The Blue Ridge Academic Health Group

17 Pages·2017·3.48 MB·English

WINTER 2017-2018 F REPORT 22
The Blue Ridge
Academic Health Group
The Hidden Epidemic: The Moral
Imperative for Academic Health Centers to
Address Health Professionals’ Well-Being
Members and participants Michael A. Geheb, MD
Senior Consulting Director, IBM Watson Health Mission The Blue Ridge Academic Health Group seeks to take a societal
(June 2017 meeting) Board of Directors, Wayne State University Physicians Group
William N. Kelley, MD view of health and health care needs and to identify recommendations
MEETING CO-CHAIRS Professor of Medicine, Perelman School of Medicine,
Jonathan S. Lewin, MD (current Co-Chair) University of Pennsylvania for academic health centers (AHCs) to help create greater value for society.
Executive VP for Health Affairs, Emory University Trustee Emeritus, Emory University
Executive Director, Woodruff Health Sciences Center Arthur H. Rubenstein, MBBCh The Blue Ridge Group also recommends public policies to enable AHCs
President, CEO, and Chairman of the Board, Emory Professor of Medicine, Perelman School of Medicine
Healthcare University of Pennsylvania to accomplish these ends.
Jeffrey R. Balser, MD, PhD (current Co-Chair) John D. Stobo, MD
President and CEO, Vanderbilt University Medical Center Executive VP, UC Health, University of California
Dean, Vanderbilt University School of Medicine
Bruce C. Vladeck, PhD
Former CMS Administrator and Health Policy Adviser
OTHER MEMBERS
Contents
S. Wright Caughman, MD FEATURED PRESENTERS
Professor, Emory School of Medicine and Rollins School of Don E. Detmer, MD, MA (see Senior Members)
Public Health, Emory University Darrell G. Kirch, MD (see Members) Report 22. The Hidden Epidemic: The Moral Imperative for
Emeritus Executive VP for Health Affairs, Emory University
Gary Gottlieb, MD, MBA Thomas Lee, MD Academic Health Centers to Address Health Professionals’ Well-
Chief Medical Officer, Press-Ganey
CEO, Partners In Health
Being
Lloyd Minor, MD
Michael M.E. Johns, MD
Dean, Stanford University School of Medicine
Professor, Emory School of Medicine and Rollins School of
Public Health, and Emeritus Executive VP for Health Affairs, Tait Shanafelt, MD
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Emory University; Emeritus President, CEO, and Chairman Chief Wellness Officer, Stanford Medicine (current)
of the Board, Emory Healthcare Director, Program on Physician Well-Being, Mayo Clinic (at
time of Blue Ridge meeting)
Darrell G. Kirch, MD Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
President, Association of American Medical Colleges Christine Sinsky, MD

VP for Professional Satisfaction, American Medical
Steven Lipstein
Association I . Problem Statement: A Growing Threat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
President and CEO, BJC Health Care
Mary D. Naylor, PhD, RN, FAAN FACILITATORS
Marian S. Ware Professor in Gerontology Steve Levin II . Drivers of Burnout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Director, NewCourtland Center for Transitions & Health Director, The Chartis Group
University of Pennsylvania School of Nursing
Keith Dickey, PhD III . Impacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Kenneth S. Polonsky, MD Principal, The Chartis Group
Executive VP for Medical Affairs; Dean, Biological Sciences
Division and School of Medicine, University of Chicago Alexandra Schumm
Director of Research, The Chartis Group IV . Solutions and Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Claire Pomeroy, MD, MBA
President, Albert and Mary Lasker Foundation
GUEST
Marschall S. Runge, MD, PhD Charles H. (Pete) McTier V . Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Executive VP for Medical Affairs, University of Michigan President Emeritus, Woodruff Foundation
Fred Sanfilippo, MD, PhD Trustee Emeritus, Emory University
VI . Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Director, Healthcare Innovation Program, Emory University
STAFF
Richard P. Shannon, MD
Anita Bray
Executive VP for Health Affairs VII . Rationale and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Project Coordinator, Woodruff Health Sciences Center,
University of Virginia Health System
Emory University
Irene M. Thompson References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Gary L. Teal
Vice Chair, AMC Networks Board of Managers
Vice President, Woodruff Health Sciences Center,
Vizient, Inc.
Emory University About the Blue Ridge Academic Health Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
SENIOR MEMBERS REPORTER
William R. Brody, MD, PhD Kathleen Getz Previous Blue Ridge Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Professor Emeritus Director, Special Projects, Woodruff Health Sciences Center,
Salk Institute for Biological Studies Emory University
Don E. Detmer, MD, MA
EDITOR
Professor of Medical Education
University of Virginia Ron Sauder
Communications Consultant
Michael V. Drake, MD Reproductions of this document may be made with written permission of Emory University’s Woodruff Health Sciences Center by contacting Anita Bray,
President, Ohio State University EDITORIAL AND DESIGN CONSULTANTS Woodruff Health Sciences Center Administration Building, Suite 400, Atlanta, GA, 30322. Phone: [phone]. Email: [email protected].
Karon Schindler, Peta Westmaas Recommendations and opinions expressed in this report represent those of the Blue Ridge Academic Health Group and are not official positions of Emory
Woodruff Health Sciences Center, Emory University University. This report is not intended to be relied on as a substitute for specific legal and business advice. Copyright 2017 by Emory University.
That physician will hardly be thought very careful institutions that are not organized under a single mentally healthy if one is to provide compassion- academic leaders that their physicians, nurses, and
of the health of his patients if he neglects his own. umbrella as is an AHC. The BRAHG recognizes ate, exceptional clinical care to patients. However, administrators are at substantial risk in day-to-
—Galen (130-200 AD)1 that although progress has often been chaotic and it is clear that the “healing” of caregivers cannot day dealings with each other and with the public.
uneven, significant advances have been and are be- be accomplished solely through “self-help.” Just as In this year’s report, the BRAHG confronts
ing made in each of the mission domains. the best care for patients is achieved through team this widely debilitating and sometimes lethal
Introduction
That said, even with progress in the clinical do- work and support, addressing the challenges of phenomenon head-on. We declare that the time is
main, there is increasing uncertainty in the clinical burnout and advancing the wellness of health care ripe for us as AHC leaders to claim a central role
Over the past 20 years the Blue Ridge Academic environment evidenced by rapidly consolidating providers will also require AHC leadership and in- in acknowledging, owning, researching, under-
Health Group (BRAHG) has made observations health systems and constantly changing reimburse- stitutional commitment to achieve optimal results. standing, and defeating the epidemic of burnout.
