Ways to reduce physician burnout

In 2019, experts at Harvard and other health organizations in the United States declared physician burnout a public health crisis.

The issue of burnout has only worsened amid the pandemic, as physicians struggle to maintain patient volume while being understaffed, stay up to date on changing guidelines and treatment options for COVID-19, address vaccine hesitancy and more.

“When I started in medicine, HIV was at its peak. That was a very challenging time, but nothing like what we’re seeing with COVID,” Eugene Yang, MD, FACC, a professor of medicine at the University of Washington, told Healio. “Not only do we have to reduce the severity of illness and transmission, but we are also fighting politics and public misinformation about vaccines. There is nothing that comes close to approximating the level of stress in the health care system right now.”

According to Yang, the anguish is compounded by the additional strain of supporting colleagues who are unable to work due to COVID-19 illness or quarantine and severe staffing shortages in the hospitals and clinics.

Margot L. Savoy, MD, MPH, FAAFP, senior vice president for education at the American Academy of Family Physicians and an associate professor of family and community medicine at the Lewis Katz School of Medicine at Temple University, said she has lost more patients amid COVID-19 than she did in the 20 years before the pandemic.

“Grief, moral injury and not really being sure whether society cares if you live or die as long as you are there to support their needs” are taking an emotional toll and exacerbating burnout, Savoy, who is also a Healio Primary Care Peer Perspective Board member, said in an interview.

Resources for combating burnout

According to The Physicians Foundation, 61% of physicians in the U.S. reported burnout in 2021, “an incredible increase” from the 40% who reported it in 2018.

Health care systems and practices across the country are promoting strategies to address burnout and improve well-being among physicians.

One online resource that is available to all physicians is the Mayo Well-Being Index, which can assess burnout and emotional health. After completing the tool’s short survey, users receive “a list of different treatment resources that are available at the local and national level,” said Lisa MacLean, MD, the director of physician wellness at the Henry Ford Health System in Detroit.

Stress First Aid is another tool, developed by researchers at the Veterans Affairs’ National Center for PTSD, said Peggy Chen, MD, MSc, MHS, a physician policy researcher at the RAND Corporation. It is a manual that provides a framework for engaging in self-care and coworker support. It can be used by teams and individuals within teams to identify stress reactions among team members and provide supports to help reduce poor long-term outcomes that may result from unhealthy stress.

At the Veterans Health Association, administrators are collecting information through the Employee Whole Health program to assess the needs of the health care team and find out “what matters most,” according to Kavitha Reddy, MD, FACEP, the program’s associate director.

“We also ask what they would like their environment, their relationships, their values, their nutrition and their professional development to look like,” Reddy said.

The VA has used this information to implement well-being resources, and it intends to create recommendations for system drivers of burnout, such as workplace flexibility and autonomy, based on feedback from the national taskforce to Reduce Employee Burnout and Optimize Organizational Thriving, or REBOOT, Reddy said.

Leaning on colleagues

Some health care facilities promote group activities like huddles. During these brief daily meetings, staff members discuss their tasks for the day, potential obstacles and possible solutions, according to Joseph R. Sellers, MD, FAAP, FACP, the chief physician executive of Bassett Medical Group in rural upstate New York.

“These huddles have brought some resiliency to our work units when things are very stressful,” he said.

At the University of Alabama at Birmingham (UAB), units implemented a number of wellness initiatives to help health care providers cope during COVID-19, said Irfan M. Asif, MD, chair of the university’s department of family and community medicine, associate dean for primary care and rural health, director of UAB’s primary care service line and a Healio Primary Care Peer Perspective Board member.

Asif encouraged providers to take advantage of UAB-wide mental health and wellness programs and provided regular updates and wellness resources to his team, as well as an informal virtual “coffee break” where faculty and staff members could ask questions or raise concerns. Family medicine clinics also organized “wellness walks” to encourage providers and staff to take breaks for exercise and enjoy time outside when possible.

“We try to schedule these across our different clinics at the same time, so that people can have a sense of togetherness,” he said.

Beginning this spring, the department will also host “wellness lunches” that will provide team members with a healthy lunch and optional wellness educational presentation. The first lunch will include a talk on flourishing given by a department faculty member, Asif said.

