Clinician and Researcher Well-Being: The Time is Now

This edition of Missouri Medicine addresses a growing threat to our health care system: physician burnout. Most physician readers have either experienced burnout firsthand or have had a colleague who has suffered from burnout. And too many of us have known colleagues who have died from suicide with burnout either causing or contributing to their deaths. Over the past year, the COVID-19 pandemic has only exacerbated this already significant problem. Few physicians can remember a time in their careers when health care worker well-being has been so challenged…and is also so critically important!

Burnout is not a new condition but has long been a potential consequence from the stress and expectations of working in the “helping professions” during modern times. The term was first used in the 1970s by Herbert Freudenberger¹ and has since been expanded to encompass anyone with situational stress creating the triad of symptoms: emotional fatigue, cynicism, and inefficacy.^2,3 While symptoms overlap with those of depression and experts don’t always agree on exactly the definition, burnout is always work related.⁴ The World Health Organizations included burnout for the first time in the ICD-11 in 2019 and defined it as “chronic workplace stress that has not been successfully managed.”⁵ Sadly, physicians have higher burnout rates than the general population.⁶

Research suggests that the incidence of burnout in physicians has been increasing over the past decade as have the consequences of burnout on them, their patients, and the health care institutions in which they work.⁷ Those on the front lines (i.e., emergency medicine, family medicine, neurology, and general internal medicine) suffer the most.⁸ While some may be quick to blame this rise on younger generations of physicians, studies have shown that incoming medical students actually have higher resilience and quality of life scores than other graduate students.⁹ Unfortunately, they lose this advantage during medical school, and the incidence of burnout increases in early career physicians, especially residents, and is more prevalent among female physicians.^17,10 Interestingly, work-life balance does not appear to be the sole driver. For example, emergency physicians report a high satisfaction with their work-life balance, but as a group suffer some of the highest incidence of burnout.¹¹

Scholars have identified multiple factors and stressors that could account for greater rates of burnout among female physicians that need to be considered not only for moral reasons but because women account for 50 percent of U.S. medical students.¹² Fewer studies have been done on physicians from racial or ethnic minority groups, but a recent investigation found that burnout was highest among non-Hispanic, white physicians and higher among physicians holding more explicit and implicit racial biases.^{13, 14} It is critical for further research to examine diversity variables if we are to attract and retain the most talented workforce in health care systems.

While burnout was once thought to be primarily caused by a lack of resilience in the individual or simply by the demands the EHR, much research suggests that burnout is largely caused by larger environmental variables in physicians’ work lives such as clinic environment, workload control, long work hours, time with family, and an alignment of values with leadership.¹⁵ Possibly reflective of this, a meta-analysis of physician burnout interventions suggested that interventions that only target individual physicians and not their organizations yield only small changes in burnout.¹⁶

What circumstances and factors have led to this increasingly challenging work environment for so many physicians? Unfortunately, the answers may be largely beyond the direct control of physicians themselves: health care policy, societal impact on patients, and the health care industry. Several physicians’ surveys cite increasing administrative burdens.¹⁷ One study demonstrated that for one hour of patient contact in a primary clinical setting there existed two hours of administrative work.¹⁸ Federal mandates have incentivized the widespread adoption of the electronic health record, a trend which has obvious benefits for patients and physicians but has also increased the administrative workload for physicians. Compared to most other countries, the patient record increasingly has become a billing document over a patient care and legal document. Federal pay for performance measures such as MIPS and MACRA require extra physician time in the EHR for benefits that are still uncertain.^19,20 One scholar even suggested that U.S. physicians’ documentation is “four times longer” than clinical notes in other industrialized countries.²¹ All of this at a time when declining reimbursement from payers has pressured institutions and physicians to see even more patients per hour. And, our patients have more chronic physical and mental health conditions than ever. A large number of patient complaints in primary care settings now involve mental health concerns or have psychological components.²² The challenges of responding to the opioid crisis, at times, seem almost insurmountable. And physicians are under more scrutiny than ever. One negative patient satisfaction report can be demoralizing to even the most resilient clinician.