and recommendations on a number of topics ment. In particular, with the implementation of In this report, we explore and make recommenda- The role of AHCs in addressing this issue is
important to the special roles of academic health user-unfriendly and poorly integrated information tions to address what is becoming a crisis in health especially important because we educate, train,
centers (AHCs) in American society. The AHC technology systems including the EHR, daily work- care delivery. We recommend that AHC leaders and acculturate each new generation of health
uniquely integrates the missions of education, flows are being interrupted, and key relationships take immediate steps in addressing the real human professionals, including physicians, dentists,
research, and clinical care and aspires to create and between patients and caregivers are being disrupted stresses in the “human capital” upon which their nurses, and all other health professionals. Our
apply new knowledge for the broad benefit of the as well. AHCs and all health care organizations depend. faculty model—in their lives, practices, and class-
communities it serves. The AHC in its many itera- At the center of this maelstrom are the physi- rooms—the disciplinary values and professional
tions is the developer of strategies to take advantage cians, nurses, and supporting health workers who lifestyles that our students will emulate in their
of opportunities and to mitigate mission risks in a on a daily basis have the obligation and calling to own careers. In our organizational life, we help
Executive Summary
changing environment; it is the organizer of opera- provide care to individual patients. Consequently, to create the norms and expectations that define
tional plans to implement mission strategies; and it what should be a joy is often a burden. our professions’ canons, credentialing protocols,
is the steward of the human capital without which In an earlier publication, Getting the Physician With this background, the BRAHG views it as an and societal commitments.2 We must address the
strategies and plans have no meaning. Underpin- Right: Exceptional Health Professionalism for a New essential duty of health professionals to maintain burnout crisis or risk ongoing problems not only
ning the AHC are human and technical systems Era,2 the BRAHG reviewed the elements of profes- their own well-being, so that they can be effec- among our current cadre of providers, but also
that allow the work to get done. The observations sionalism for individual physicians and interdisci- tive healers of others. As a recent British Medi- among our next generation of health care profes-
and recommendations of the BRAHG have urged plinary teams. Perhaps the key value is altruism— cal Journal editorial phrased it, “doctors have a sionals.
AHCs and others that have the same missions to which stated simply means that serving the best professional responsibility to be at their best.”3 Additionally, we share in and are subject to the
operate as orderly businesses, and to be innovative interest of patients, and not one’s own interest, is Hippocrates himself captured a version of this same environmental and organizational pressures
leaders in each of their mission domains. While the rule. Our observation is that altruism is difficult commitment when he asked the new physician to that impinge on every health professional and
each of the mission domains are specific, in the even for the most committed professionals when vow, “In purity and holiness I will guard my life health practice, whether inside or outside of the
well-functioning AHC their activities intersect. one is working in a maelstrom. As you read this re- and my art.”4 AHC.
Trouble in one is often reflected in others. port, we suggest that “Getting the Physician Right,” It is a failing of our health care system that we We have a special responsibility—as educa-
In the clinical care arena, we have strongly along with all members of an interdisciplinary have made it increasingly difficult for so many tors, researchers, stewards of community health,
supported social equity in the provision of patient professional team, will require “Getting the Physi- clinicians to meet this primary imperative despite and managers of large-scale health systems—to
care, recommending that adjustors (social determi- cian Well,” “Getting the Nurse Well,” and “Getting the growing focus on quality and outcomes. There address and defeat burnout. The leadership of our
nants) in reimbursement be developed to recognize All the Team Members Well.” are many causes, but one growing result: clinician health centers, in particular, have a special and
populations at social risk. We have also supported Classical and scriptural proverbs have con- burnout. We pay a staggering cost in lost produc- acute obligation to place this issue front and center,
the move to pay-for-value that explicitly recognizes sistently addressed wellness in physicians and, by tivity, risks to mental and physical health, eroding recognizing it as among the most important issues
improvement in measurable patient quality, safety, association, all professional care givers. The Greek quality and safety, diminished patient satisfaction, they must address. AHCs are not fulfilling their
and service and the expansion in access to care playwright Aeschylus in Prometheus Bound has staff turnover, and lost dollars. At the extreme, we fundamental obligation to society if they do not
made possible through the Affordable Care Act. the chorus saying “Like some inferior doctor who’s have an unacceptably high personal toll of depres- epitomize the optimal practice of medicine and
The BRAHG has a particular interest in the explo- become ill, you’re in despair and are unable to dis- sion and suicide. that of every other health profession. The danger of
sion of knowledge and its management, develop- cover, by what medicine you yourself can be cured.” The alarming rate of clinician burnout might burnout is not only impairment of our own health
ments in information technology, and the move “Physician, physician heal thine own limp” is found well be called a hidden epidemic. Although the professionals; it is also the erosion of quality in the
from paper to electronic health records (EHRs) in Genesis Rabbah (23:4). The additional scriptural phenomenon is well known in the health profes- delivery of health care to our patients and a fraying
that in theory provides more accuracy and broader quote, “Physician, heal thyself,” is found in the sions and is even increasingly recognized in the of morale and institutional effectiveness at every
access to patient clinical information. gospel of Luke (4:23), who himself was a physician. lay press (e.g., The New York Times,5,6 US News & level of our organizations. Optimizing the well-
Our recommendations often broadly apply to These proverbs apply to all professional caregivers. World Report special report7-9), it is still not ade- being of individual professionals and the teams
the health, education, and research missions of Each suggests that one must be emotionally and quately acknowledged by many health system and they work in is a requirement if we are to meet the
2 3
benchmarks of efficient quality patient care. The Societal Impact of from 12% to 18%.11 Based on the approach to calcu- The preceding analysis of the total cost of burnout
Part of our need is to understand and define late the organizational impact of burnout outlined in to the American health care system, though it results in
Physician Burnout
burnout appropriately. It is not a simple func- Shanafelt et al,12 the increased rate of turnover due to a formidable dollar figure, is undoubtedly partial for two
tion of stress, depression, overwork, or exhaus- burnout is 2.4%, which equates to an annual cost of reasons:
tion. Rather, all of those states and conditions This report describes the many causes and dimensions of $9 billion to $18 billion for the nation. First, many important factors have not been
can be and are drivers, but burnout itself is a physician burnout. No matter its full scope, there is one n Productivity loss. This is an extrapolation based quantified, even to the sometimes-tenuous extent of the
complex psychological and sociological outcome consequence that health care executives and policymak- on a comprehensive analysis of Canadian physicians aforementioned drivers. They include the following:
that results in depersonalization, loss of caring, ers must understand and account for: it costs money. We by Dewa and colleagues.13 Comparing burnout rates n Increased diagnostic testing and specialty
and withdrawal of engagement in many critical are not aware of any analysis that has tallied the full bill between the two countries, which are virtually identi- referrals
dimensions of attentiveness and energy that may for the United States. cal,14 and adjusting for the much larger physician pool n Rise in malpractice risk and cost
spell the difference between success and failure For this report, the Blue Ridge Academic Health in the U.S. (approximately nine times that of Canada), n Degradation in patient experience
in therapeutic environments. Group asked consultants from The Chartis Group (who we come up with a productivity loss figure of $1.7 n Erosion in organizational morale and harm to organi-
At the extreme, burnout can eventuate in also assist BRAHG in planning and facilitating its annual billion. zational culture
suicide, a low-percentage but high-impact meetings) to help run the numbers. Their calculation is n Quality of care, patient safety, and medi- n Long-term increase in physician shortages due to
“black swan” event that shatters lives, families, based on several assumptions and extrapolations reflect- cal errors. Shanafelt and co-authors15 found that fewer entering the field
and colleagues when it occurs. Suicide of health ing the limited cost analysis completed to date. Within each one-point increase in a surgeon’s self-reported n Negative impact on physicians’ families’ lives
care professionals, though a rare cause of death, this context, the dollar signs become extraordinary: emotional exhaustion led to a five-point increase in n Total cost and impact of physician suicide due to
is high enough in comparison with other profes- Physician burnout costs as much as $150 billion per year. reported errors. The same effect was doubled for every burnout as a risk factor; more research is needed to
sions to merit our special attention and preven- That formidable sum amounts to more than 4.7% of one-point increase in the surgeon’s depersonalization quantify.
