‘We must act’: Physician burnout reaches ‘crisis levels’ in COVID-19 aftermath
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On Oct. 24, 2023, Debra Houry, MD, MPH, chief medical officer and deputy director for program and science at the CDC, issued a grim warning to members of the media: Burnout among health care workers “has reached crisis levels.”
“The COVID-19 pandemic only intensified many health workers’ long-standing challenges and contributed to new and worsening concerns including compassion, fatigue, depression, anxiety, substance use disorders and suicidal thoughts,” Houry said during a CDC press briefing. “While usually health workers care diligently for others in their time of need, it is now our nation’s health workers who are suffering, and we must act.”
Source: Jonathan Ripp, MD, MPH
According to a CDC Vital Signs report from Nigam and colleagues, more than double the number of health workers reported harassment at work in 2022 than in 2018, including threats, bullying or verbal abuse from patients and coworkers that generate a hostile work environment.
Critically, the report found that 46% of all health care workers reported that they often felt burned out in 2022, a stark increase from 32% in 2018. Moreover, 44% of health care workers reported that they intended to look for a new job in 2022 — a jump from 33% in 2018 — even as the percentage of workers in every other profession who voiced their intention to find a new job actually dropped from 19% to 14% over the same time period.
“When you look at health care workers vs. other essential workers, what was so striking about the findings of this study were that nearly half of health workers intended to look for a new job in 2022, whereas with other essential workers, there wasn’t that change,” Houry said. “I think that this speaks to the uniqueness of the health care setting, as it really struck health care workers hard.”
Provider burnout — in gastroenterology and other specialties — had been an ongoing issue even before the COVID-19 pandemic. But the stresses of the pandemic have pushed the health care system “to the brink” and health workers and their families “to the tipping point” by failing to account for their mental health, Houry said in the press briefing.
‘Dirty Secret’ of Patient Care
“Health care has been sort of late to this idea of creating better work environments,” L. Casey Chosewood, MD, MPH, director of the Office for Total Worker Health at the CDC’s National Institute for Occupational Safety and Health, said during the CDC press briefing.
“After the pandemic, workers really demanded it — better commutes, better telework opportunities, better quality of the work/life fit — but health care, in general, has been late to that sort of movement.”
He added: “I think it’s because many felt that health care workers were sort of immune to some of these challenges. They are incredibly resilient as a workforce, but at the end of the day, health workers are human and they are telling us that they really can’t do any more, and that we must address the system.”
The burden on gastroenterology providers was hefty even before the pandemic: With nearly half of the current GI workforce aged 55 years or older, a sizeable proportion of gastroenterologists are set to retire within the next two decades; yet, there has not been commensurate growth in GI fellowship positions to fill these vacancies. Moreover, as a victim of their own successful calls for colonoscopy screening, GI providers are inundated with increased demand for GI care spread among a dwindling workforce.
COVID-19 exacerbated these stressors in the system, delaying routine GI care as well as surgeries, screening and surveillance exams, which has left the shrinking pool of GI providers wading through a colossal backlog while denying timely access to consultative appointments and cancer screening exams for new patients.
Saddled with longer work hours, a bottleneck of administrative work demands and growing exposure to workplace abuse and harassment, clinicians have struggled to deliver high-quality patient care. The cost has been their own mental well-being.
“The dirty secret of medicine is that hospital administrators know that good clinicians are the type of people who will do whatever it takes to make sure care is delivered to a certain standard, even if they are short-staffed or shorthanded,” Kenneth G. Saag, MD, MSc, professor of medicine and Jane Knight Lowe Endowed Chair in the division and department of medicine at the University of Alabama at Birmingham, told Healio Gastroenterology. “This is how we are programmed.”
The implication is that employers have historically worked physicians and other advanced care providers beyond their capacity, often with little relief for stress or burnout — and their associated consequences. However, given the shift toward recognizing the importance of work-life balance, this may no longer be acceptable.
“Because of a growth in the literature on this topic, we have made great strides in making this issue resonate with hospital and health system leadership,” Jonathan A. Ripp, MD, MPH, senior associate dean for well-being and resilience and chief wellness officer at the Icahn School of Medicine at Mount Sinai, said. “At this point, you would be hard pressed to find a hospital administrator who does not recognize burnout as a significant problem.”
‘A Moral Imperative to Fix Burnout’
In a longitudinal cohort study published in the Annals of Family Medicine, Willard-Grace and colleagues found that 53% of primary care providers reported burnout. Burnout, in turn, predicted clinician turnover (adjusted OR = 1.57; 95% CI, 1.02-2.4), as did low engagement vs. high engagement (aOR = 0.58; 95% CI, 0.33-1.04).
Ripp expanded on this concept of “engagement” as a way of understanding how administrators and employees communicate.
“The less you engage with hospital leadership, and the further away you are from decision-making, the more likely you are to think that they do not care about you as a person,” he said, noting that these feelings of isolation and abandonment can contribute to burnout. “But these things are never black and white.”