The consequences of ignoring burnout in clinicians are substantial. Struggling physicians provide lower quality and less safe patient care. Not surprisingly, their patients are less satisfied with the care they receive.²³ The behavior of these physicians may be toxic to their care team. Fatigued physicians often decrease their schedule and access. The human costs of burnout on physicians are also substantial. Physicians as a group have poorer mental health than that of the general population, but physicians suffering from burnout have an even higher incidence of broken relationships, alcohol and substance abuse, depressions and suicide.^24,25 It is estimated that between 300–400 U.S. physicians take their lives each year; double that of the general population and representing one of the highest rates of any professional group.²⁶

Burnout in physicians also affects the institutions in which they work. One study estimates the annual U.S. physician burnout costs to be around 4.6 billion dollars.²⁷ Struggling physicians often reduce their productivity and professional effort just to survive and often end up leaving their institutions. One industry group suggests that the cost for an institution to replace a physician could be as high as one million dollars when factoring in lost revenue with recruitment and startup costs.²⁸ And often it’s the physicians who care the most who leave as they are not willing to tolerate a dysfunctional work environment. Academic medical centers and their accreditation agencies have learned that faculty burnout affects the learning environment. The ACGME and LCME now assess faculty burnout as part of their learning environment evaluations.^29,30

Physician burnout has such a significant impact on physicians, patients and the overall health care that several physician organizations advocate for creating a “quadruple aim” by adding “improving the experience of providing care” to the triple aim of improved patient experience, lower costs, and better outcomes.³¹ Indeed, the critical importance of a healthy and high functioning clinician work force has led academic and private health care institutions across the country to develop physician wellness programs led by chief wellness officers as advocated by Stanford, the AMA and others.^32,33

Since the policies and societal features that drive burnout will be slow to improve and could even worsen, efforts to reduce physician burnout and to enhance physician well-being have focused on developing a culture of wellness, optimizing clinical efficiencies, and promoting physician resilience^34,35 (Figure 1). For at its core, burnout is an imbalance of job demands and resources. Difficult work schedules, unreasonably workload, “administrative burden,” poor staffing, unfriendly technology, ineffective workflow, “moral distress,” patient variables, and invasion into personal time all add to the demands of serving as a physician. Several strategies that have been shown to offset these demands include optimizing practice efficiency, creating meaning and purpose in work, developing a positive organization culture while aligning values, setting expectations but allowing for job control and autonomy wherever possible, providing rewards and recognition, fostering more collegial relationships and social networks, and nurturing “work-life integration.”³⁶

Figure 1.

Stanford WellMD Professional Fulfillment Model

Source: Stanford WellMD Center

The idea for a University of Missouri physician well-being initiative began in 2016 with discussions within the School of Medicine’s University Physicians Professionalism and Quality Committee. Several committee members questioned whether burnout was a contributing factor to professional lapses. The committee advocated for a physician well-being program build as detailed in the AMA’s 2017 STEPSforward (Table 1). In September 2018, the Office of Clinician Well-Being (OCW) and the Chief Wellness Officer position were created and co-funded by University of Missouri Health Care (MUHC) and the MU School of Medicine (SOM). In March of 2019, optimizing clinician well-being was incorporated into the MUHC strategic plan, and the first formal budget for the OCW was authorized. Office space was secured, and a counseling psychologist/program director as well as an administrative assistant were hired during the summer of 2019.

Table 1.

AMA’s Creating the Organizational Foundation for Joy in Medicine^TM

Culture of Wellness

Step 1. Engage senior leadership

Step 2. Track the business case for well-being

Step 3. Resource a wellness infrastructure

Step 4. Measure burnout and the predictors of burnout longitudinally

Step 5. Strengthen local leadership

Step 6. Develop and evaluate interventions

Practice Efficiency

Step 7. Improve workflow efficiency and maximize the power of team-based care

Step 8. Reduce clerical burden due to the HER

Resilience

Step 9. Support the physical and psychosocial health of the workforce

While initially targeted at physicians, the OCW has been expanded to encompass faculty, fellow and resident physicians, advance practice clinicians, as well as SOM faculty researchers since each of these groups are critical to the missions of SOM and MUHC. The current mission of the OCW is “Saving and Improving Clinician and Researcher Lives,” but the overall theme of the initiative is for leadership to partner with clinicians and researchers to make MUHC/SOM a great workplace for everyone while encouraging all to practice self-care and to reach out when they need support. To that end, the University of Missouri OCW devotes time both to providing a clinician safety net of counseling and consultation services modeled after an EAP and to the development of programs that seek to tackle structural components of burnout. Members of the OCW are included in regular high-level meetings including strategic planning session so we can be “at the table” to raise issues of clinician well-being throughout major organization decisions and considerations.