tive energies as educators, administrators, and the nation’s $3.2 trillion expenditure on health care—an score. Extrapolating those marginal increases to the Second, a critical caveat: this computation made
colleagues. enormous sum that could have great consequence for entire active population of physicians, more than half no attempt to assess the societal impact of burnout on
One phrase that has been often employed to the future of our health care system and the directions of whom are found to be suffering from burnout, we the part of other health professionals, including nurses,
describe the vital quality most essentially threat- of health reform, were there a way to save or redeploy made assumptions about the overall increase in re- pharmacists, dentists, therapists, physician assistants,
ened by burnout is “joy in work.” This is akin those dollars. ported medical errors by all physicians in the country. and all other members of the care team. Any and all
to the phenomenon of “flow”—the absorption There are both quantitative and qualitative factors Using the denominator of $735 billion to $980 billion professionals anywhere along the chain of care can
we experience while working on a completely driving the cost of physician burnout. Through this as the total annual cost (both direct and indirect) of experience burnout contributing to increased errors, from
enjoyable task at the height of our powers. Also analysis, we estimated the additional costs that are rea- medical errors in the U.S.,16 we estimate the portion misdiagnosis to mistreatment, as well as suboptimal
related to this is the status of professionalism. sonably attributable to burnout and its effect on mental of medical errors attributable to burned out physicians patient support.
Professionals are educated, trained, licensed, health and job performance in the following areas: as $97 billion to $129 billion.
and respected as they perform rare and need- n Turnover. Various studies have estimated the cost A full outline and explanation of the methodology
ful functions in a way that meets the duty to of turnover at $500,000 to $1 million per physician. used by Chartis has been posted on the Blue Ridge *The total U.S. active physician count of 923,308, per the Kaiser
Family Foundation and Redi-Data Inc., was adjusted down
the patient. Professionalism in health care is Current studies estimate the overall rate of burnout at Academic Health Group website: http://whsc.emory.
to account for part-time and academic physicians who do not
selfless, expert, excellent, judicious, accountable, about 54% among the nation’s 750,000 active physi- edu/blueridge/publications/reports.html as an appendix spend all their time in clinical activities.10
and effective. Respect for oneself, the team, and cians.*10 The rate of early retirement has increased to this report.
especially the patient is a hallmark. Honor and
integrity are key attributes.2 Burnout is both a
consequence of the loss of one or more dimen-
sions of professionalism and a contributor to I. Problem Statement: A Growing as well as avoidable errors, and it threatens the History and scope
the loss of professionalism. The cycle is a vicious Threat health of practitioners, through a spectrum of The phenomenon of occupational burnout,
one. outcomes that range from exhaustion and deper- especially in the human services and helping
What is at stake is nothing less than the sonalization all the way to depression, suicidal professions, has been recognized since 1974, with
“joy in work” that the most productive and Burnout in health care is a threat to all of us. It ideation, and all too tragically, suicide itself. the work of psychologist Herbert Freudenberger.
empathetic clinicians bring to the workplace; hurts quality of life, the morale of groups and The insidious spread of burnout, reflecting a Christina Maslach and colleagues at Berkeley
the sense of professionalism that every doctor, teams, and the productivity of organizations. It perfect storm of personal, professional, academic, wrote a seminal 1981 study of physician burnout,
nurse, and other health professional has a right costs money through inefficiency, ineffectiveness, and societal factors, is so relentless that it might identifying its cardinal symptoms as emotional
to expect from their career; and the satisfaction, and the unnecessary and premature turnover of well be termed epidemic. Concerted action will be exhaustion, depersonalization (or negative feel-
quality, and safety that is expected by patients. highly trained professionals representing substan- needed to recognize, analyze, and reverse it where ings toward patients and clients), and loss of
tial societal investment. It threatens the health present today and to prevent it in the future. personal accomplishment (or feelings of com-
of patients, in the form of suboptimal outcomes
4 5
petence).17 They found that the consequences of of burnout on residents, physicians, nurses, and health of health professionals—not to mention the of relationships and obligations—to patients,
burnout include lower quality of care, along with other health professionals. But at the extreme, safe and high-quality functioning of the American colleagues, the health care system, and society at
such damaging symptoms as insomnia, drug and the impact of suicide is the most catastrophic. A health care system. large. Further, professionalism is a quality that is
alcohol abuse, absenteeism, marital and family recent study of 381,614 residents in more than While suicide is not an immediate outcome enhanced and developed over time, throughout
difficulties, and job turnover. This work led to the 9,000 training programs nationwide, covering the of burnout, a Venn diagram would show areas of the course of one’s career. In this endeavor, “the
development of a written instrument, called the period from 2000 to 2014, found that suicide was overlap between the categories of burnout, mental principles of emotional intelligence, reflective
Maslach Burnout Inventory, which has become the second-leading cause of death in that period, health disorders such as depression, and suicide.25 practice, and mindfulness [are] critical to nour-
a standard means of testing for the problem. It behind only all forms of cancers.22 Overall, 66 Hence the importance of early recognition and ishing professionalism in practice.” These qualities
typically takes no more than 10-15 minutes to residents were reported to have died of suicide, mitigation strategies. While well-designed studies are antithetical to the corrosive experiences of
complete.18 though the authors noted there were possible show that entering medical students, on aver- exhaustion, disengagement, and depersonaliza-
In recent years, surveys have shown that the ambiguities about some other categories, such as age, score higher than their peers in the general tion that characterize burnout. The enhancement
levels of burnout are high and continuing to climb accidental poisonings, that may have led to under- population on measures of mental health, follow- of professionalism may be expected to counteract
in the health professions, especially medicine, cre- reporting of suicide. (While high in absolute up studies show their mental health has fallen burnout, while conversely, burnout will corrode
ating a special issue—and problem—at the heart terms, the overall rate of death among residents, as below the mean after two years of medical school. the high-quality performance, ideals, and values
of a system that is designed to improve the health well as the rate of death due to suicide, were both Something has gone awry—whether in the “hero of the professional. The two qualities are inversely
of individuals and communities. significantly lower than age- and gender-adjusted culture” they imbibe as part of the hidden cur- correlated. While professionalism brings great joy,
The first large-scale study of U.S. physicians, rates in the general population.) Nevertheless, riculum, the extreme zero-sum competitiveness it requires remarkable individual commitment
conducted in 2011, found that burnout was more the authors lament the failure of the health care of some traditional models of medical education, that can be difficult to sustain when complex sys-
rampant among physicians than in the workforce at system to detect such extreme distress among or other factors that chip away at their resilience, tems that support clinical care are not optimized.
