‘Moral imperative’ to address physician burnout emerges in wake of COVID-19 pandemic
On May 23, 2022, U.S. Surgeon General Vivek Murthy, MD, issued an advisory on health worker burnout and wellbeing, declaring the situation a “crisis,” and addressing it a “top national priority.”
Provider burnout — in rheumatology and other specialties — had been an ongoing issue dating back prior to 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 in a statement accompanying the advisory.
Source: Jonathan Ripp, MD, MPH
In rheumatology in particular, where an ongoing workforce shortage has been fueling burnout in many areas of the country, the pandemic has poured gasoline on what has been a pile of smoldering embers for some, and an already raging fire for others.
“We are seeing a lot of early retirements, with rheumatologists in their 50s and 60s deciding to hang it up or move to another area,” Kenneth G. Saag, MD, Anna Lois Waters endowed chair of rheumatology, and division director of clinical immunology and rheumatology at the University of Alabama at Birmingham, told Healio Rheumatology. “It is disturbing.”
Saag, who is also the immediate past president of the American College of Rheumatology, added that the COVID-19 pandemic caused many health care professionals to “reassess their work-life balance” as a form of not only self-care, but also self-preservation.
However, if any positives can be taken from the current situation, it is that the events of the last 3 years have pushed the issue of provider burnout to the forefront.
“The silver lining of the pandemic is that both physicians and health system administrators recognize the importance of the exhaustion and mental health issues that contribute to burnout,” Carrie Beach, BSN, RN-BC, president of the Rheumatology Nurses Society and staff rheumatology nurse at the Columbus Arthritis Center, in Ohio, told Healio Rheumatology.
That said, recognizing these issues is one thing — acting on them is another.
“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,” Saag said. “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,” said Jonathan Ripp, MD, MPH, dean for well-being and resilience, and chief wellness officer at the Icahn School of Medicine at Mount Sinai. “At this point, 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 H. 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.”
The EMR issue is just one part of the bigger picture regarding technology in rheumatology. COVID-19 quarantines advanced the use of telemedicine in the specialty and, in some ways, facilitated better communication with patients and increased access to care. However, it also may have increased the workload for already-overworked specialists.
Understanding these and other work-related concerns may hold the key to minimizing burnout in rheumatology. Although there are no easy solutions, many 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 reported that 53% of primary care providers reported low engagement and 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 the 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.
“These findings suggest substantial economic value for policy and organizational expenditures for burnout reduction programs for physicians,” Han and colleagues wrote.
The reason for the high cost of turnover is simple: It is cheaper to keep an employee on staff than it is to train a new one.
Daniel F. Battafarano, DO, chair of the ACR Workforce Solutions Committee, 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 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 Bower 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 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.”
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.
“Large-group, physician-led rheumatology clinic models have been more effective in minimizing the burnout in their staff by personalizing effective strategies and allowing input from their stakeholder employees,” Battafarano said.
‘We are All in This Together’
Like Battafarano and Ripp, Cathy Patty-Resk, MSN, RN, CPNP, a pediatric rheumatology nurse practitioner at Wayne Pediatrics, in Michigan, also believes that mitigating burnout is personal — and often connected to personal issues.
“The most important thing administrators in a health system can do is show their staff grace when it comes to personal and family illness and other unexpected daily life situations,” she told Healio Rheumatology. “Remember we are all in this together and doing the best we can.”
Administrators also should recognize that the current state of the economy is taking a toll on staff families, according to Patty-Resk.
“Let employees work from home part-time to save on gas if they have a job that does not require direct patient care,” she said. “Have plans in place for your staff who may need to be off work to care for children that are ill or in quarantine.”
Building teams with members that support one another is another step health systems and administrators can take, Patty-Resk added.
“Be creative,” she said. “If you do not have funds, bring in an industry partner for lunch or organize lunch time videos teaching yoga or techniques such as visualization and breathing exercises.”
Systems with funds, meanwhile, can organize drawings for gas cards, provide meals or bring in an actual yoga instructor, Patty-Resk added.
“Most importantly, thank your people for everything they do for the organization and for their patients,” she said. “We are in a caring profession and too many times we forget to show each other the grace needed. These steps not only can decrease staff stress but also promote loyalty and improve job satisfaction.”
A health system that places a premium on employee well-being can foster that same spirit among individual providers. Additionally, their staff may be more likely to engage in essential self-management activities to minimize their own feelings of burnout and make the whole organization more effective.
Just Say ‘No’
The suggestions for self-care presented to individual physicians in the literature will be of no surprise to the average rheumatology practitioner. A paper published by West and colleagues in the Journal of Internal Medicine lists a few of them, including “mindfulness-based stress reduction” and “small-group programs to promote community, connectedness and meaning.”
According to Battafarano, individual rheumatologists should be knowledgeable about themselves, their personal needs, their strengths and their weaknesses.