According to Ripp, hospital administrators have multiple priorities and difficult jobs, and for most there is “a moral imperative to fix burnout.”
“They lose sleep knowing that their employees are suffering,” he said.
However, this is not the only reason hospital administrators lose sleep.
“They realize that burnout impacts not only individuals but the functioning of their system, which includes the finances of their organization,” Ripp said.
What this means is that when employees are overworked and unhappy, they are either less productive or they quit. Both outcomes affect the overall system, including the financial bottom line.
The data bear this out. In a paper published in Annals of Internal Medicine, Han and colleagues concluded that approximately $4.6 billion in costs related to physician turnover and reduced clinical hours in the United States each year can be attributed to burnout. Meanwhile, the researchers estimated the annual cost associated with burnout related to turnover and reduced clinical hours, at an organizational level, to be approximately $7,600 per employed physician each year.
Daniel F. Battafarano, DO, adjunct professor of medicine at University of Texas Health San Antonio and professor of medicine at Uniformed Services University, explained how burnout leads to turnover.
“If the work environment is chronically unhealthy and inflexible, this makes self-care challenging,” he said. “Changing jobs may be the only solution.”
Recognizing that burnout affects both people and finance is the first step hospital administrators must take.
“The question is, what can they do?” Ripp said.
‘Align the Priorities’
Placing someone in charge of wellness is one place to start. In a paper published in The New England Journal of Medicine, Brower and colleagues described the importance of incorporating a chief wellness officer (CWO) in any given health system. They wrote that CWOs have been critical in addressing staff needs throughout the COVID-19 pandemic.
According to Brower and colleagues, a good CWO can recognize evolving sources of worker anxiety and deploy support resources to mitigate that anxiety. These officers also should participate in operational decision-making.
Although some administrators may view keeping their staff happy and saving money as an either/or proposition, Ripp, as a CWO himself, understands this is not the case.
“You have to align the priorities,” he said. “If your workforce is working more efficiently, you are going to have a high-value, productive system and people who are happier.
“Recognizing and thanking people is just one part of it,” Ripp added. “Listen to people’s complaints and then follow up words with actions. Partner with operational teams to improve the well-being infrastructure within your organization.”
Again, the key here is not just knowing the problem, but acting on it as well.
According to Battafarano, there is still much work to be done in terms of putting words into actions.
“Health care administrations have been slow to act effectively on improving the overall health care work environments despite mandating training modules or similar solutions,” he said.
However, the onus of action at the systemic level does not fall entirely on administrators, Battafarano added. Physician leaders need to “step up” as well, and “redirect the priorities” of health care while making them clear to the people who run the business side of the health system, he said.
Just Say ‘No’
“We don’t just want to treat workers who are suffering; we want to prevent that harm to all workers in the first place,” Chosewood said. “The ultimate goal is to build a sustainable infrastructure for future generations of health workers that optimizes the culture of health care settings. Patients in our communities and, really, all of us will fare better when our health workers are thriving.”
A paper published by West and colleagues in the Journal of Internal Medicine lists a few suggestions for physician self-care, including “mindfulness-based stress reduction” and “small-group programs to promote community, connectedness and meaning.”
“Integrative personal stress relievers like exercise, reading, creative writing, meditation or spiritual practice, family time or a combination is key for each individual,” Battafarano said, adding that healthy programmed social interactions may benefit other practitioners.
That said, physicians and nurses have a long history of not taking their own advice.
“Nurses are prone to ignore their own needs and power through, putting ourselves on the back burner,” Carrie Beach, BSN, RN-BC, a registered nurse at the Columbus Arthritis Center in Ohio, told Healio Gastroenterology. “We should not do that.”
However, simply telling providers to follow their own advice is just a starting point, according to Leonard Calabrese, DO, R.J. Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.
“Telling a burned-out physician to go home, meditate and exercise is a one-dimensional solution to a three-dimensional problem,” he said.
For Cathy Patty-Resk, MSN, RN, CPNP, a pediatric nurse practitioner at Wayne Pediatrics in Michigan, camaraderie among providers is another component of self-care.
“Our peers can remind us to take the time to care for ourselves,” she said.
Meanwhile, recognizing the characteristics of burnout and then acting on them is an essential part of the equation for Beach.
“If you notice that you are feeling any of the symptoms, speak up and be honest — with management and yourself,” she said. “If we do not take care of ourselves, the care of our patients will suffer.”
According to Beach, possibly the most impactful way to reduce burnout that she has learned is the ability to simply say, “no.”
“Saying no without feeling guilty has been life changing for me,” she said.
In fact, saying “no” can be a critical component of communication among staff members, regardless of their position or status.
Top-Down Solutions
Although the CDC Vital Signs report stressed the significant failings in health system strategies for alleviating burnout, it also drew attention to areas where there is still hope to improve the outlook for the health care workforce: Workers who reported that they trusted management and could rely on help from their immediate supervisor had fewer symptoms of burnout.
