“Invert the Pyramid, Let Internists Design the Job as Pilots Do a Cockpit”: The Views of General Internal Medicine Physicians on Enhancing Well-Being Through Human Factors Engineering

Abstract

Objectives:

Understanding the protective factors of general internists’ well-being helps maintain a resilient health care system. As human factors engineering (HFE) offers promising solutions to the challenges physicians face, it is essential to explore how internists understand the field.

Methods:

A cross-sectional survey focusing on the well-being of general internal medicine physicians was mailed out to a random sample of 1,463 internal medicine physicians using the American Medical Association national database. This study focused on the HFE aspects of the survey.

Results:

A total of 655 general internists responded to our survey (44.8% response rate). Out of 632 respondents, more than half (59.5%) believed that HFE has a role in enhancing their well-being as an internist, and roughly one-third (36.1%) were unsure. A qualitative analysis performed for the 176 open-ended responses revealed 15 unique categories, with most internists referencing their benefits for improving leadership quality, developing shared mental models among teams, and optimizing current processes.

Conclusions:

Our findings indicate that most internists recognize the potential of HFE to positively impact their well-being, though a substantial portion remain uncertain about its applications and benefits. This highlights a need to conduct systems analyses to identify barriers and facilitators of internists’ tasks to design tailored, systemic interventions, such as support from leadership in adaptation, support during patient rounds, and improvements to the EMR system. These systemic improvements in combination with spreading HFE knowledge have the potential to enhance internist well-being.

The well-being of health care professionals has emerged as a critical concern, with direct implications for both patient safety and the overall quality of care. Burnout, a key factor affecting individual well-being, is a long-term stress response, characterized by emotional exhaustion, depersonalization (i.e., lack of empathy or negative attitudes toward patients), and a reduced sense of personal accomplishment.^1–3 General internal medicine physicians, one of the largest medical specialty groups in the United States, face substantial challenges due to the demanding nature of their work and relatively low pay compared with procedural-based specialties. They are required to manage heavy patient loads, navigate complex cases, and handle increasing administrative duties, all within high-pressure environments.^4,5 These challenges not only compromise their personal well-being but are also linked to higher incidences of medical errors, reduced patient satisfaction, and lower care quality.⁶ Thus, addressing burnout and supporting general internists’ well-being is vital to maintaining high-quality patient care and a resilient health care system.

Human factors engineering (HFE), a discipline focused on optimizing the interaction between humans and systems, offers a promising framework for addressing these issues. By leveraging knowledge of human behavior, capabilities, and limitations, HFE seeks to design systems, tools, tasks, and environments that promote safety and efficiency, as well as clinician well-being.^7,8 In health care, HFE has been effectively applied to enhance the performance of health care professionals, minimize risks, and improve patient safety. The Department of Veterans Affairs (VA) National Center for Patient Safety, for instance, integrates HFE principles in the design of medical equipment, the optimization of electronic health record systems, and the restructuring of workflows to minimize risks and maximize efficiency.^9–11

Despite HFE’s benefits in improving patient safety and health care systems, its potential to address internist burnout and enhance well-being remains underexplored. Previous research underscores the importance of integrating human factors into health care delivery to mitigate burnout, highlighting that the goal of HFE is to adapt the system to the human, not the other way around.^12,13 However, a key gap exists in understanding how general internists perceive and interpret HFE concepts—an essential factor for tailoring health care systems to their specific needs. If internists are unaware of HFE or misinterpret its relevance, they are less likely to engage in or advocate for system-level changes that could alleviate their workload, reduce burnout, and enhance their well-being. As part of an initial problem analysis component of our patient safety learning laboratory that is focusing on both patient and clinical well-being, we sought to assess how general internists understand HFE and its role in addressing burnout and improving well-being.