large, with 45.5% reporting at least one symptom.19 doctors in training. It is noteworthy, for instance, perhaps by isolating them from peers and support
A 2014 survey found an even higher rate, of 54.4%, that suicides peaked during the first quarter of the networks. Indeed, focused education and support Organizational dimensions
with authors Shanafelt and colleagues concluding, first year of residency and were also higher in the of health care provider resilience is an important A multitude of factors in the design of organi-
“More than half of US physicians are now experi- first quarters of the third and fourth years. component of the strategies that can counter the zational systems impinge on the satisfaction,
encing professional burnout.”20 Burnout also affects “Our findings present the education com- forces that often lead to burnout. engagement, and effectiveness of clinicians and
other health professionals, including RNs, NPs, PAs, munity with an opportunity to reduce unneces- Professionalism—“A profession… is an oc- staff. (See table 1.) These range from productiv-
and medical assistants, among others. sary deaths by increasing preventive strategies, cupation that regulates itself though systematic, ity targets to the relative efficiency (or not) of the
scheduling preemptive education, and fostering required training and collegial discipline; that has institution’s EHR, billing, ordering, and appoint-
Personal dimensions access to counseling and confidential mental a base in technical, specialized knowledge; and ments systems; the prevailing values and collegial-
Joy in work—The notion of “joy in work” speaks to health services for residents,” they write. “In addi- that has a service rather than a profit orientation, ity (or not) of clinical care teams; the level of sup-
the sense of fulfillment that is most highly prized tion, all of those who are engaged in the clinical enshrined in its code of ethics,” writes Paul Starr port and collegiality; and communication from
by individuals as well as teams that are working to learning environment—both faculty and residents in The Social Transformation of American Medi- senior levels of leadership—in short, a myriad of
their highest capacity. While difficult to define pre- themselves—need to watch for signs of resident cine.26 dimensions of bureaucracy and workplace design
cisely, it is the sensation of hitting on all cylinders burnout, depression, social isolation, or significant This definition captures essential characteris- and culture.
that often is most highly prized in retrospect, when changes in performance.”22 tics identified by most scholars, including that a One of the most persistent organizational
one steps back to take a breather. Many positive Equally devastating is the annual toll of profession is2 issues centers on the EHR, which is a large and
qualities contribute to this sensation, which might suicide among practicing physicians. The Ameri- n Based on required intellectual training in spe- inescapable part of modern practice, consuming a
also be defined as the converse of burnout. can Foundation for Suicide Prevention estimates cialized knowledge large percentage of the workday.
As the Institute for Healthcare Improvement that 300-400 practicing physicians die of suicide n Oriented toward public service As Bodenheimer and Sinsky observe: “More
put it, “The most joyful, productive, engaged staff every year,23 also citing a 2004 meta-analysis n Rooted in a code of ethics EHR functionalities—email with patients, physi-
feel both physically and psychologically safe, ap- showing a heightened suicide risk ratio of about n Not strictly profit-oriented cian order entry, alerts and reminders—intended
preciate the meaning and purpose of their work, 1.41 times (for male physicians) and 2.27 times n Infused with common, collegial norms to promote the Triple Aim—are associated with
have some choice and control over their time, (for female physicians) when compared with the n Authorized by society to operate as a relatively more burnout and intent to leave practice.”28
experience camaraderie with others at work, and population at-large.24 While this is an area ripe autonomous, largely self-regulating occupation. Constant changes in regulatory standards such as
perceive their work life to be fair and equitable.”21 for further research, it is shocking to consider Along with joy in work, it is equally important “meaningful use” become “meaningless,” as the
Risks to mental health, including suicide— that the estimated loss equates to two to three (or to note the definitional importance of profes- EHR becomes harder and not easier to use.
When joy is lacking and burnout is present, the more) graduating classes of medical students. This sionalism. Cara Lesser and colleagues, writing
stakes are high. It would be difficult to quantify should be regarded as a grievously high and unac- in JAMA,27 note that professionalism entails Healthcare delivery impact
the overall impact of all the negative impacts ceptable number by everyone concerned with the learning about and respecting a complex web Burnout has a deleterious impact on the health
6 7
care system as a whole and on the delivery of health n Work-life integration | Drivers of burnout and engagement in physicians34
TABLE 1
care as it is experienced by patients. Summarizing a Although individual factors vary from place
series of studies, Christine Sinsky, an internist and to place, there is almost universal agreement that
vice president of professional satisfaction for the changes in health care that require substantial
Individual Work unit Organization National
AMA, observes that physician burnout is associated amounts of time to be spent on “clerical” duties as factors factors factors factors
with an increased risk of medical errors and mal- opposed to the face-to-face practice of medicine
practice, decreased physician empathy for patients, are resulting in a perceived loss of professionalism n Specialty n Productivity expectations n Productivity targets n Structure reimbursement
n Practice location n Team structure n Method of compensation n M edicare/Medicaid
a lower rate of patient adherence to treatment and accomplishment. In an observational study of Workload n Decision to increase work to n Efficiency n S alary n B undled payments
orders, and less patient satisfaction. Furthermore, physicians in ambulatory settings, Sinsky and co- and job increase income n Use of allied health profes- n P roductivity based n D ocumentation requirements
demands sionals n Payer mix
physicians experiencing burnout are much more authors found that physicians spend nearly two
likely to turn over, an enormously costly loss for hours on desk and EHR duties for every hour of
health systems as well as society as a whole. With direct face time with patients.35 n Experience n Availability of support staff and n Integration of care n Integration of care
n Ability to prioritize their experience n Use of patient portal n Requirements for:
about 50% of MDs experiencing burnout, a health Particular issues include:
n Personal efficiency n Patient check-in efficiency/ n Institutional efficiency: n E lectronic prescribing
system of 3,000 MDs might expect 75 physicians n Record keeping and documentation required Efficiency and n Organizational skills process n E HR n M edication reconciliation
leaving prematurely each year due to burnout, with for physician orders resources n Willingness to delegate n Use of scribes n A ppointment system n M eaningful use of EHR
n Ability to say “no” n Team huddles n O rdering systems n Certification agency facility
average replacement costs amounting to $500,000 n Billing procedures and requirements n Use of allied health profes- n How regulations interpreted regulations (JCAHO)
to $1 million, for a total cost of at least $40 million n Physicians’ productivity demands (as described sionals and applied n Precertifications for tests/
treatments
per year.12, 29-33 in the next point) and hours of work are in-
n Self-awareness of most person- n M atch of work to talents and n O rganizational culture n E volving supervisory role of
creasing due to the amount of computer time ally meaningful aspect of work interests of individuals n P ractice environment physicians (potentially less
consumed by EHR interfacing, in-box manage- n Ability to shape career to focus n O pportunities for involvement n O pportunities for professional direct patient contact)
Meaning in on interests n E ducation development n R educed funding
II. Drivers of Burnout ment, and other clerical tasks—leading to the work n D octor-patient relationships n R esearch n R esearch
widespread belief that technology is a time sink. n P ersonal recognition of positive n L eadership n E ducation
events at work n R egulations that increase
Collectively, many of the factors driving the epi- These demands are creating stress as physicians clerical work
try to juggle patient needs, while trying to find
demic reflect the law of unintended consequences.