Marie Wilson, MSN, RN, an infection prevention specialist and member of the Association for Professionals in Infection Control and Epidemiology, said that just talking to colleagues can be therapeutic.

“Being in an environment where we truly felt like a family, where I know I have that trust and shared faith, was the only way I made it through some days,” she told Healio.

While Wilson seeks support from her coworkers, Sellers said his institution secured grant funding to create a peer-to-peer support program.

“We think that's an important step for people to share their stories,” he said. “The trained peer is there to help support you, hear you and to help keep your perspective on things.”

Steven P. Furr, MD, FAAFP, a family physician at a rural southwestern Alabama clinic, told Healio that delegating work is a good way to alleviate burnout.

“For a while, I’d have a to-do list with 50 items on it. Now I prioritize and figure out which of these things I really need to do tomorrow,” he said. “Before I ever go in to see a patient, my nurses have completely updated the patient’s medication list and problem list, so all I have to do is the exam, update the patient’s chief complaint, and then do the diagnosis and [offer solutions] to the problem.”

Chen noted that a shift to the patient-centered medical home model would be beneficial. This model provides team-based care, in which medical assistants and nurses take on some of the physicians’ tasks, she added.

Electronic health records

Another possible way to reduce burnout is to install shortcuts on electronic health records, which have long been cited as a major cause of burnout, Furr said.

“Taking 15 to 20 minutes to install a template can save typing a lot of notes or doing voice recognition,” he said.

The EHR shortcuts are a temporary fix, Furr added, but many say that more long-term solutions to EHRs are needed.

“Given the immense strain that clinicians are facing — particularly during the pandemic —we need to be addressing all systemic factors that we can,” Lisa J. Merlo, PhD, MPE, the director of wellness programs at the University of Florida College of Medicine, said in an interview. “The electronic health record is a prime target for intervention.”

Oliver T. Nguyen, a research coordinator in the department of health outcomes and behavior at H. Lee Moffitt Cancer Center & Research Institute, called for greater EHR reform such as changes to interoperability and a more user-friendly design that “identifies a sweet spot on how much information should be on the screen at the same time.”

How are smaller practices coping?

Some burnout reduction initiatives are harder for smaller practices to implement, David Pizzimenti, DO, a member of ABIM's Internal Medicine Board and an internist at the North Mississippi Medical Center, told Healio.

“With the challenges that we face in staffing, it’s hard to justify having a single person to support wellness,” he said.

In rural Kansas, Jen Brull, MD, FAAFP, and the leaders of four other primary care practices implemented a collaborative model where physicians step in to assist colleagues in other practices.

“We put into place a policy and workflow that when you go on vacation, your inbox work gets done by someone else,” she told Healio. “So, when you come back, you don't come back to piles and piles and piles of messages, or you are not trying to do it while you're on vacation.”

According to Vineet Arora, MD, a hospitalist who is also on the ABIM Board of Directors, burnout is not going to subside in rural areas until the COVID-19 pandemic is under control.

“In rural areas where vaccine and mitigation is not as well adopted, especially in certain parts of the south and Midwest where health care workers have less infrastructure to begin with, ... I know [the pandemic] has been very painful,” she said in an interview.

National efforts

National efforts are underway to combat physician burnout. Last month, the U.S. Senate passed The Dr. Lorna Breen Health Care Provider Protection Act to support evidence-informed practices for preventing suicide and burnout as well as mental and behavioral health and job satisfaction.

Also, in 2019, the AMA launched the Practice Transformation Initiative to fill knowledge gaps on interventions targeting burnout. The initiative involves collaborations with other organizations, including The Physicians Foundation, which is supporting state medical societies in helping member practices enhance job satisfaction while reducing burnout.

“The Physicians Foundation’s collaboration with the [AMA] in the Practice Transformation Initiative is a notable example of how institutions can create and encourage evidence-based, field-tested and targeted solutions to help guide physicians, care teams and health system leaders on developing and implementing strategies to optimize practice efficiencies, reduce burnout and improve professional well-being,” Gary Price, MD, the President of the Physicians Foundation, told Healio.