“Importantly, the Vital Signs report noted that poor mental health outcomes are less common when working conditions are positive, and where health workers have the potential to thrive,” Chosewood said. “Supportive work environments had a positive impact on health workers.”
Source: CDC
Changing the way employers operate and how supervisors manage health workers at a systemic level could play a key role in building a supportive work environment, even if funds are unavailable to bring in additional staff, Houry noted. Employers can preemptively address burnout by allowing “health workers to participate in decision-making on how the work is done and what aspects of the work should be targeted for improvement,” which builds trust in management.
Supervisors can likewise play a critical role in intercepting the significant drivers of burnout, by aiding their staff in accomplishing job tasks and “ensuring workers have enough time to complete their work,” Houry said.
“Inviting cross-level employee participation and input doesn’t have to cost a lot in terms of financial resources, but it may require a shift in thinking for leadership,” Houry said. “Health workers dedicate themselves to caring for us, our families and our communities, and they are pouring from an empty cup. By improving work conditions and work design, we can have a positive impact on health worker well-being and mental health, and retain a critical asset to the nation’s health system and public health.”
Hospital and health system leadership must also do a better job of taking responsibility for the mental health needs of their workers, noted Chosewood. The stigma of mental health care remains a common barrier preventing clinicians from seeking the appropriate mental or behavioral health care to deal with burnout, and “intrusive mental health questions” on hospital credentialing applications only reinforce the idea that clinicians are not permitted to have mental health concerns.
Providers, as with patients, are entitled to their own struggles with compassion fatigue, depression, anxiety, substance use disorders and suicidal thoughts without concerns of losing their positions. Auditing and changing hospital credentialing application questions to expunge any bias against mental health care would go a long way in reaffirming for health care workers that leadership support their mental well-being.
“There tends to be quite a bit of stigma still associated with admitting that you have depression or seeking help,” Chosewood said. “As a health worker, you are supposed to be above those concerns, but in truth, obviously it’s a critical issue that people feel comfortable getting the help they need.”
‘Good Starting Point’
Within days of its press briefing on the burnout crisis, the CDC’s National Institute for Occupational Safety and Health (NIOSH) unveiled its Impact Wellbeing campaign, the first federal initiative of its kind to provide hospitals with “evidence-informed resources” to reduce health care worker burnout.
The CDC highlighted three key resources for hospital leaders:
- The NIOSH Worker Well-Being Questionnaire, which can show how a workforce is doing and help to identify ways to improve worker well-being
- The Leadership Storytelling Guide, which can help leaders publicly talk about their own experiences and concerns with mental health and advocate staff to do the same
- Total Worker Health Strategies, which can train front-line staff on how to help health care workers balance work and home responsibilities
Among these, Chosewood recommended the NIOSH questionnaire as “a very good starting place” for hospital leaders to assess the well-being of their workers.
“It’s really the first-of-its-kind measure to look at many aspects of worker well-being, including their physical health, the workplace climate, their interactions with peers, coworkers and managers,” he said. “It’s a very simple 15-minute, 68-item survey that gives organizations a lot of very valuable information.”
Although the CDC has provided these actionable steps to implement quality improvements and set up new workflows that could curb future burnout in the health care workforce, in the end, the decision rests with employers on whether the mental well-being of their workers is valued enough to change the current paradigm.
“We are calling on employers to take this information to heart and take immediate preventive actions,” Chosewood said. “To label our current and long-standing challenge a ‘crisis’ is an understatement. Many of our nation’s health care systems are at their breaking point. Staffing crises, lack of supportive leadership, long hours of work and excessive demands and flexibilities in our nation’s health systems all must be addressed.”
- References:
- Brower KJ, et al. NEJM Catal Innov Care Deliv. 2021;doi:10.1056/CAT.20.0612.
- Han S, et al. Ann Intern Med. 2019;doi:10.7326/M18-1422.
- Nigam JAS, et al. MMWR Morbid Mortal Wkly Rep. 2023;doi:10.15585/mmwr.mm7244e1.
- West CP, et al. J Intern Med. 2018;doi:10.1111/joim.12752.
- Willard-Grace R, et al. Ann Fam Med. 2019;doi:10.1370/afm.2338.
- For more information:
- Daniel F. Battafarano, DO, can be reached at dbattafarano@gmail.com.
- Carrie Beach, BSN, RN-BC, can be reached at carrieeburke@hotmail.com.
- Leonard Calabrese, DO, can be reached at calabrl@ccf.org.
- Cathy Patty-Resk, MSN, RN, CPNP, can be reached at cathy.resk@icloud.com.
- Jonathan A. Ripp, MD, MPH, can be reached at jonathan.ripp@mountsinai.org.
- Kenneth G. Saag, MD, MSc, can be reached at ksaag@uabmc.edu.
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