METHODS

Study Design, Participants, and Setting

We conducted a cross-sectional survey of internal medicine physicians practicing in the United States. In addition to assessing physician views of HFE, the survey also assessed other factors related to burnout and well-being. A paper survey was sent to a random sample of internal medicine physicians identified from the American Medical Association Physician Professional Data (which consists of physicians who completed medical school or residency in the United States, independent of their membership in the American Medical Association). A random sample of 3000 physicians from the American Medical Association was requested in the following distributions. Hospitalists and physicians affiliated with the Department of Veterans Affairs were oversampled at 30% for each group, with the remaining sample representing equal portions (10% each) of the 4 geographic regions of the United States: Northeast, Midwest, South, and West. A second level of randomization was conducted using a random number generator within each group to identify the final sample to be included in the mailing. In total, 1611 paper surveys were mailed to internal medicine physicians. Surveys that were returned as undeliverable were removed, resulting in a final sample of 1463 internists.

We used the survey methods developed by Dillman to distribute the survey.¹⁴ This included sending a prenotification email or letter (when email was not available), the initial survey mailing, a 2-week reminder email or letter to nonrespondents, and additional reminder surveys sent to nonrespondents ∼1-month, 2-months, and 3 months after the initial mailing. The initial mailing included a study information letter, a paper survey with an optional link to complete electronically, a postage-paid return envelope, and a $20 incentive. Survey participation was voluntary.

Any linking information was removed once the survey was received, rendering the surveys anonymous. The University of Michigan Institutional Review Board (HUM00228326) gave this study an exempt status.

Survey Development

The entire Internist Wellness Survey was developed to assess wellness among internal medicine physicians across the nation and included several measures on burnout and factors that could be protective against burnout. However, this study focuses solely on a 2-part question on internists’ perceptions of HFE, developed by 2 researchers with HFE expertise (Fig. 1). Participants were asked the following:

FIGURE 1.

Question 1a (closed-ended) and 1b (open-ended) from the Internist Wellness Survey.

Question 1a) Do you believe that “human factors” —defined “as the scientific discipline concerned with the understanding of interactions among humans and other elements of a system to optimize human well-being and overall system performance”—has a role to play in enhancing your well-being as an internist?

Question 1b) If yes, do you have any examples or suggestions for how?

Responses to both parts of the question were collected, along with details about the respondents’ work experience such as years of practice, work setting (inpatient versus outpatient) and the type of facility where they primarily work (VA medical center/clinic, academic medical center/clinic, or community medical center/clinic).

Data Analysis

Descriptive statistics were conducted to analyze responses to Question 1a, and the work and demographic characteristics of the respondents. Responses to Question 1b, the open-ended question (e.g., examples or suggestions for how HFE can play a role in optimizing well-being), were reviewed and analyzed by 2 researchers with expertise in HFE. Following the recommendation by Hsieh and Shannon (2005)¹⁵ for performing a qualitative content analysis, researchers began by independently reviewing an initial subset of 20 responses to immerse themselves in the data and identify common themes. During this phase, the researchers identified common phrases and developed preliminary codes through discussion to reach a consensus. All codes were developed inductively, grounded directly in patterns emerging from the data rather than preset categories.

After establishing an initial codebook, the coding process proceeded in 4 rounds (round 1: 20 responses, round 2: 40, round 3: 40, and round 4: 76). The codebook contained a brief code label, a short definition, a full definition, an example, and parameters for when and when to not use the code. Coding was conducted independently for each round, with both researchers reviewing and coding each response. Researchers met biweekly to discuss each round’s results and resolve any disagreements. Codes and definitions were refined as needed throughout the coding process, based on discussion and consensus between both coders, with new codes applied if any changes were made to the codebook. Changes included consolidating codes into larger groups based on similarity (e.g., usability of technology), or breaking codes down further if they were too broad, (e.g., teamwork). This process increased inter-coder reliability and ensured consistent coding across the data set.

RESULTS

The overall survey had a response rate of 44.8% (N = 655). The average number of years practicing for those surveyed was 22.7 years (SD = 9.7). Most respondents reported spending most of their clinical time working at a community medical center/clinic (43.4%) or a VA medical center clinic (30.9%). The average number of years in practice differed for internists by their predominant facility type, with those in academic and community medical centers averaging 6 years less experience than those at VA and other medical centers (Table 1).

TABLE 1.

