrupted the end of the physician’s day, making it difficult to get home for dinner or to pick up a child from daycare. It was an end-of-day disruptor that was stressful because control over one’s schedule was lost. The scheduling template was then changed to have new patients come in earlier in the afternoon. Ultimately, stress was significantly reduced among the providers in this particular clinic by making a fairly easy schedule change. It wasn’t about seeing fewer patients, but about seeing them at a different time that made all the difference.
MDAdvisor: What can healthcare organizations do to improve burnout and stress?
Stillman: The first thing that they can do is recognize that burnout is real and includes physicians and other types of healthcare workers. I have seen that starting to happen in a positive way over the past five to ten years. Now it is much more common to go to meetings of all specialties and have some sort of educational session addressing burnout.
In addition to the humanitarian aspect of reducing burnout, a valid business model supports paying attention to burnout. We know that physicians with burnout often look to work less. Additionally, they tend to leave their practice earlier than non-burned-out physicians, and increased turnover is a real expense for an organization. In fact, it is estimated to cost a healthcare organization a minimum of $250,000 when someone leaves. That’s not referring to the hiring cost alone, but additional factors such as the productivity loss associated with a vacant position, ramp-up time for the oncoming physician, etc. The bench is not so deep in certain areas of medicine that when a physician leaves, another can just pick up where the departing physician left off.
Also, when an organization recognizes that it is worth reducing burnout, it can develop a wellness plan and decide what the action items are going to be. This can be accomplished with a relatively modest infrastructure. A wellness committee can be formed with representatives from different areas within the organization, and they can begin by measuring baseline degrees of burnout among the physicians. The costs to get something going are fairly modest. Some of the survey tools don’t cost anything. They can then be analyzed, and the results can be distributed. That information is crucial to identifying the specific areas that need to be improved. Some institutions have implemented a Chief Wellness Officer to oversee the work, which puts the subject on the radar screen and helps to make changes to get things done.
Recognizing physician burnout as an issue does not change the financial demands of hospitals and healthcare institutions and I don’t think that working to reduce burnout and pursuing financial stability are mutually exclusive. Successfully reducing burnout often comes down to listening to physicians and having them be part of generating solutions to address the stresses that they’re living. The fear that the only way to reduce burnout is to have physicians work less isn’t the answer. Physicians aren’t afraid to work hard. Rather, it’s about fixing how physicians work and the environments in which they practice that can make a significant difference.
MDAdvisor: What resources are available to someone interested in developing a wellness program for his or her organization?
Stillman: There are many resources available. The American Medical Association has a STEPS Forward program, which has a number of modules that can be followed to assist in developing more specific ways to reduce burnout. The Institute of Professional Worklife at Hennepin Health System or others doing this work can assist with program development when organizations want to take some more concrete steps. I also encourage any physician or provider who feels the need for immediate help due to burnout to contact a healthcare provider or a crisis line because, for some, the risk of self-harm among burned-out physicians is real and concerning.
MDAdvisor: What might risk managers and even medical liability insurance carriers do to address the concern of physician burnout and its associated liability risks?
Stillman: Perhaps carriers can help drive the effort to reduce burnout by encouraging their insureds to obtain measurements in physician burnout and develop an action plan to address it depending on what they find. This could help in identifying possible troubled areas or practices before potential medical errors or disruptive interactions take place. The good news is that the goals are aligned for insurance carriers, risk managers and physicians when it comes to reducing burnout: To have fulfilled providers deliver standard of care medicine in ways that are well received by patients. Reducing burnout allows the best chance for this to happen.
Catherine E. Williams is Senior Vice President, Business Development and Corporate Secretary, and Janet S. Puro is Vice President, Business Development and Corporate Communications, at MDAdvantage Insurance Company.