By ROBERT D. MORTON
The term “burnout” has been questioned as a labeling error – and rightfully so. Burnout implies victim shaming. What many healthcare professionals on the frontlines are experiencing is a normal response (symptoms) to an abnormal situation (cause), like sick fish in a tank of toxic water. A diagnosis of burnout suggests that the solution is to medicate the fish. A more holistic view is to say, “There’s really nothing wrong with you; let’s clean the tank.”
The World Health Organization (WHO) announced plans to include what it labels “burn-out” as an occupational phenomenon in the International Classification of Diseases (ICD-11). The syndrome, which results from chronic workplace stress, is characterized by feelings of exhaustion, increased mental distancing from one’s work or cynicism about work, and reduced professional efficacy.[1]
The WHO’s actions seem to further legitimize what many are experiencing: an ever more exhausting, distancing, and chronically stressful healthcare system that makes connecting with patients and providing quality care more challenging and contributes to burnout, healthcare professional distress, or to what some have even labeled moral injury or human rights violations.[2][3][4]
Physician Burnout Thought Leaders Weigh In
Drs. Simon Talbot and Wendy Dean, who co-founded the nonprofit organization MoralInjury.healthcare, borrowed the expression “moral injury” from Jonathan Shay, MD, PhD, a clinical psychiatrist who coined the phrase. Briefly, it is (1) a betrayal of what’s right, (2) by someone who holds authority, (3) in a high-stakes situation.[5] Discussions of moral injury include the view that repeated daily betrayals by authorities within the system are manifest in healthcare every day in the form of mandates from leaders to see more patients with less time to care for them, forced use of dysfunctional electronic health record (EHR) systems, overburdens by payers, competing financial considerations, fear of litigation, and more. These types of betrayals run counter to patients’ best interests—which pains doctors, whose unifying creed is that patients come first.
While other physician thought leaders like Dr. Dike Drummond (thehappymd.com), Dr. Paul DeChant (author, Preventing Physician Burnout), Dr. Zubin Damania (aka ZDoggMD), and Dr. Pamela Wible (idealmedicalcare.org) may differ on the terminology, each makes a similar call for leadership and action equal to the severity and scope of the dilemma. They all call for partnering with enlightened leaders to change the systemic and institutional patterns that inflict betrayals on the practice of good medicine.
Dr. Wible calls these issues human rights violations that begin in medical education and training due to labor law abuses, sleep/food/water deprivation, discrimination, violence, understaffing, and more—driving up depression and suicide rates.[6] Because of the profound impact on individuals, there is broad consensus about the immediate need to expand access to confidential, nonpunitive mental healthcare for doctors and nurses.
In response to systemic conditions, some doctors are quitting because having less time with patients has driven morale to rock bottom, and those who remain are warning of a mass exodus if things don’t improve.[7] According to Paul DeChant, MD, MBA, a failure to step up and meet this challenge is a failure of leadership and constitutes management malpractice, with some administrators asserting that they are suffering from management burnout.[8]
Dr. Howard Marcus, an internist in Austin, Texas, responded, “Most of us do not see our administrators as oppressors but, rather, as stuck along with the rest of us in a system that has piled on time-consuming burdens—which saps us of the time and energy required to do the best we can for our patients in the time available.”
An Annals of Internal Medicine cost-consequence analysis reported that physician burnout is costing $4.6 billion per year related to physician turnover and reduced clinical hours. The authors offer a prescription that burnout “can effectively be reduced with moderate levels of investment,” suggesting there is “substantial economic value for policy and organizational expenditures for burnout reduction programs for physicians.”[9]
The National Academy of Medicine issued a report that offers a bold vision for systemic change—because “the system,” the amorphous healthcare-industrial complex, is designed, unwittingly or not, to produce the results it is producing. When you take what is at its core a moral and scientific enterprise, that is the practice of medicine, and relentlessly mess with it in an unscientific manner driven by economics and regulation, physician burnout is the expected outcome. The scope and breadth of the problem requires unprecedented leadership, shared “collective and coordinated action across all levels of the health care system—front line care delivery, the health care organization, and the external environment.”[10]
Leadership matters. The Mayo Clinic reported that a one-point increase in the leadership score of a physician’s immediate supervisor was associated with a 3.3 percent decrease in the likelihood of burnout.[11] This and other reports support the often-quoted conclusion that your supervisor is more important to your health than your primary care doctor. If leadership will not make this issue a priority, lead as though no help is coming.
Executive leaders in some healthcare systems are beginning to require all executive staff to frequently round with or shadow physicians and to ask questions like “What isn’t working?” To be of value, executive leaders must be armed with the courage to lead and an organizational commitment to change. Some systems have appointed chief wellness officers and formed clinician wellness teams, giving them authority to create opportunities to support well-being and resiliency.
