We are pleased to offer you the following expanded selection of practice management-related articles on timely topics from experts in the field.
At the beginning of every flight, there is a reminder to “put the oxygen mask on yourself before helping others.” We must be reminded that we cannot effectively help others before we take care of ourselves. Although this is a longstanding adage in aviation, it is a newer concept in medicine. The practice of anesthesiology requires dedication to lifelong learning and the ability to quickly respond to catastrophic events. Our patients depend on us to be ever-vigilant, quick-thinking and focused for the length of the case; their lives depend on us and our well-being and health.
Richard Gunderman, M.D., Ph.D., describes burnout as “the sum total of hundreds of tiny betrayals of purpose, each one so minute that it hardly attracts notice.” Burnout is a term used ubiquitously in the lay and scientific press describing when the job of patient care no longer brings joy but, in fact, negatively effects one’s personal and professional life. Approximately 50 percent of U.S. physicians suffer from burnout,1 with anesthesiologists ranking close to the average at 42 percent, according a recent Medscape survey.2
Everyone Should Care
When burnout and physician well-being are seen as personal issues and “dismissed as the whining of a privileged class,”3 there is little public attention to the issue. There is an abundance of literature supporting the argument that these issues directly impact safety, quality and patient access to health care.1,4-6 Over a decade ago, Jones and colleagues demonstrated a “strong relationship between a stressful workplace and malpractice risk.”6 A decade later, Tawfik et al. demonstrated a “strong dose response” between burnout scales and reported medical errors across all medical specialties, which is a finding supported by previous studies.1 Williams also found that “stressed, burned-out and dissatisfied physicians who are misaligned with leadership” report a higher probability of making errors in medical care and delivering “suboptimal patient care.”7
Physicians matched with similarly degreed professions have much higher scores of burnout and suicide. Health care workers experiencing stressful events often take one of three possible paths: “dropping out, surviving or thriving.”8 When workers “drop out” or merely “survive,” it is costly for health care organizations. According to a study done at Mayo Clinic, “for each one-point increase in burnout (on a seven point scale) or one-point decrease in satisfaction (on a five point scale) there was a 30-40 percent increase in the likelihood that physicians would reduce their professional work effort during the next 24 months.”9 Another alarming finding is that 400 physicians a year commit suicide, with female physicians at a 130 percent higher chance of completing suicide than age-matched peers.10 Physicians who leave their profession are expensive to replace; often estimated to be two to three times their yearly salaries. The AMA STEPS Forward webpage has an interactive calculator that can help you estimate the true costs of burnout for an individual practice.11
Peer-to-peer support programs have been established as a way to address burnout. The intent of these programs is to provide timely support to health care providers experiencing stressful events such as medical errors or a patient death with the hope of improving the provider’s coping strategies and overall well-being.
Measures of physician well-being can be impacted by work-life imbalance. Sexton and colleagues examined the impact of “work-life climate” on teamwork and safety climate among a sample of U.S. health care workers. They found that physicians, nurse practitioners and physician assistants reported the poorest work-life behaviors most frequently. Better work-life climate scores were associated with improved teamwork and safety climate, which have been linked with improved clinical outcomes, thus giving leaders seeking to improve quality of care a new focus for intervention.4
So … What Can We Do?
Laying the burden for well-being and burnout solely at the feet of the individual provider is unlikely to be effective and fails to acknowledge that there are both individual and system drivers of burnout. Low perceived control of the environment, discordant values of organizations and individuals, high responsibility burden, isolation, loss of meaning in work and unsupportive work environments have all been implicated as causes of burnout.3 West et al. performed a comprehensive meta-analysis of interventions targeted at both individuals and organizations to improve burnout. He found that among all interventions studied, the initial step is awareness and acknowledgement of the issue as important and impactful within health care. The authors also found that the most commonly studied interventions included “mindfulness, stress management and small group discussions,” which all demonstrate improved burnout scores.5
Simply telling physicians to “be well” will not fix the problem, but giving coping strategies like mindfulness and peer-to-peer support has been shown to be helpful. Meditative physical exercise is an intervention that has been shown to decrease emotional exhaustion and depersonalization.12 A review of some mindfulness applications for your personal device can be found at www.mindful.org/free-mindfulness-apps-worthy-of-your-attention. The authors Sotile and Simonds wrote a book titled The Thriving Physician, published in 2018.13 The subtitle for the book is “How to avoid burnout by choosing resilience throughout your medical career.” They promote many practical applications of well-being and burnout literature to a physician’s personal life, but more generally they promote two strategies for building resilience and preventing burnout: bringing “positivity to the workplace” and taking “care of yourself and nourish the relationships that are important to you.”13 They encourage physicians to take time to identify how they are specifically helping people each day, and the authors feel strongly that “meaning is the antidote to burnout.” In a 2015 editorial by Sikka et al., introducing the Quadruple Aim for health care, the authors also endorse this concept and propose that a focus of health care must be targeting workforce engagement, which they define as “the experience of joy and meaning in the work of healthcare.”14
Peer-to-peer support programs have been established as a way to address burnout. The intent of these programs is to provide timely support to health care providers experiencing stressful events such as medical errors or a patient death with the hope of improving the providers’ coping strategies and overall well-being.8 After examining the impact of these programs on health care worker retention and turnover, it was determined that a U.S. hospital could save up to $1.81 million each year by instituting this type of program. These support systems can be hospital-based, and formalized, or can start with a group that decides to reach out after hearing about an unanticipated outcome. Physicians surveyed at academic institutions identified perceived appreciation and peer support as two critical factors for high job satisfaction/fulfillment15 ; while only 10 percent of physicians agree that their organization offers adequate support in coping with error-related stress.16
Leaders in health care organizations must strive to promote engagement among their providers and align values with their workers. Cultivating relationships with their workforce and recognition of medicine as a “human endeavor and not an assembly line” can address issues of depersonalization.3 They can also recognize that the “culture of endurance” does not promote high-quality care. Instead they must promote greater “interprofessional coordination” and system-wide structural supports (such as scribes, “debulking of the EHR”) to support the delivery of high-quality care.3
When examining work-life climate, Sexton et al. found that “WalkRounds” with senior leaders allowed frontline workers to express feedback and improved awareness of safety initiatives. This finding aligns with other research indicating that a lack of leadership support led to emotional exhaustion and increased work-family conflict. An engaged, supportive leadership who show up for their frontline workers in an approachable way is a meaningful intervention.4
The above-mentioned interventions and investments can be justified when a system considers the costs associated with turnover (including training and hiring of new staff), malpractice, medical errors, lost revenue due to decreased productivity and reduced patient satisfaction, which are all linked to a workforce suffering from burnout.17
As stated by Epstein and Privitera, “Although optimisation of programmes to address burnout will require further research, we should not wait for the perfect understanding before acting; too much is at stake.”3 There are interventions demonstrated to improve physician well-being and reduce burnout. Within Table 1 you will find some definitions relevant to this topic, and within Table 2 you will find some commonly used outcome measures in this area of research. We hope you find this article and its references useful as a resource for your practice as you strive toward saving physician and patient lives.