Differences in Characteristics of Internists' Responses to Question 1a by Their Primary Facility Type

Primary facility type	Years in practice (M±SD)	Overall (n=655); n (%)	Answered “Yes” (n=376); n (%)	Answered “No” (n=28); n (%)	Answered “Not sure” (n=228); n (%)	No answer (n=23)
VA medical center	26.6±8.2	198 (30.9)	110 (57.6)	8 (4.2)	73 (38.2)	7
Community medical center	19.7±9.4	278 (43.4)	159 (58.2)	11 (4.0)	103 (37.7)	5
Academic medical center	20.4±8.6	89 (13.9)	53 (62.4)	7 (8.2)	25 (29.4)	4
Other medical center	26.3±11.0	75 (11.7)	45 (61.6)	2 (2.7)	26 (35.6)	2
Unknown	—	15	9	0	1	5

Closed-ended Responses

A total of 632 respondents answered Question 1a. The majority (59.5%; 376/632) reported believing that HFE has a role in enhancing their well-being as an internist, while 36.1% (228/632) reported being unsure, and only 4.4% (28/632) did not believe so. The distribution of responses within each facility type (VA, community, academic, and other) was consistent with the overall responses to the question (Table 1). However, when comparing responses across facility types, notable trends emerged: respondents who answered “Yes” were predominantly from academic medical centers, whereas those who answered “Not Sure” were predominantly from VA medical centers.

Open-ended Responses

A total of 176 respondents answered Question 1b. Responses were coded and organized into 15 categories under 7 overarching domains: (1) organizational environment; (2) health care professionals; (3) teamwork; (4) internist-engineer partnerships; (5) health information technologies; (6) optimization of processes; and (7) lack of HFE knowledge. Table 2 presents the codebook for the identified categories, including definitions and examples for each. Codes were not mutually exclusive, and multiple codes could apply to a single response if more than one category was discussed, resulting in 283 phrases coded.

TABLE 2.

Codebook of Overarching Domains, Code Categories, Definitions, Participant Examples, and Subthemes Identified

Code category	Definition (Belief that HFE can aid well-being by…)	Example	Common subthemes identified
Organizational environment
Leadership	Improving leadership style of superiors, including hospital administration	“Effectiveness of leaders to create change/improvement directly impact job satisfaction”	Feeling undervalued, more support, more open communication, lacking autonomy in patient care
Safety culture	Shifting culture surrounding safety concerning patients and staff to be more transparent	“Being more of a supportive culture at work to improve morale and performance versus gaslighting your employees”	Being more open about safety, debriefing misunderstandings, and challenges
Needs assessment	Conducting needs assessment of staff to solicit feedback about current processes or procedures that can be improved	”[Hospitals] are not interested in the physician or patients views or recommendations for improvement—we have no input, treated like numbers”	More opportunities to share feedback about what needs are not being met
Patient-centered care	Adopting a patient-centered model of care that prioritizes patient experience and moves away from traditional cost-benefit approaches	“An approach to patient care and hospital administration which is patient-centered”	Placing less emphasis on metrics and more on patient-centered care
Health care professionals
Workload	Improving staff levels of workload, including delegating tasks to other roles or units	“Treat us like human beings and not machines to work as hard or as long as needed to meet management goals”	Sustainable workload levels, reducing shift hours, distributing work fairly and equally
Patient-Provider interactions	Enhancing patient-provider relationships and interactions	“More time face to face with patients to listen to and help outline what they consider their health to involve”	Spending more time with patients, improving patient interactions
Training	Including HFE education in internists’ training to learn and apply HFE methods	“All internists would benefit from human factors training—it is the essence of patient interactions”	Training methods for role definition, leadership, patient interactions
Teamwork
Shared mental models	Developing shared mental models between team members, including a common understanding of shared goals, roles, and responsibilities	“Clear identification of members of team and responsibilities of each member.”	Clarification on responsibilities, goals, and roles, more team support
Communication	Improving closed-loop communication strategies within/between teams and with hospital administration	“We moved from pagers to secure chat in EPIC—there is now zero verbal or face-to-face interactions in our hospital—it is dehumanizing”	Open and clear communication, in-person meetings, discussing problems, non-work conversations
Unit coordination	Being able to coordinate across hospital units to solve challenges that arise	“Use consultants (subspecialists, administrative, management, IT, interdepartmental) + colleagues (internists, PCP) + Nursing, and other clinical staff as the situation demands”	Coordinating across hospital units
Internist-Engineer partnerships
Collaboration	Developing HFE-clinician partnerships to involve them in applying HFE approaches to system improvement	“Invert the pyramid, let frontline PCPs/internists design the job as pilots do a cockpit”	Collaboration between clinicians and engineers
Health information technologies
Usability	Designing usable technology that is more intuitive, including the electronic medical record interface	“User friendliness and functionality of EHR [electronic health record]”	Electronic medical record system interface, usability of medical devices
Optimization of processes
Process Analysis	Optimizing specific hospital processes to make them safer or more efficient	“Improving the efficiency and effectiveness of rounding, workflows”	Streamlining health care processes to make them less burdensome and quicker
Lack of HFE knowledge
Misunderstandings	Responses showing fundamental misunderstandings of the HFE discipline	“More opportunities for social interaction with colleagues”	Making meaning, yoga, social engagement with coworkers, spirituality
No examples	Responses showing not enough understanding of the HFE discipline to identify examples	“Not familiar enough with concept, but sounds promising”	Unfamiliar, unable to provide response

