When physi­cians burn out, so­lu­tions are elu­sive

Sup­port groups can’t counter the root causes of a crisis

Modern Healthcare - - NEWS - By El­iz­a­beth Whit­man

Phone calls in the mid­dle of the night and on week­ends even­tu­ally over­whelmed Dr. Bar­bara Mor­ris, a geri­a­tri­cian who served five years as med­i­cal director of a re­tire­ment com­mu­nity in Colorado.

It wasn’t that the calls were in­ap­pro­pri­ate. She sim­ply couldn’t en­dure re­spond­ing to the con­stant bar­rage, and the health sys­tem where she worked had no plans to add more staff.

“I ac­tu­ally loved that job,” Mor­ris re­called. “But you hit your wall. And you re­al­ize you can’t con­tinue if you’re not go­ing to get the re­sources that you need.” About four years ago, she started look­ing for a new job, found one and quit.

Why Mor­ris hit her wall is ob­vi­ous to her in ret­ro­spect: She was burned out. That ex­pe­ri­ence is not unique among physi­cians. And as awareness grows about burnout and its de­struc­tive con­se­quences for doc­tors and pa­tients, ideas to ad­dress the prob­lem have pro­lif­er­ated. But no or­ga­ni­za­tion has ar­rived at a set of sus­tain­able so­lu­tions.

Health­care sys­tems, prac­tices and med­i­cal schools are de­ploy­ing an ar­ray of tac­tics to help physi­cians cope with the unique stress of mod­ern medicine. Some pro­grams of­fer reg­u­lar mo­ments of re­flec­tion, con­nec­tion with other doc­tors or other sources of cathar­sis.

Health­care lead­ers main­tain that us­ing other meth­ods to en­gage physi­cians will mit­i­gate the main driv­ers of burnout— elec­tronic health records and mul­ti­ply­ing re­port­ing re­quire­ments—in a more sys­tem­atic fash­ion. “We have to, in this pro­fes­sion, find a bal­ance,” Mor­ris said. “There are on­go­ing strug­gles that we don’t have an­swers to.”

Such strug­gles threaten doc­tors and pa­tients alike. Burned-out doc­tors don’t col­lab­o­rate as well with col­leagues and they make more mis­takes, which can harm pa­tients. Some­times, they exit the pro­fes­sion al­to­gether, deal­ing a blow to an in­dus­try with a loom­ing short­age of nearly 95,000 physi­cians in the next decade.

Some piece­meal so­lu­tions ad­dress in­di­vid­ual burnout, but few ef­forts tar­get sys­temic change. Those that do of­ten face op­po­si­tion.

Pro­pos­als to ex­pand the work of clin­i­cians who aren’t physi­cians, such as nurse prac­ti­tion­ers and physi­cian as­sis­tants, to fur­ther treat pa­tients and pre­scribe more med­i­ca­tions have met with re­sis­tance from doc­tors’ groups. Al­though these changes could help al­le­vi­ate burnout and al­low clin­i­cians to prac­tice at the top of their li­censes, physi­cian so­ci­eties see them as in­cur­sions into physi­cian ter­ri­tory.

The Amer­i­can Med­i­cal As­so­ci­a­tion and the Amer­i­can Academy of Fam­ily Physi­cians have is­sued cau­tious warn-

ings about ex­pand­ing nurse prac­ti­tion­ers’ scope of prac­tice to pre­scribe con­trolled sub­stances, for in­stance. When Cal­i­for­nia passed a law in Fe­bru­ary al­low­ing phar­ma­cists to pre­scribe birth con­trol, the Amer­i­can Congress of Ob­ste­tri­cians and Gyne­col­o­gists op­posed it, al­though it ad­vo­cated for fully over-the-counter con­tra­cep­tion.

“There’s a lot of fo­cus on build­ing in­di­vid­ual re­silience,” Dr. Te­jal Gandhi, CEO of the Na­tional Pa­tient Safety Foun­da­tion, said of ef­forts to counter burnout. “We think there needs to be a fo­cus on sys­tems as well,” she said, call­ing for re­design­ing pro­cesses in health­care to make work­flows more ef­fi­cient. Physi­cian burnout is a “pre­con­di­tion to pa­tient safety” that has been “ne­glected,” she added.

In this tem­pest of dif­fer­ent views, the lone area of con­sen­sus seems to be that burnout is get­ting worse. In 2011, a sur­vey of nearly 7,000 physi­cians by the Amer­i­can Med­i­cal As­so­ci­a­tion and the Mayo Clinic found that just over 45% met cri­te­ria for burnout. Three years later, a fol­low-up sur­vey found signs of burnout among nearly 55% of physi­cians.

