Addressing physician burnout ‘a moral imperative’
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Last year, U.S. Surgeon General Vivek Murthy, MD, issued an advisory on health worker burnout and well-being, declaring the situation a “crisis” and naming it a “top national priority.”
Provider burnout — in infectious diseases and other specialties — was an ongoing issue since before the COVID-19 pandemic. However, the stresses of the pandemic proved to be a “uniquely traumatic experience” for health workers and their families, pushing them “past their breaking point,” Murthy said.
Source: Jonathan Ripp, MD, MPH
Despite a continuing decline in COVID-19 cases, burnout remains an issue for health care workers. For this month’s cover story, we checked in with physicians from ID and other specialties to discuss the causes of burnout and ways it can be mitigated.
‘Phone a friend’
According to Priya Nori, MD, FSHEA, FIDSA, medical director of antimicrobial stewardship and the outpatient parenteral antibiotic therapy (OPAT) program and associate professor of medicine and orthopedics at the Montefiore Health System and Albert Einstein College of Medicine, there are issues specific to ID that have impacted the specialty’s work/life balance and contributed to burnout.
“Perhaps more than others, ID specialists — physicians and pharmacists — incur a heavy ‘citizenship tax,’ where our altruism and willingness to help in personal and professional circles is frequently tested,” Nori told Healio | Infectious Disease News. “This was intensified during the COVID-19 pandemic.”
She highlighted some common reasons ID clinicians are susceptible to burnout — “heavy patient volume, excess documentation requirements, lower reimbursement rates compared with other specialties” — and noted that ID clinicians are often involved in non-relative value unit activities like infection prevention and antimicrobial stewardship.
“We spend [a lot of] time answering questions about colleagues’ kids’ rashes, COVID vaccine timing for elderly parents — the list goes on and on. All of these are nonreimbursable tasks. We’re often asked these questions in our downtime,” Nori said.
“Revenue is a driving factor in U.S. health care, so despite our ‘phone a friend’ status, we can feel less seen and heard — or feel limited negotiating power as our work is not high revenue,” she said. “Our efforts protect patients and help save money, which can be difficult to quantify in our current health care system.”
Recognizing the issues contributing to burnout is one thing — acting on them is another, experts indicated.
“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 short-handed,” said Kenneth G. Saag, MD, the Anna Lois Waters Endowed Chair of Rheumatology and division director of clinical immunology and rheumatology at the University of Alabama at Birmingham. “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. 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,” said Jonathan Ripp, MD, MPH, dean for well-being and resilience and chief wellness officer (CWO) at the Icahn School of Medicine at Mount Sinai in New York.
“At this point,” Ripp said, “you would be hard pressed to find a hospital administrator who does not recognize burnout as a significant problem.”
Another thing that both physicians and administrators recognize is that the electronic medical record system, with all of its flaws and administrative hurdles, is part of the problem, according to Leonard Calabrese, DO, RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.
“People who do not believe that the EMR has contributed to this are deluding themselves,” Calabrese said. “We are looking at a screen and not at the patient while the evaluation is going on.”
Although there are no easy solutions to minimizing burnout, experts believe it has to start from the top, with hospital administration addressing the problem at the systemic level.
‘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 impact 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 impacts 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, Bower and colleagues described the importance of incorporating a CWO in any given health system. They wrote that CWOs have been critical in addressing staff needs throughout the COVID-19 pandemic.
According to Bower and colleagues, a good CWO can recognize evolving sources of worker anxiety and deploy support resources to mitigate it. 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 that 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.”
According to Battafarano, there is still a lot of 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’
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.
Nori encouraged clinicians to identify the parts of their job that bring them the most joy and work with supervisors to maximize the time they spend on them, and to do the same in their personal lives.
“My beloved division chief, Dr. Liise-anne Pirofski, always says, ‘Focus on controlling the things you can control,’ meaning that we can choose how we respond to difficult circumstances, like harsh feedback, and so on,” Nori said. “Only we determine how we feel and how we react. That is in our control, and it’s time we exercise that.”
However, simply telling providers to follow their own advice is just a starting point, according to Calabrese.
“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 rheumatology 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 Carrie Beach, BSN, RN-BC, president of the Rheumatology Nurses Society and staff rheumatology nurse at the Columbus Arthritis Center in Ohio.
“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 the communication among staff members, regardless of their position or status.
‘Good lines of communication’
Communication starts with the way the organization is set up, according to Saag.
“The right people doing the right things at the right time can be hugely beneficial,” he said.
For example, Saag’s organization employs registered nurses in their call center to handle inquiries from patients. This saves time for physicians to see patients in person while simultaneously allowing nurses to use their expertise in patient care.
“Nurses have a fairly broad scope of practice,” Saag said. “Allow your doctors and advanced practice providers to work at the top of their practice.”
The EMR is tied into the association between operations and employee happiness, according to Saag.