Interestingly, a large portion of respondents showed a fundamental misunderstanding of HFE principles (n = 64, 22.6%), commonly referencing topics such as creating meaningful work (without reference to applications of HFE), social events with coworkers, and spirituality. Several also did not give examples (n = 17, 6.0%), with some participants citing not having enough knowledge to explain ways in which HFE can be applied. For example, one participant mentioned they were “not familiar enough with concept but sounds promising” (ID 1062).

From the remaining categories, those most frequently mentioned by respondents regarding how HFE can be applied to support their well-being were “leadership” (n = 40, 14.1%), “shared mental models” (n = 30, 10.6%), “process analysis” (n = 29, 10.2%), and “usability” (n = 21, 7.4%). Leadership refers to improvements in leadership styles and/or quality from direct superiors, including having skilled leaders who prioritize the growth of their team members. Shared mental models refer to the alignment of a team’s understanding of each other’s goals, roles, and responsibilities to ensure everyone can anticipate one another’s needs. Process analysis refers to streamlining health care processes to make them safer and more efficient, including removing unnecessary or burdensome steps. Usability refers to designing health care information technology that is more intuitive and reduces the risk of error. Figure 2 includes the frequency (%) of all 15 categories identified by internists.

FIGURE 2.

The frequency of categories (%) identified by internists regarding how human factors engineering can support their well-being.

In the leadership category, many responses related to internists feeling undervalued and wanting more support from leadership or administration (32.5%), desiring more open communication with administration (20.0%), and lacking autonomy or control over scheduling and patient care (15.0%). One participant articulated these sentiments, stating, “upper management needs to treat us like human beings and not machines to work as hard or as long as needed to meet management goals” (ID 1152). In the process analysis category, nearly a quarter of responses (24.1%) referred to wanting to eliminate the “grunt” work that internists perform as part of their duties. One participant noted, “The focus on having physicians work at least half their time as data entry clerks is highly detrimental” (ID 1044) and further suggested this takes away time from patient care, such as getting to know them and listening to their concerns. For shared mental models, most responses related more to clarification on responsibilities, goals, and roles within teams (15.0%). One participant emphasized the importance of this in relation to training purposes, “I think this discipline can help us better define roles and help us in training all members of the team to fill our roles effectively” (ID 1141). Notably, in the usability category, 85.0% of responses were specifically related to dissatisfaction with or the desire for improvements to the electronic medical record (EMR) interface design. One participant explicitly stated, “when changes are made to the electronic health record that greatly simplifies an aspect(s) of my work, I feel relieved/ happy/looked-out for” (ID 1093). Other participants referenced their dissatisfaction with current technology with comments such as, “laptops which are too small to effectively display needed information without scrolling, thus increasing both frustration and the inherent error rate relate[d] to scrolling” (ID 2160) and, “It seems like often systems (… electronics) are not designed or modified based on how the actual end users are using them/needing them” (ID 1080). The least frequent category mentioned was collaboration, with only one respondent highlighting clinician-engineer partnerships as a way to enhance their roles. This participant specifically suggested, “invert the pyramid, let frontline PCPs/internists design the job as pilots do a cockpit” (ID 1054), advocating for greater direct involvement in designing their work environments.