Burnout is also in­ten­si­fy­ing, the Med­scape Life­style Re­port 2016 found when it asked physi­cians to rate the sever­ity of their ex­haus­tion. “Too many bu­reau­cratic tasks,” “spend­ing too many hours at work” and “in­creased com­put­er­i­za­tion of prac­tice” were the top three causes; other cul­prits in­cluded com­pas­sion fa­tigue, too many dif­fi­cult pa­tients and “feel­ing like just a cog in a wheel.”

Some sources of burnout are sim­ply in­her­ent in mod­ern health­care. Doc­tors and ad­min­is­tra­tors alike sug­gest a fun­da­men­tal dis­con­nect be­tween health­care as a busi­ness and the al­tru­ism en­tic­ing many doc­tors to medicine.

Oth­ers stem from U.S. govern­ment ef­forts to con­vert its health­care pay­ments into a sys­tem based on value rather than vol­ume. In or­der to avoid re­duc­tions in Medi­care re­im­burse­ments un­der sev­eral of these ini­tia­tives, doc­tors have to sub­mit qual­ity data from EHRs that many find time­con­sum­ing and con­fus­ing.

The health IT fac­tor

When doc­tors are re­quired to use health IT more, some adapt seam­lessly. Oth­ers find their work­flow in­ter­rupted, said Julie Tay­lor, CEO of Alaska Re­gional Hos­pi­tal, An­chor­age.

A re­cent study pub­lished in the An­nals of In­ter­nal Medicine ob­served 57 physi­cians. The study found that they spent nearly 50% of their time on EHR and desk work, and just 27% of their time with pa­tients. Even in the ex­am­i­na­tion room, physi­cians spent 37% of their time on EHR and desk work.

At its most extreme, burnout is a mat­ter of life and death. Ev­ery year, 300 to 400 physi­cians in the U.S. com­mit sui­cide. Fe­male physi­cians are 2.3 times more likely to die by their own hand than women in the gen­eral pop­u­la­tion; male physi­cians are 1.4 times more likely.

The prob­lem is well-de­fined, but so­lu­tions are not. Ad­dress­ing burnout at var­i­ous lev­els car­ries with it a host of bar­ri­ers that co­a­lesce into a sin­gle tidy co­nun­drum: If el­e­ments of health­care that drive burnout are in­evitable, is burnout in­evitable too? Af­ter all, EHRs are not go­ing away.

Yes and no, doc­tors say. “There are con­trib­u­tors to burnout that we can’t mod­ify,” said Dr. Al­li­son Lud­wig, as­sis­tant dean for student af­fairs at the Al­bert Ein­stein Col­lege of Medicine in New York and an ex­pert on med­i­cal student burnout.

For in­stance, a doc­tor might have to tell one pa­tient they have cancer, then step into the next room to see an­other pa­tient and quickly don a cheery face. “That’s never go­ing to go away in medicine,” Lud­wig said.

Med­i­cal cul­ture is prob­lem­atic too. When doc­tors stand up for them­selves, the in­ter­pre­ta­tion is of­ten, “That per­son’s a prob­lem,” Mor­ris, the geri­a­tri­cian, said. “I think our pro­fes­sion needs to get off of that and un­der­stand that peo­ple are set­ting bound­aries they need to set for them­selves.”

Med­i­cal schools should help stu­dents cul­ti­vate re­silience early on, Lud­wig said. Its student well­ness pro­gram, Wel­lMed, aims to help stu­dents de­velop healthy, bal­anced habits and at­ti­tudes to make them “bet­ter heal­ers and role mod­els for their pa­tients.”

In sev­eral health sys­tems in Colorado, not-for-profit Lu­munos has been rolling out its col­leagues pro­gram, which fosters re­la­tion­ships be­tween physi­cians. Through a com­pi­la­tion of weekly emails, monthly con­ver­sa­tions led by a fa­cil­i­ta­tor and oc­ca­sional re­treats, it guides them in healthy re­flec­tion.

Mor­ris, who is now at Cen­tura Health Physi­cian Group and is in­volved in the Lu­munos pro­gram, said she found the pro­gram highly sup­port­ive since it helped doc­tors de­velop re­la­tion­ships with each other. Ul­ti­mately, she said, it also ben­e­fits pa­tients to have hap­pier doc­tors.