sufficient time for personal, academic, and other n P ersonal values n B ehavior of work unit leader n O rganization’s mission n S ystem of coverage for
With the best of intentions, a profusion of regula- n P rofessional values n W ork unit norms and expecta- n Service/quality vs profit uninsured
tory requirements related to billing, quality, safety, pursuits. n L evel of altruism tions n O rganization’s values n S tructure reimbursement
n Growing productivity demands placed on all Culture and n M oral compass/ethics n Equity/fairness n B ehavior of senior leaders n W hat is rewarded
and compliance have turned the lives of many n C ommitment to organization n C ommunication/messaging n Regulations
clinicians into a blur of keystrokes and computer members of the care team, including physicians, values n O rganizational norms and
APPs, RNs, and other health professionals expectations
screens. The fundamental human interactions n J ust culture
n The “consumer” movement in health care bring-
of physician and patient, nurse and doctor, or
one colleague with another, in unhurried, casual ing ever higher demands and expectations from n Personality n Degree of flexibility: n Scheduling system n Precertifications for tests/
patients to the table n Assertiveness n C ontrol of physician n Policies treatments
settings, such as simply having lunch together, Control and n Intentionality calendars n Affiliations that restrict referrals n Insurance networks that restrict
have been increasingly interrupted and greatly n Pace of advancements in medical practice, flexibility n C linic start/end times n Rigid application practice referrals
requiring ongoing continuing education, as n V acation scheduling guidelines n Practice guidelines
decreased in frequency.
n C all schedule
well as the increasing severity and complexity
Drivers of burnout are legion, and importantly,
they exist at multiple levels of the organization. of many illnesses being treated and managed in n P ersonality traits n Collegiality in practice environ- n C ollegiality across the n S upport and community created
quaternary care centers such as the typical AHC n L ength of service ment organization by medical/specialty societies
They manifest as conflicting incentives, stressors,
Social n R elationship-building skills n Physical configuration of work n P hysician lounge
and dysfunction at the level of the individual and n Burdensome and costly recertification require- support and unit space n Strategies to build community
ments, which vary from specialty to specialty n S ocial gatherings to promote n S ocial gatherings
the workplace team; the overall organization; and community
community
the larger society or environment (world at large). but loom large over busy professionals, requir- at work n Team structure
ing “cramming” at the expense of personal time
Table 134 summarizes this multitude of factors
n The persistence of the “hero” and “ego ideal”
which are at play across seven driver dimensions:
n P riorities and values n C all schedule n Vacation policies n R equirements for:
models in physician culture, often modeled by
n Workload and job demands n P ersonal characteristics n S tructure night/weekend n S ick/medical leave n M aintenance certification
n Efficiency and resources faculty and unconsciously adopted by students Work-life n S pouse/partner coverage n P olicies n Licensing
and residents integration n C hildren/dependents n C ross-coverage for time away n P art-time work n R egulations that increase
n Meaning in work n H ealth issues n E xpectations/role models n F lexible scheduling clerical work
n Culture and values n Working harder to maintain compensation lev- n E xpectations/role models
els, as flat traditional and risk-based reimburse-
n Control and flexibility Drivers of burnout and engagement with examples of individual, work unit, orgaization, and national factors that influence each driver.
n Social support and community at work ment rates require increased volumes—at the EHR = electronic health unit; JCAHO = Joint Commission on the Accreditation of Healthcare Organizations.
Adapted with permission from Mayo Clinic Proceedings.34
8 9
same time as there is growing recognition of the n Insufficient staffing
therapeutic need for better work-life balance n Juggling personal obligations for an increasing FIGURE 1 | Causes and Impact of Nurse Burnout36-40
n For nurses, challenging staffing ratios result in number of single parents
burdensome workloads, and poor management n Wages stagnant for more than 12 years relative
practices and lack of leadership compound to inflation36 Contributors to nurse burnout are slightly different.
their risks for burnout. Nurses may also experi- n Low morale
ence moral distress at dissonance between n Growing rate of turnover
Contributors to Nurse Burnout Impact of Burnout
their beliefs and training about best practice
as compared with the actual care delivery they For patients, they include: n Increased workloads, longer working hours, less flexibility n Mental health concerns for nurses
experience. They may also be susceptible to n Increased susceptibility to avoidable errors in schedule and shift preferences n Drop in quality of patient care
post-traumatic stress (as are some doctors) n Loss of face-to-face time n Insufficient staffing, with reduced pipeline n Low morale, workplace satisfaction
based on their clinical experiences with vulner- n D ecreased satisfaction (fewer students accepted into nursing programs) n High rate of turnover, with high cost of replacement
n Lack of support outside of work—high prevalence ($60,000 -$70,000 to recruit a replacement nurse)
able patients of every age. n Increased delays in access to care
of single workers/parents
n Stagnant wages on average, relative to inflation, 2000-201236
For organizations, they include:
III. Impacts n Turnover expenses—$500,000+ for MDs,
$60,000+ for nurses
Source: The Chartis Group, LLC. 2016
Burnout among clinicians—both doctors and
n Opportunity costs associated with not operat-
nurses—has substantial consequences for clini-
ing at top of license/scope of practice
cians, the organizations they serve, and patients.