One specific example is the implementation of pre-visit laboratory testing at Washington Permanente Medical Group, which gives physicians the opportunity to discuss test results with patients during their appointment, according to Price.

“This streamlined administrative tasks and contributed to a reduction in the number of hours spent on indirect patient care by 3 hours,” he said. “Physicians reported they experienced an increase in both overall job satisfaction and value alignment with clinical leaders.”

Another example, Price said, involves transformation efforts at MultiCare, a nonprofit health care organization in Washington state, to streamline intake processes and lab work before patient visits.

“On average, they saved 1 minute per patient in Epic systems, a statistically significant improvement and something the physicians could really feel,” he said. “In 1 month, an OB/GYN saved 6.5 hours; a critical care physician saved 6.8 hours; and an endocrinologist saved 16 hours in their electronic health record.”

The Physicians Foundation also collaborates with ALL IN: Wellbeing First for Healthcare, which worked with the National Academy of Medicine to identify the top five actions that leaders should take to support health care workers.

“These evidence-based actions can be initiated within 3 months and build a foundation for a long-term system well-being strategy,” Price said.

Downstream effects of burnout

Without additional effective solutions to burnout, the physician workforce is at stake, experts said. Last year, the Association of American Medical Colleges predicted that in 2034, there would be a shortage of between 17,800 and 48,000 primary care physicians and a shortage of between 21,000 and 77,100 physicians from non-primary care specialties.

Janis Orlowski, MD, the group’s chief health care officer, told Healio that there was an 18% increase in medical school applicants in 2021 compared with the year before. However, this gain will likely be offset by a wave of physicians who will retire soon.

“About 40% of physicians are over the age of 60,” she said. “We see millennial physicians working just a few hours a week less than their older peers. You might think that is not that much of a difference, but when you do it across 100,000 physicians, we see a significant decrease in physician time.”

Arora said the pandemic has led to a surge in physicians leaving medicine altogether.

These physician shortages will almost certainly negatively impact patient care, Orlowski said.

“We are already seeing some specialties where it takes several weeks to get an appointment,” she said. “The concern is that delay in access will grow.”

References:

• AAMC report reinforces mounting physician shortage. https://www.aamc.org/news-insights/press-releases/aamc-report-reinforces-mounting-physician-shortage. Published June 11, 2021. Accessed Feb. 22, 2022.
• AMA fights burnout with new Practice Transformation Initiative. https://www.ama-assn.org/press-center/press-releases/ama-fights-burnout-new-practice-transformation-initiative. Published Sept. 15, 2019. Accessed March 16, 2022.
• Malasch Burnout Inventory. https://www.mindgarden.com/117-maslach-burnout-inventory-mbi. Accessed Feb. 28, 2022.
• Mayo Well-Being Index. https://www.mywellbeingindex.org/. Accessed Feb. 28, 2022.
• Medical school enrollment more diverse in 2021. https://www.aamc.org/news-insights/press-releases/medical-school-enrollment-more-diverse-2021. Accessed Feb. 22, 2022.
• Nguyen OT, et al. J Am Med Inform Assoc. 2021;doi:10.1093/jamia/ocaa339.
• Reducing physician burnout. https://www.va.gov/HEALTH/docs/REBOOT_Task_Force_Fact_Sheet_030122_508.pdf. Accessed March 16, 2022.
• Stress first aid for health care workers handbook. https://www.ptsd.va.gov/professional/treat/type/SFA/docs/SFA_Workbook_508.pdf. Accessed Feb. 2, 2022.
• The Physicians Foundation 2021 physician survey: COVID-19 impact edition: A year later. https://physiciansfoundation.org/physician-and-patient-surveys/the-physicians-foundation-2021-physician-survey/. Accessed Jan. 27, 2022.
• The Physicians Foundation Viewpoints: Physician Wellbeing. http://physiciansfoundation.org/wp-content/uploads/2020/01/PF-Issue-Brief-Physician-Wellbeing.pdf. Accessed March 16, 2022.
• Valid and reliable survey instruments to measure burnout, well-being and other work-related dimensions. https://nam.edu/valid-reliable-survey-instruments-measure-burnout-well-work-related-dimensions/. Accessed Feb. 2, 2022.