Lud­wig ac­knowl­edged that the jury is still out on which pro­grams work. “We don’t know what the suc­cess of any of this is. We just keep try­ing stuff,” she said. “It’s a lot of trial and er­ror at this point.”

‘Un­der de­vel­op­ment’

Anti-burnout pro­grams are nei­ther wide­spread nor ro­bust. When Mod­ern Health­care asked 93 health­care CEOs as part of its third-quar­ter Power Panel sur­vey whether their or­ga­ni­za­tions had pro­grams to ad­dress physi­cian burnout, just less than 36% said yes. Nearly 28% had not, while slightly more than 36% said such pro­grams were “un­der de­vel­op­ment.”

Of those who did have pro­grams, 81% said their ef­fec­tive­ness “re­mained to be seen.”

The C-suite per­spec­tive holds that a lack of con­trol in­duces burnout. Some ex­ec­u­tives ad­vo­cate an ap­proach to ad­dress­ing burnout that em­pha­sizes physi­cian em­pow­er­ment rather than cop­ing mech­a­nisms.

“I be­lieve that that feel­ing of help­less­ness is re­ally at the root of burnout,” said Dr. Mark Keroack, CEO of Baystate Health, a not-for-profit, in­te­grated health­care sys­tem based in Spring­field, Mass.

To give physi­cians a greater sense of con­trol, Baystate of­fers a physi­cian lead­er­ship academy that trains them in com­mu­ni­ca­tion and other man­age­ment skills. “It ba­si­cally em­pow­ers doc­tors to be part of shap­ing the way care is de­liv­ered,” Keroack said. “The least burnt-out physi­cians are the ones who are most in­volved in mak­ing the changes hap­pen.”

Other CEOs voice sim­i­lar views. “It’s a ques­tion about, ‘Do I have con­trol over my en­vi­ron­ment?’ ” said Mary Brain­erd, CEO of HealthPart­ners, a not-for-profit health­care or­ga­ni­za­tion based in Min­nesota. She said HealthPart­ners has spe­cific pro­grams to en­gage physi­cians and al­low them to have an im­pact on the or­ga­ni­za­tion, as well as sim­plify tech­nol­ogy use.

Draw­ing com­fort from art

Tap­ping into the power of art—es­pe­cially words—is the ba­sis for yet an­other ap­proach to shore up doc­tors’ spir­its.

Pulse: Voices from the Heart of Medicine is an on­line mag­a­zine “fo­cused on the ex­pe­ri­ence of medicine as told by the peo­ple ex­pe­ri­enc­ing it,” said Dr. Paul Gross, Pulse’s founder and edi­tor-in-chief. Doc­tors, nurses, pa­tients and stu­dents alike can con­trib­ute.

Writ­ing and shar­ing are not meant to be merely cathar­tic, ex­plained Gross, who is also an as­sis­tant pro­fes­sor in the fam­ily and so­cial medicine depart­ment at Mon­te­fiore Health Sys­tem in New York.

“Pol­i­cy­mak­ers read sto­ries like this,” Gross said, nam­ing a former CMS ad­min­is­tra­tor as an ex­am­ple. “It makes peo­ple who are mak­ing de­ci­sions about leg­is­la­tion and pol­icy to think … ‘Oh, we’ve got a prob­lem.’ ” Pulse sto­ries with pol­icy im­pli­ca­tions have been reprinted by es­tab­lished main­stream out­lets such as the Wall Street Jour­nal, as well as the pop­u­lar med­i­cal site Kev­inMD, Gross said.

“We look for sto­ries that have sys­temic im­pli­ca­tions,” Gross said. “It’s not just fix­ing in­di­vid­u­als.”

If any­thing about the fu­ture of health­care is cer­tain, it’s that the list of pay­ment re­form ini­tia­tives will grow, and they will tie physi­cians more closely to EHRs, which re­main far from user-friendly. As of 2014, only 74% of physi­cians in the U.S. had adopted cer­ti­fied EHRs, mean­ing that EHR-re­lated burnout still awaits a quar­ter of physi­cians.

In many ways these changes will lead to a bet­ter health­care sys­tem, said Dr. Dar­rell Kirch, CEO of the As­so­ci­a­tion of Amer­i­can Med­i­cal Col­leges. At the same time, some physi­cians feel these changes “are tak­ing the heart or the soul out of medicine,” he added. And un­til more sys­tem­atic so­lu­tions arise, the con­se­quences of those frus­tra­tions can be dev­as­tat­ing.

“Our big­gest chal­lenge is to help the work­force come through it and get to the other side,” Kirch said. “We can’t af­ford to lose them.”

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