n Patient safety, quality, and satisfaction decline—
The impact is summarized in figures 136-40 and 2. with heightened risk of malpractice leading to FIGURE 2 | Consequences: Impact of Physician Burnout
Many of these issues were discussed in Part I.
quality, financial, and brand costs and damage
n Overuse of testing and referrals
For physicians, they include: n Contagious impact on morale Physician burnout can impact patient outcomes,
n An erosion of the sense of meaning or fulfillment
Costs to society at large are substantial, given which presents real challenges to the viability and
that comes from their experience of medicine as
the investment in the education and training of
sustainability of a hospital or health system.
a “calling” with professional status and values
health care professionals. A recent study in Canada
n Less time with patients and ability to nurture
estimated that burnout among the current cohort
caring relationships
of approximately 70,000 physicians would cost the
n Loss of work-life balance in which they have
country $213 million in lost future health services
adequate time for families and intimate rela-
over a 24-year study horizon, based on reduction Patient
tionships, adequate sleep, balanced diet, hobbies
in clinical hours by
and sports, and exercise regimens A recent study in
burnt-out physicians
n Reduction in time and attention to patients
n Increase in “pajama time” (i.e., time at home as well as burnout- Canada estimated Physician Burnout n Significant negative impact on quality of care
spent on EHR) as evening hours for R&R or
induced early retire- that burnout among and patient outcomes
even professional literature review are be- ment.13 Of course, n Significant rise in patient dissatisfaction
ing overtaken by catch-up work on computer the current cohort n Loss of joy, passion, motivation for career and “calling”
this does not include
n Disengagement in daily patient care activities
medicine tasks many other cat- of approximately
and practice operations
n Growing sense of dissatisfaction, exhaustion,
egories of burnout- 70,000 physicians n Increase in apathy and erosion of professionalism
and depersonalization related cost that n Risk to physician’s own care and safety (suicide rates) Hospital/Health
would cost the
n Growing incidence of medical errors might be imagined, n Depression and other mental healh concerns System
n Growing rate of turnover country $213 mil-
including the impact
of lower productiv- lion in lost future n Erosion of physician community and clinician collaboration
For nurses, they include: ity on teams and n Permeating sense of negativity and dissatisfaction
health services over
n An erosion of the sense of meaning or fulfill- within the health system
organizations, in ad-
ment that comes from their experience of a 24-year study n Increase in clinician turnover and staffing challenges
dition to the direct
(recruitment/retention)
nursing as a “calling” with professional status and indirect costs of horizon.
n Drop in patient loyalty and loss of patient volumes/visits
and values
sub-optimal care. n Brand damage
n Increasing workloads, longer working hours
Source: The Chartis Group, LLC. 2016
10 11
Analogies to the National Quality approaches to team-based care and solutions to change being willing to acknowledge and seek help for early Solutions and interventions aimed at ad-
documentation approaches better aligned to the digital warning signs of burnout, stress, depression, and dressing and mitigating the phenomenon of
Movement
health care environment anxiety—without becoming stigmatized—is obvious. burnout need to occur at the individual, team,
4. Messaging and Communications, developing a End the shame—Given the “heroic” nature of and organizational level, among others.
The publication of To Err Is Human (1999)41 and knowledge hub that will create a repository for sharing the medical impulse, and the perfectionist nature of
Crossing the Quality Chasm (2001)42 by the Institute toolkits, data, and models. The NAM has also formed a many physicians’ personalities,25 we need to promote Individual focus (Provider, heal thyself!)
of Medicine (now the National Academy of Medicine broad network of organizations that are also committed fundamental changes in how some physicians—and First and foremost, individual practitioners
[NAM]) were milestone events that over time, catalyzed to addressing clinician well-being and burnout. physicians-in-training—regard themselves and relate are responsible for following the same health-
significantly different ways in which AHCs—and our Transparency—Countering decades of denial and to others on the care team, as well as patients and ful wellness routines they would prescribe for
health care system in general—thought about the secrecy, the quality movement led to the recognition that colleagues. their patients—engaging in exercise, eating
problem of medical errors and their impact on the health it is best—for patients, their families and loved ones, for Empower team members—The same logic healthful diets, and attending to their own
and safety of patients. clinicians, and for health care organizations—to frankly that recognized the importance of empowering all medical care.19 “Activities to enhance self-
Today, we are seeing the beginnings of analogous acknowledge error when it occurs. Not only is sunlight members of a surgical team, for instance, to stop a awareness (e.g., mindfulness, narrative medi-
leadership on the issue of clinician burnout and wellness the best disinfectant, the best learning can occur in no procedure immediately if mistakes were about to be cine, cognitive behavioral techniques, connect-
by the NAM, together with the Association of American other way. Even more fundamentally, honesty is always committed—without fear of repercussion—find their ing with meaning and purpose in work) and
Medical Colleges (AAMC) and Accreditation Council for the best policy. analogy in addressing the issues of burnout. Team resilience can reduce burnout. These qualities
Graduate Medical Education, in league with the Ameri- Systems-level emphasis—Although errors are, members must be mindful of the problem and watch- are skills that can be taught, and individual
can Medical Association, American Hospital Association, by definition, committed by individuals, the quality ful for symptoms, in themselves and others. physicians should commit to learning, devel-
America Nurses Association, and more than 30 other movement understood that fundamental improvements C-suite leadership—The quality and safety oping, and complementing these skills,” say
flagship organizations.43 ultimately depend on system changes. With a variety movement required governing boards and CEOs to Shanafelt and colleagues.19
The BRAHG believes it is an urgent priority to of quality and performance improvement models— acknowledge the need and elevate it to the top of On the organizational side, AHC lead-
address the issue of clinician burnout with the same including the six sigma movement in several major their agendas. The same must be said of clinician ers can move culture in significant ways. For
forthrightness and prominence that characterized the industries—providing a guiding star, health care began burnout. All over the country, in organizations of vary- instance, performance reviews can be used
quality movement. Many of the principal findings and to look at creating checklists, reducing redundancies, ing sizes, we now have chief quality officers, housed conscientiously to assist staff in focusing on
consequences of those IOM publications apply directly to and developing algorithms and other types of systems literally or figuratively in the C-suite, empowered to their true passion and protecting time in
this issue and the position we are in today. to create safer and more robust processes and controls intervene in any situation or any crisis precisely at which to pursue it. Leaders can also prioritize
As clinician well-being is a complex multifactor undergirding fallible individuals. Similarly, much work is its most uncomfortable point, and reporting directly the creation of safe spaces for peer-to-peer
problem, the NAM Action Collaborative on Clinician needed to understand and mitigate the role of health to the CEO. In years to come, the same should be interactions and connections, ranging from
Well-Being and Resilience has concentrated its efforts care systems, as currently designed, in stressing, tiring, true of chief wellness officers. Indeed, they may find intentionally creating (and subsidizing) new
around four work streams: and even embittering physicians and nurses, leading themselves working closely with chief quality officers types of dining clubs for professionals, to en-
1. Research, Data, and Metrics, gathering validated to the potential for disengagement, exhaustion, and on many points of mutual interest. couraging use of faculty lounges and doctors’
measurement tools and benchmarks to track progress depersonalization. Sustained work over time—Many years after dining rooms.