DISCUSSION

Our study assessed how general internists understand HFE and their perceptions regarding the role it plays in enhancing their well-being. The majority of respondents, particularly those at academic medical centers, believed that HFE plays a role in their well-being. However, a large percentage remained uncertain, indicating a lack of widespread knowledge of HFE in internal medicine. Among the open-ended responses, many participants displayed a misunderstanding or not enough knowledge of HFE. The top 4 categories that internists referenced as applications of HFE to enhance their well-being were improving leadership practices, developing shared mental models, optimizing current processes, and improving the usability of health information technology.

The similar distribution of responses to believing HFE has a role in enhancing physician well-being among internists across VA, community, academic, and other medical centers suggests that no single facility type is outperforming the others in integrating knowledge of HFE into their operations to support well-being. This is in line with prior research indicating fewer applications of HFE in primary care environments compared with nonacute care environments, such as in surgery and emergency medicine.¹⁶ Nonetheless, most internists who agreed that HFE can enhance their well-being were primarily employed at academic medical centers. Unlike other medical centers, these facilities typically handle more complex patient care needs, have access to advanced technologies, and place a strong emphasis on education and research. These factors indicate that academic medical centers are uniquely suited to a greater need for embedded HFE professionals and solutions, which may explain why internists at these facilities showed higher levels of agreement compared with those at other centers. Patients with more complex diagnoses have increased risks, and with the growing availability of new technology alongside an influx of physicians-in-training, it is essential to examine how people interact and coordinate in these environments to help reduce the likelihood of adverse outcomes.

Interestingly, most internists who reported being unsure if HFE can enhance their well-being were primarily employed at VA medical centers, which have several ongoing patient safety initiatives centered on HFE applications. The VA National Center for Patient Safety developed a pilot HFE curriculum in 2013 that contains 12 distinct modules and aims to make HFE training more accessible beyond just professionals.¹⁷ Several of the current initiatives related to HFE focus on risk mitigation strategies, such as root cause analysis of medical devices and improving information technology designs to reduce future risks of patient harm, which typically involve human factors or usability specialists. However, key aspects of systemic HFE applications related to understanding and improving sociotechnical systems, or complex and adaptive environments wherein humans interact with technology to accomplish work, have only begun recently, hence the uncertainty of its merit across internists in the VA medical system. The emerging VA Human Systems Integration program seeks to improve patient safety from a holistic systems perspective by increasing HFE training practices at the facility level.¹⁸

Our analysis showed that several misunderstandings of HFE exist among internists, with many referencing actions that would improve their well-being but are not directly rooted in HFE applications. This provides evidence for the need for more patient safety research conducted in primary care settings. The SEIPS (Systems Engineering Initiative for Patient Safety) 2.0 Model¹⁹ has been successfully applied across several health care settings and can be used to identify and describe the barriers and facilitators that internists may face in tasks such as interactions with patients during bedside rounds and the usability of health care information technology. Furthermore, internists can benefit from HFE education programs based on this model such as the graduate level certificate program offered at University of Wisconsin-Madison aimed at providing interdisciplinary, patient safety education to health care professionals and engineers.¹² In recent years as HFE has become more integrated into health care systems, there have been greater efforts for its topics to be integrated into early medical education and several curricula have been developed as a result.²⁰ However, several barriers to their widespread implementation currently exist within undergraduate health care curricula, including a lack of both HFE expertise among clinical faculty and shared terminology. In addition, more HFE experts need to be trained in health care applications to provide them with a better understanding of “work as done” and aid them in their development of novel solutions to the challenges that internists’ face.¹⁶