“The EMR has been a major driver of burnout,” he said. “We spend so much time treating the medical records. There needs to be a general overhaul of patient documentation.”
Although voice-activated software and other technological solutions to the EMR problem are potentially on the horizon, Saag stressed that these solutions will take time to improve workflow.
“We are at a rather primitive stage of the EMR,” he said. “Figuring this out will be essential to allowing doctors and advance practice providers to perform at the top of their skill set rather than doing clerical work.”
Having adequate staff to perform that clerical work — including emails, copays and prior authorizations — can also help physicians and nurses do what they do best, which is to “think about complicated medical problems,” according to Saag.
“I recognize that not every organization will have the resources for this kind of staffing,” he said. “But you need to look at your organization in a systematic and judicious way to make sure everyone’s skills are being optimized.”
Implementing components of the doctor-patient relationship — particularly shared decision-making — into the workplace can also be beneficial, according to Beach.
“Shared decision-making is a concept that we often talk about when it comes to the provider-patient relationship,” she said. “This idea can also be extremely helpful in the leadership-nursing relationship.”
When nurses feel like they are involved in the decisions of the practice — especially those decisions that will directly impact their workflow or responsibilities — they are more likely to feel valued and empowered to “go above and beyond,” Beach said.
‘ID altruism bubble’
In many ways, the COVID-19 pandemic brought uncommon attention to the field of ID.
“Outside of the last few years, our work has remained in the background, supporting our hospital heavy hitters like transplant, oncology and orthopedics,” Nori said.
With the increased recognition came an increase in what Nori called the “ID citizenship tax” — the continuous development, updating and disseminating of COVID-19 protocols while other specialties may have experienced a “waxing and waning” of pandemic-related stressors, depending on their activities during the pandemic.
“We spent countless hours researching, preparing, and educating our colleagues on rapidly evolving public health guidance,” Nori said. “These were largely unreimbursed, yet unrelenting functions. We rapidly became trusted content experts, yes, but at quite a cost to our mental and sometimes physical well-being.”
Despite regularly reporting high levels of burnout, ID clinicians also have some of the highest reported levels of job satisfaction. More than half of adult and pediatric ID faculty surveyed by Nori and colleagues for a 2019 study met the criteria for burnout. However, in the same survey, more than 90% of respondents reported being satisfied with their job.
“Dr. Judy Guzman-Cottrill, a well-known pediatric ID specialist in Portland, Oregon, explains that ‘the ID altruism bubble’ could burst if ID experts continue to feel undervalued for their contributions,” Nori said. “Many argue that we must focus on the work we love, learn to let go of tasks without personal value and empower our people to negotiate assertively.”
According to Nori, the major barriers to improving the quality of life in ID — including relative value units, documentation, insurance red tape and staff attrition — are often out of clinicians’ hands.
“These organizational and systemic issues that reflect the state of U.S. health care in general, threaten the value of our work and self-worth and increase moral injury,” Nori said. “Feeling uncertain about the future of health care can contribute to the demoralization we feel.”
Self-advocacy and preservation
Amid the decline in COVID-19 — and mpox — Nori said many ID specialists have returned to caring for patients in person and have been able to “focus on teaching, research, training and other activities we love.”
“For me, that means caring for OPAT patients, helping to oversee an antimicrobial stewardship program and ID fellowship program, plus teaching and mentoring house staff, and immersing myself in professional society activities,” Nori said. “I’ve recently taken on journal editorial roles, helping to provide a platform for the academic contributions of the ID community.”
Nori said there has been more of a focus on teaching self-advocacy and preservation in ID fellowship.
The Infectious Diseases Society of America “continues to focus on systemic issues impacting our health and well-being,” she said. “Their policy and advocacy focusing on workforce sustainability, reimbursement, loan repayment, funding for [antimicrobial resistance] prevention programs is important to our future. IDSA’s ID Physician Compensation Initiative gives us tools to advocate for ourselves, improve our professional circumstances, and sustain ourselves long term.”
- References:
- Han S, et al. Ann Intern Med. 2019;doi: 10.7326/M18-1422.
- Nori P, et al. Antimicrob Steward Healthc Epidemiol. 2022;doi:10.1017/ash.2022.240.
- Nori P, et al. Open Forum Infect Dis. 2019;doi:10.1093/ofid/ofz092.
- 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 Battafarano, MD, 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.
- Priya Nori, MD, FSHEA, FIDSA, can be reached at pnori@montefiore.org.
- Cathy Patty-Resk, MSN, RN, CPNP, can be reached at cathy.resk@icloud.com.
- Jonathan Ripp, MD, can be reached at jonathan.ripp@mountsinai.org.
- Kenneth Saag, MD, can be reached at ksaag@uabmc.edu.
Click here to read the At Issue, "How are ID pharmacists dealing with burnout?"
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