and understanding the financial costs of burnout De-stigmatization—If systems are to be im- publication of the milestone IOM quality reports, the Additionally, AHC leaders can work to re-
2. Conceptual Model, developing a logic model that proved, individual practitioners must be able to candidly issues of quality and safety have not been definitely duce the potential stigma often associated with
will help establish a shared framework to address key acknowledge making mistakes and freely discuss how solved. Six sigma remains an elusive goal in health professionals seeking help for stress or other
factors to remedy them and improve in the future. The analogy care. But the quest is critical. It will continue. The kinds of psychological issues, whether they
3. External Factors and Workflow, identifying optimal for physicians, nurses, and other health professionals same must be said of the problem of burnout. are intrinsic to the organization (for instance,
promotion and tenure) or in the discipline or
profession at large (redesigning licensure ques-
tions that can be used, or misused, to identify
and stigmatize physicians who seek psychiatric
care). Illustrating the scope of the problem,
care Improvement has become foundational in care—the BRAHG joins its voice to others in sup- a 2008 national survey found that one out of
IV. Solutions and Interventions efforts to reform and transform the American porting the addition of a fourth: maintaining and 16 surgeons had experienced recent suicidal
health care system.44 To the three current goals— promoting the wellness of health care profession- ideation (significantly higher than among the
improving the experience of care (including safety als. This is an indispensable basis for the success- general population) but more than half of
The “triple aim” of quality improvement first artic-
and quality) for individuals, enhancing the health ful delivery of high-quality, safe, and satisfying those individuals (60.1%) reported they were
ulated by Don Berwick and then institutionalized
of populations, and reducing the per capita cost of patient care. reluctant to seek psychiatric or psychologic as-
with the establishment of the Institute for Health-
sistance because of medical license worries.45
12 13
Yoga mats and grit In fact, coursework in Eastern practices—such Thomas H. Lee, chief medical officer of Press zations, pursuing There is no doubt
Many leaders of the well-being movement caution as Tibetan Buddhist compassion cultivation Ganey, offers a striking model of the opposing improvement on
that one significant
institutions who are entering the fray anew not to and mindfulness training—is becoming more forces—rewards and stresses—that converge every these four dimen-
dimension of ad-
“lead” with such well-intentioned announcements common. Emory, for example, has been offer- day on the individual clinician (see figure 3). sions leads to the
as free yoga classes for all. Clinical staffs who are ing free cognitively based compassion training While symptoms of burnout (exhaustion, cyni- matrix depicted in dressing the problem
already ragged with cynicism and exhaustion (by courses since 2014 to medical faculty, staff, and cism, depersonalization) are obviously one com- Table 2.
of burnout is to
definition) may resent what they perceive as an at- students. Stanford Medicine offers compassion mon response to being in the middle of all these
give individuals the
tempt to foist institutional failings onto the back of cultivation training, incorporating both medita- tensions, Lee finds grounds for another and more Team focus
already-overburdened clinicians. tion disciplines and positive set of responses in the “positive psychol- Burnout for every- tools, skills, and mo-
AHC leaders can
And yet there is no doubt that one significant scientific study. The ogy” movement, which includes such leading one on the team, tivation they need
dimension of addressing the problem of burnout Washington Post work to reduce the exponents as Martin E. P. Seligman, director of the from physicians to
to practice self-care
is to give individuals the tools, skills, and motiva- reported finding Penn Positive Psychology Center at the University nurses to all other
potential stigma of-
tion they need to practice self-care and wellness. similar programs of Pennsylvania, and author Angela Duckworth, allied health profes- and wellness.
ten associated with
If half of all physicians are experiencing burn- at Massachusetts also a professor of psychology at Penn, who has sionals staff, can be
out and half are not, it seems likely that there General Hospital, the professionals seek- written the bestselling book Grit: The Power of mitigated through a number of strategies. Perhaps
are individual strategies that can be taught and University of Virginia Passion and Perseverance. most important are cultivating and respecting
ing help for stress
learned46—in addition to those structural changes School of Nursing, Lee sees grounds for cultivating resilience collegiality and values in which each member feels
or other kinds of
that can only be enacted by AHCs and/or by even and Georgetown and grit through pursuing four key psychological respected and has clearly defined job descriptions
larger organizations, such as professional societies, University School of psychological issues. assets: that call on his or her competencies in meaningful
regulatory agencies, and payers. Medicine.47 n Interest—following your curiosity ways. An optimal organization will also maximize
n Practice—with the goal of improvement the opportunity for each team member to practice
n Purpose—the intention to contribute to the at the “top of their license,” enhancing their sense of
| We Offer “Perks” to Try to Offset the Stress48
FIGURE 3 well-being of others pride and professionalism.
n Hope—that efforts can improve the future.48
As applied across individuals, teams, and organi-
Reward Stress/Distress
| How Do We Build Resilience and Grit from the Inside out?48
TABLE 2
- Always “on call”
T
EN - Income - Workload/productivity Individuals Teams Organizations
M
N - Benefits - Electronic medical record requirements
O
VIR - Prestige - Scheduling and patient flow Interest—following your Clinicians should be Should be comfortable Put patients first
EN - Seniority/privileges - Other departments’ performance curiosity genuinely curious about with the routine and searching
Y what they do for the non-routine
B - Poor management/leadership
D
DE - Alignment to values - Lack of aligned values Practice—with the goal Try to improve something Move the needle on Improve coordination across
AD - Teamwork and trust - Dysfunctional relationsihps of improvement important to patients outcomes that matter teams and across time
E --- RCPrehacacoltlgiecnneig/tIiemonprovement - - - LCMaoocmkn opotlfeo xrneiytcyognition Ptboeu icnropgn ootrsfi beou—thteet rhtsoe tihnete wnteioll-n Rtheediru cpea ttiheen tssuffering of Rofe dau gcreo uthpe o sfu pffaetriienngt s Rfoerd puacteie cnotmsplexity and chaos
OL - Autonomy/control - Ultimate responsibility
R
NT IN -- IMndeeapneinngdence - - IWsoitlanteisosn to suffering Himopproev—e ftuhtautr eefforts can Eoxvuerlt aind vpeersrsiteyvering Ccloamssp—etaen tdo wbein t mhea rbkeestt sihna yroeur Mthae kceo hreig ohf- vsatrlautee ghyealth care
E
ER - Can save a life - High-stakes pressure
H
IN - Can help/heal - Can’t fix everything Courtesy of Press Ganey Associates and Thomas Lee.