Related to how HFE can aid their well-being, the topic most frequently mentioned by internists was related to improving different aspects of leadership, an area that has received increasing attention.²¹ Most respondents specifically cited feeling undervalued or a lack of support from superiors and/or administration, which is consistent with the challenges that internists have shared previously. In a recent cross-sectional survey of the impact of supervisor leadership behaviors on physician well-being and fulfillment, researchers found that physicians with more favorable views of their leadership were more likely to have greater professional fulfillment. However, it reported that internal medicine physicians were less likely than other specialties to rate their immediate supervisor in the top third of the leadership scale, suggesting they are less likely to have professional fulfillment.²² Another study cited lack of communication with leadership and lack of control over work schedules as potential sources of burnout, as perceived by internists.²³ This was also mentioned by respondents, as they believed having more opportunities for open communication with leadership and more autonomy in their work would be beneficial. An HFE principle that might be beneficial in overcoming these challenges is the ability to adapt performance within dynamic work environments.²⁴ Leadership support for engagement in this kind of adaptation by internists, especially in asserting autonomy in unanticipated events, is critical for creating more resilient health care systems. However, these behaviors may lead to violations of protocols and may lead to unintended safety consequences,¹⁹ warranting investigation into the safe alternatives that internists can engage in within their superiors’ guidance and constraints, such as spending extra time with a patient during bedside rounds.

The next most frequently mentioned topic was the necessity to develop shared mental models among team members, defined as a shared understanding of a team’s goals and of the responsibilities of each team member.²⁵ Prior research suggests that having shared mental models is a crucial coordinating mechanism of essential teamwork skills; without them, team members may instead strive towards individual goals and struggle to anticipate the needs of another team member. For internists, developing a shared understanding among team members is crucial to effectively coordinating patient care, especially given the increasing patient loads, unrealistic workloads, and unpredictability in their work-all of which contribute to their sense of burnout.²³ An approach to overcoming this challenge may be to implement multidisciplinary, or interdisciplinary, bedside rounds that involve multiple stakeholders (e.g., internists, nurses, pharmacists, social workers, etc) to ensure shared goals and aligned patient care plans. For example, the Division of Hospital Medicine at Michigan Medicine—University of Michigan has implemented structured interdisciplinary bedside rounds in inpatient care to enhance patient-centered care and foster effective team communication.²⁶ Although beneficial for patient outcomes, time constraints and coordination have often been cited as constraints to their implementation, therefore, it is critical to consider how this redesign might impact multiple aspects of the work system.²⁷

Finally, improvements to the usability of the current EMR interface were frequently referenced as a source of added burden, and many internists suggested a redesign of the system. This is a common perception among health care professionals and there have been efforts to understand the source of their inefficiency, including studies on the impacts of visual clutter.²⁸ Designers of these health care technologies need to train their staff in HFE principles, and conduct iterative usability studies that involve end-users in the design process to ensure that the systems in place are suited to the needs of the users, or internists in this case. As mentioned previously, a SEIPS analysis of internists’ interaction with the EMR system can provide a deeper analysis of the relevant work system elements that can be improved and help anticipate any risks to patient safety if a new interface design is implemented.²⁹

Our study has several limitations. First, the survey response rate was 44.8%, which may increase the chance for selection bias, although it is considered average for a physician survey.³⁰ Second, analyzing a single open-ended question limited our understanding of the full breadth of internists’ perceptions of HFE, warranting further exploration. Finally, the survey provided a definition of HFE and did not assess participants’ prior knowledge or understanding of the field. As a result, some participants might not have fully understood what HFE is or how its principles could be applied to improve internists’ wellness, potentially impacting the quality of our responses and analysis.

CONCLUSIONS

Our study suggests internists believe that HFE holds promise in improving their well-being at work, though many remain unsure of its benefit. Efforts to spread HFE knowledge in combination with systemic changes, such as empowering internists in their autonomy and identifying opportunities to develop shared goals among teams, may be most beneficial to enhance internists' well-being and maintain patient safety. There is a need to explore the systemic challenges that directly impact internists’ work through further HFE and systems analyses, to develop resiliency in the health care system.