Steven Beeson, MD, founder of the Clinician Experience Project, urges “to advance care for patients and take on the healthcare imperatives in front of us, we have to care for those caring for others first. To care for the care team we must listen to clinicians, respond to the things they need, invest in burden reduction, support and develop them to be their best, empower them to lead the way, allow them to be the clinician they envisioned, and appreciate the impact they make when we do these things.” (Stephen Beeson, MD, email communication, July 17, 2019.)
Efforts to Improve EHR Usability
EHR rescue and optimization work is becoming more common to regain lost relationships with patients. Executive leaders who are desperate for help often contact firms like Medical Advantage Group (MAG), a subsidiary of The Doctors Company. MAG conducts system database audits, followed by workflow analysis, previsit planning, and redesign of work screens to make the EHR function better as a convenient, accessible clinical source of truth. Ironically, this improvement in EHR accessibility and usability makes the EHR function more like old paper charts when everything was at hand. Other benefits of this work include increases in quality-based payments, improved EHR user efficiency and experience, reduced time spent searching, and reduced or eliminated “pajama time” (charting at home).
On a smaller scale, Dr. Gabe Charbonneau (fightburnout.org), a family physician and EHR problem-solver who is on a mission to disrupt burnout, finds his greatest fulfillment in helping doctors one-on-one. Another example related to EHR usability is at Atrius Health, where a collaboration with its IT department reduced inefficiencies by cutting 1,500 clicks per day per physician.[12] This sustained, resourced commitment to improvements resulted in less time spent in the EHR and improved professional satisfaction.
Like any meaningful change, improvements require leadership with a growth mindset that demonstrates a deep respect for people and for the nature of their work. This means exhibiting leadership behaviors such as deference to expertise and sensitivity to clinical operations—two characteristics of the continuous improvement mindset on the journey toward high reliability. Effective leaders meet physicians where they live—on the frontlines of care—and seek to understand what is getting in the way of connecting with patients and providing quality care. The best leaders then work tirelessly to remove the barriers.
Additional Resource
American Hospital Association and AHA Physician Alliance. Well-being playbook: a guide for hospital and health system leaders. https://www.aha.org/system/files/media/file/2019/05/plf-well-being-playbook.pdf. Published May 2019.
Robert D. Morton, CPHRM, CPPS, is the Assistant Vice President in the Department of Patient Safety and Risk Management for The Doctors Company. Visit https://www.thedoctors.com/
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
[1] Burn-out an “occupational phenomenon”: International Classification of Diseases. World Health Organization. https://www.who.int/mental_health/evidence/burn-out/en/. May 28, 2019. Accessed June 12, 2019.
[2] Swenson S. Esprit de corps: turning vicious cycle virtuous. Talk presented at: NEJM Catalyst event Essentials of High-Performing Organizations; July 25, 2018; Institute for Healthcare Policy and Innovation, University of Michigan. https://catalyst.nejm.org/videos/esprit-de-corps-vicious-virtuous-cycle/. Accessed March 4, 2019.
[3] Talbot SG, Dean W. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. Stat website. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Published July 26, 2018. Accessed April 30, 2019.
[4] Wible P. Not “burnout,” not moral injury—human rights violations. https://www.idealmedicalcare.org/not-burnout-not-moral-injury-human-rights-violations/. Posted March 18, 2019. Accessed May 10, 2019.
[5] Shay J. Moral injury. Psychoanal Psychol. 2014;31(2):182–191. https://www.law.upenn.edu/live/files/4602-moralinjuryshayexcerptpdf.
[6] Wible P. Not “burnout,” not moral injury—human rights violations. https://www.idealmedicalcare.org/not-burnout-not-moral-injury-human-rights-violations/. Posted March 18, 2019. Accessed May 10, 2019.
[7] Eichacker C. Doctors quit EMMC as changes leave less time with patients, push morale to ‘all-time low.’ Bangor Daily News. May 13, 2019. https://bangordailynews.com/2019/05/13/news/bangor/doctors-quit-emmc-as-changes-leave-less-time-with-patients-push-morale-to-all-time-low/. Accessed May 14, 2019.
[8] DeChant P. Management burnout. www.pauldechantmd.com/management-burnout/. Posted April 26, 2019. Accessed April 29, 2019.
[9] Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. [Epub ahead of print 28 May 2019] 170:784–790. https://annals.org/aim/article-abstract/2734784/estimating-attributable-cost-physician-burnout-united-states. Accessed June 12, 2019.
[10] Taking action against clinician burnout: A systems approach to professional well-being. Slide 19. National Academy of Medicine. https://nam.edu/wp-content/uploads/2019/10/Public-release-PPT-10-23-19.pdf. Published October 23, 2019. Accessed October 25, 2019.
[11] Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146. https://www.mayoclinicproceedings.org/article/S0025-6196%2816%2930625-5/pdf.
[12] Berg S. How collaboration with IT cut 1,500 clicks a day per physician. American Medical Association. https://www.ama-assn.org/practice-management/digital/how-collaboration-it-cut-1500-clicks-day-physician. Published March 7, 2019. Accessed May 1, 2019.