- Affirmation/appreciation - Blame
Courtesy of Press Ganey Associates and Thomas Lee.
14 15
Emory Critical Care Center national trends in the field. sible), measuring burnout and wellness metrics nurses, and/or medical assistants have offload-
For nurses, the leadership took a series of steps throughout the organization, and setting (and ed two to three hours per day from MDs in
Tackles Burnout Syndrome
to ease staffing pressure, from implementing self- accepting) compensation plans in which well- patient documentation and computerized
scheduling to reducing floating of critical care RNs in being metrics are one important component of order entry. At Cleveland Clinic Strongville,
The publication of a white paper on Burnout Syn- non-critical care units. A new mentorship program is incentive targets. primary care physicians are assigned either
drome (BOS) last year by the Critical Care Societies being developed, along with new forms of recogni- A quote from one of the giants of American two medical assistants, or one medical as-
Collaborative precipitated a wide range of actions by tion for outstanding performance by nurses and medicine reminds us that this is yet another area sistant and one
leaders of the Critical Care Center at Emory Health- physicians alike. where doing the right thing for organizations nurse. Daily Minimizing time-
care in Atlanta. As the paper documented, studies Other steps include developing new tracks for and clinicians—minimizing time-consuming visits increased consuming drudg-
consistently show that physician intensivists and professional improvement, including a Clinical Ladder drudgery, maximizing professional concentra- from 21 to 28,
ery and maximiz-
critical care nurses rank near the top for symptoms of track to develop ethics expertise, with the goal of tion—is also the right thing for patients. “Medi- revenue rose 20%
burnout in their respective disciplines. Up to 86% of nurse retention. cal care must be provided with utmost efficiency. to 30%, and sat- ing professional
all critical care nurses display one of the symptoms of One particular issue is a form of brain drain that To do less is a disservice to those we treat, and isfaction scores concentration for
BOS; 45% of critical care physicians have symptoms results in nurses pursuing education in order to move an injustice to those we might have treated,” said improved from
physicians is also
of severe BOS49; and 49% of pediatric critical care up and out—into research or administration—and Sir William Osler, in 1893.29 all parties—pa-
the right thing for
physicians scored at least some symptoms of high leaving direct patient care. Under consideration is tients, staff, and
burnout in a recent national study.50 In response, the creation of a new position called a Clinical Nurse In search of joy in practice physicians. Said patients.
Emory Healthcare’s chief of the critical care service, Leader—“a Masters-prepared RN specifically pre- A seminal study of 23 high-functioning pri- one physician: “I
Timothy Buchman, and Emory’s chief nursing execu- pared to stay at the bedside in a new role focusing on mary care practices by Christine Sinsky and leave work earlier
tive, Sharon Pappas, agreed on a series of steps and quality outcomes, the quality-control process, maxi- colleagues, sponsored by the American Board every day and have a very fulfilling relation-
measures designed to measure, assess, and mitigate mizing safety standards, and participating in research of Internal Medicine Foundation, identified ship with my team … We’re having fun.”
BOS in the Emory Critical Care Center (ECCC). and measurement of nursing-sensitive patient care several major areas of organizational change and n Reengineer prescriptions: Give stable or
Significantly, almost all of the steps they took outcomes.” improvement that could help restore what the chronically ill patients a year’s worth of renew-
were either free or low cost, requiring leadership Additionally, heightened communication is being authors call “joy in practice” and mitigate burn- als, at the time of their annual conference visit.
backing for new types of organization and new path- regarded as critical to job satisfaction and retention. out.51 The authors suggest that joy in practice re- n In-box management: Let nurses or medical
ways of advancement. The center is creating monthly unit-based leadership sults when physicians are able to concentrate on assistants filter the flow of email to physicians,
First, a physician assistant and a critical care interdisciplinary meetings. This includes the unit nurs- their fundamental calling in health care, which is handling routine reports, requests, and renew-
nurse were charged with surveying staff in the ing director, unit medical director, lead affiliate, clini- “to create healing relationships with patients.” als. Also, replace inbox messages with verbal
ECCC, using the Maslach Burnout Inventory and cal nurse specialist, unit-based pharmacist, unit-based Tellingly, many of the changes and fixes messaging (i.e., talking to each other) for more
the Areas of Work-Life Survey. On the plus side, the social worker, director for physical therapy, nutrition instituted by high-performing groups take thorough and efficient exchange of informa-
survey found high scores among nurses and MDs for support team, and director for respiratory care. Other work off the shoulders of physicians and give tion between physicians and clinical staff.
feelings of personal accomplishment, community, team members can be invited as appropriate. it to others—including scribes, medical assis- “Fairview Clinic in Minneapolis has decreased
fairness, and value. However, nurses and MDs alike Although it is too soon for year-to-year compari- tants, nurses, or office staff—who can perform the in-box work from 90 minutes to only a few
reported negative symptoms pertaining to emotional sons, feedback from ECCC staff has been positive. it equally well or better, while physicians have minutes per day for many physicians.”
exhaustion, workload, and control, consistent with precious hours freed up and can focus their at- n Improve team functioning: Locate physicians
tention on the patient. Transformative solutions and medical assistants side by side. Hold fre-
to commonly encountered problems include the quent team meetings. Minimize the need for
following: e-mail tag. Use systems analysis to map more
Organizational focus practice, and hope. Leaders can recognize and n Pre-visit planning: organizing lab tests in time efficient workflows for complex offices.
AHC leadership has the potential, through a encourage such positive development by practic- to ensure results are available for discussion Overall, Sinsky says, it is possible to save
wide range of organizational levers and incen- ing good stewardship and care of clinicians and and decision-making during the patient visit. three to five physician hours per day through
tives, to promote and encourage the development staff at all levels. n Spreading responsibility for care: taking tasks practice re-engineering, as these high-function-
of resilience. As an outgrowth of the positive Examples of burnout-mitigating leadership away from the physician and assigning them ing practices have documented.29
psychology movement, our new understanding might include setting reasonable productivity to medical assistants, nurses, and health
of resilience recognizes our ability to nurture expectations, supporting well-being and wellness coaches. These members of the team can
and grow the capacity of individuals to resist initiatives, interpreting regulations and billing handle immunizations, screening and testing,
burnout. Resilience is promoted by rewarding procedures wisely, adapting EHR systems to and medication reviews.
and strengthening the traits of interest, purpose, local needs and conditions (to the extent pos- n Let scribes help: In some practices, scribes,
16 17