“Integrative personal stress relievers like exercise, reading, creative writing, meditation or spiritual practice, family time or a combination is key for each individual,” he 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,” Beach said. “We should not do 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 Patty-Resk, 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 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, noting that they can write certain prescriptions renewals and order bone density tests. “Allow your doctors and advanced practice providers to work at the top of their practice.”
Beach underscored this point with her own experience.
“I am extremely fortunate to work with a rheumatologist who recognizes my accomplishments, makes me feel appreciated and allows me to work at the top of my scope of practice,” she said. “It is important for rheumatologists to understand that when their nurse is having feelings of burnout, the whole practice can be impacted. Treat your nurses with respect, let them know they are valued, and recognize their true importance as an integral part of the care team.”
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.”
And 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.
As employees within health systems continue to improve lines of communication, another facet is also taking deep root in rheumatology — telemedicine.
The Solution to Burnout or ‘Technologically Disruptive’?
The advantages and disadvantages of tele-rheumatology continue to be debated, including within the pages (online and in print) of Healio Rheumatology.
According to Saag, telemedicine is another source of confusion and consternation the busy clinicians.
“It is unclear when it should be implemented and under what specific circumstances,” he said. “We need to better delineate how to best integrate it into a clinic along with in-person visits. For example, it can be technologically disruptive to do in a single session.”
Since the start of the COVID-19 pandemic, some patients have come to expect even evening phone calls or video conferences with their providers after hours. A rheumatologist may be stuck in the office on Zoom with patients rather than at home with their family eating dinner.
Before the logistics of telemedicine in rheumatology are worked out, it may be necessary to update the technological infrastructure in all practices.
“Many doctors and patients do not have adequate internet or devices to allow good audio and video platforms,” Saag said.
Given that most health care organizations, large and small, are working with limited resources even for fundamental patient care, this may be a huge request.
“Another big problem is the reimbursement scheme,” Saag added, noting that many providers “end up earning considerably less” for telehealth visits, particularly if they must resort to telephone only, which disincentivizes their use.
Meanwhile, when they are in use, more time spent navigating the complexities of reimbursement for telehealth can often mean less time for themselves.
“That being said, let us not forget about the rheumatology deserts in our country,” Patty-Resk said. “There are large areas where the only means of seeing a rheumatology provider is going to be via telemedicine. Those providers have really figured it out well before pre-pandemic times and continue to do so.”
Learning from those providers may be key to improving the use of telemedicine in rheumatology and making it a tool for saving time rather than wasting it.
Ultimately, transitioning telemedicine from its emergency use status during the pandemic to an integrated part of clinical practice will take time and effort. Organizations like the ACR may be of use in improving this and other components of physician burnout.
Eliminating ‘Joy Killers’
According to Battafarano, the ACR Workforce Solutions Committee has spent the past year designing and implementing critical intervention strategies for severely underserved areas in the northwest, southwest and south-central regions of the United States.
“Our focus is primarily directed at facilitating timely adult and pediatric rheumatology care for patients,” he said. “However, all of our proposed solutions are very cognizant of protecting individual rheumatology providers and the rheumatology workforce from fatigue and burnout.”
The strategies involve creating rheumatology networks with primary care providers, community stakeholders and insurance carriers for optimal patient care, Battafarano added.
The ACR can also advocate for payment reform for telehealth, recruit and train advanced practice practitioners, address the gender gap among practitioners and provide resources for developing a more user-friendly, and inter-operable, EMR, according to Saag.
Although Calabrese applauds these efforts, he stressed the pervasiveness of the burnout problem in health care.
“COVID has been a major blow to the sanity of people in the practice of medicine,” he said. “The level of societal anger, anxiety and PTSD has been reproducibly risen to palpable levels.”
That said, like Saag, Calabrese noted the “toughness” of health care professionals.
“We got into this knowing there would be long hours and hard work,” he said. “But we have also recognized that institutions look at medicine more as a product line than a healing art.”
It was with this in mind that Calabrese called on all health care stakeholders to make a commitment to one simple goal: “Remove the elements of our profession that are joy killers and let us try to bring the humanity and the joy back into what we do.”
- References:
- Han S, et al. Ann Intern Med. 2019; doi: 10.7326/M18-1422.
- 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 1818 Flintbed, San Antonio, TX; email: dbattafarano@gmail.com.
- Carrie Beach, BSN, RN-BC, can be reached at 1211 Dublin Road, Columbus, Ohio 43215; email: carrieeburke@hotmail.com.
- Leonard H. Calabrese, DO, can be reached at 9500 Euclid Ave., Cleveland, OH, 44195; email: calabrl@ccf.org.
- Cathy Patty-Resk, MSN, RN, CPNP, can be reached at 400 Mack Avenue Suite 1 East, Detroit, MI 48201; email: cathy.resk@icloud.com.
- Jonathan Ripp, MD, MPH, can be reached at 1 Gustave L. Levy Pl, New York, NY 10029; email: jonathan.ripp@mountsinai.org.
- Kenneth G. Saag, MD, can be reached at 500 22nd Street South, Floor 2. Birmingham, AL 35233; email: ksaag@uabmc.edu.
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