As the drivers are many and complex, there is no sole intervention that will mitigate burnout. The following is not an exhaustive list of interventions but highlights accomplishments and future plans. Measurement of burnout over time is fundamental and while employee engagement surveys had been conducted annually, the OCW engaged the AMA to administer the first formal clinician burnout survey at MUHC, the Mini-Z, in November/December of 2019. The results not only indicated the degree of burnout but also gave insight into strategies that may improve well-being. To reduce EMR stress, the OCW advocated for single badge sign on or “tap ‘n go” for EMR workstations. This technology was put into place during the winter of 2019–20 and is saving precious work time for every user. Strategies to optimize EMR training such as “at the elbow” mentors should also limit the time spent in the EMR. Recognizing and rewarding clinicians is another important strategy to improve and maintain well-being. The OCW is a member of a SOM committee examining faculty compensation and benefits to ensure fairness, aligned incentives, and an overall package competitive with national standards. Within this committee, the OCW is advocating for time spent on messages to be considered when calculating clinician FTE as attention to inbox messages has added to the workload of all physicians, especially those in primary care. Upgrades to the physicians’ lounge and to the annual Doctor’s Day celebration are tangible symbols of leadership’s support and appreciation of clinician work. Physician leadership is not only integral to physician well-being but also to the overall mission of a health care institution. Simply stated, what physician leaders do and say really matters. The OCW has provided physician leadership development programming to physician leaders and is developing an ongoing program to enhance and maintain leadership skills and culture as well as to grow the next generation of physician leaders. The importance of communication between leadership and physicians cannot be overly stressed but remains a significant challenge. The recent widespread adoption of virtual platforms may facilitate the flow of information and ideas, but other strategies are needed. Optimizing the efficiency of the work environment for all physicians is a lofty but critical goal and will always be a component of the well-being strategy. The OCW is teaming with members from hospital administration to ensure that social work and care coordination resources are available in key clinical areas. Strengthening collegiality between physicians and clinical units also enhances well-being. A gap analysis is underway to assess needs in these arenas.

With the onset of the COVID-19 pandemic, the OCW immediately pivoted to address the needs of clinicians. Clinicians were offered telepsychology appointments with the OCW counseling psychologist to minimize additional exposures to the virus. This technology has also been popular because it reduces the time clinicians must travel to and from appointments, reducing an additional barrier to seeking help. The OCW has been heavily involved in a Workforce Well-being ad hoc committee – founded in the early days of the pandemic – that consists of multidisciplinary professions from across MU Health Care. Their presence on this committee facilitated the involvement of other clinicians in psychiatry and various specialties within psychology. The OCW began compiling COVID-era resources specific to clinicians on their website.³⁷ Additionally, the OCW has continued to advise leadership on matters related to clinician well-being specific to the new stressors related to COVID-19 and have made itself available for consultations, presentations (locally and nationally), bringing together a network of local supports and professionals, and assisting in the development of new means of community-building and wellness concepts throughout the organization.

We hope that this Missouri Medicine issue will inspire you to enhance your own well-being as well as those around you and the clinical entities where you serve. We are excited to be able to present four additional articles on burnout and well-being from an outstanding pool of authors, introduced briefly here in alphabetical order.

William R. Carpenter, DO, is a psychiatrist and has been medical director of the Missouri Physician and Healthcare Professional Wellness Program since 2016. He is currently the Chief Wellness Officer at Capital Regional Medical Center. Jim Wieberg, MEd, LPC, is the executive director of the physician wellness program at Capital Regional Medical Center. Heather Johns, LCSW, is the program director of the physician wellness program at Capital Regional Medical Center.

Sue Scott, PhD, RN, is a nurse scientist and Adjunct Associate Professor in the Sinclair School of Nursing who pioneered peer support programs and is a nationally recognized expert in the field.

Stephanie Bagby-Stone, MD, is an Adjunct Associate Professor of Clinical Psychiatry at the University of Missouri School of Medicine and has been working directly with medical students on well-being and resilience for decades.

Stuart Slavin, MD, MEd, is the Senior Scholar for Well-being at the ACGME and former Associate Dean of Curriculum at the Saint Louis University School of Medicine. He brings a broad range experience at both the state and national level.