Much too common, according to a 2015 national survey that found 46% of physicians reporting that they were "severely stressed," up from 38% in 2011. As dramatic was that 89% acknowledged a desire to leave their current position, ranging from hopes of joining another organization to changing careers altogether.
What Healthcare Leaders Need to Know about Burnout
Of course, practicing physicians know through lived experience why burnout is important. Relieving feelings of stress, helplessness and depression are a worthy end in themselves. Certainly, if such was the plight of any patient we would be getting busy finding solutions. But why else, other than sheer humanity, should healthcare leaders care?
It turns out that this problem has too many costs to ignore, and they begin with quality of care. Studies have found, not surprisingly, a correlation between burnout and medical errors. Other investigations have shown that physician empathy, an early casualty of burnout, is associated with patient experience of care, adherence to medical advice and clinical outcomes for conditions including diabetes and others. Additionally, burnout drives up the risk of medical malpractice claims and through attrition of the medical workforce increases costs for organizations that must accelerate expensive recruitment efforts.
What Burns Us Out
One thing that everyone studying this issue agrees about is that burnout is "multifactorial." Work compression - having to do more with less - is a major theme. From what I see in our hospital, this problem sits at the intersection of two related forces - the electronic health record ("version 1.0") and administrative burden.
I would assert that every hospital in the US that migrated to an EHR without an adjustment in the number of core clinical staff effectively reduced its professional workforce by 10 - 20%. Where, you might ask, is the evidence? This phenomenon is hard to measure. But working and documenting in an electronic environment is so fundamentally different that one could argue the converse - that the burden of proof belongs to those who would hold that the EHR is work-neutral. The fact is that work compression due to electronic charting is quite real. (It is more than conceivable that a future generation of technology will close the efficiency gap, but this felicitous state is years away.)
Additionally, various quality improvement initiatives have piled on scores of things to include that physicians never thought to write about before. Why an aspirin wasn't given, or a beta blocker, or an ACEI; why the antibiotic was selected, why the antibiotic was not selected, why the heparin was given, why it was stopped, why physical therapy was not ordered, and on and on. Additionally, as these national projects come in and out of existence (like short-lived elementary particles), we send the memo - oh, you can stop worrying about documenting that; the federal government is no longer tracking x, y or z. And then there is clinical documentation improvement (or CDI). A certain kind of specificity is critically important for optimizing revenue, and certainly consistent with good practice. But it's still one more thing.
Frustratingly, the practicing physician really can't object to any one requirement. Documenting smoking cessation education (no longer tracked), or the number of days of overlap thromboprophylaxis, or the heart failure subtype? Each is totally reasonable. But when each physician spends each day crossing a minefield of such "opportunities for error" without even getting to the actual process of figuring out what the matter is with the patient or what to do about it, we have the ingredients for burnout.
But there is more.
Certain physician groups in particular - Hospitalists, Emergency physicians and Intensivists, among others - are critical to making hospitals run. Paradoxically, rather than elevating their roles in achieving high performance in domains such as quality, safety, patient experience, efficiency and throughput, as leaders we continue to layer on mandates that may conflict directly with their professional obligation to direct their skills, experience and judgment to taking the best care possible of each and every patient. And so, even as the profession of Nursing has systematically prioritized autonomy and the caregiver's role as patient advocate, in Medicine we have done almost the opposite, going so far as to treat these phenomena as a wrench in the system to be identified and eliminated.
How do we move forward?
I have had the opportunity to work for the past several months with a Northwell Task Force on physician wellbeing consisting of physician leaders, a psychologist, an attorney and other administrative staff. Two kinds of action seem warranted. Easiest is to equip physicians with more resources to sustain their inner equilibrium in the face of the current, very challenging environment. Focus areas involve stress reduction, wellness and work-life balance education and support. In the short run, this may be important, despite the fact that it fails to address the root causes of the problem.
In the longer run, however, we will need to rethink the work of physicians fundamentally, and determine how exactly we should resource our colleagues to ensure personal satisfaction, professional growth and sustainability - for their sakes, to be sure, but most especially for sake of the patients and communities we serve.
