This post was co-authored with David Brendel, a psychiatrist and executive coach who blogs at Leading Minds Executive Coaching. It appeared on KevinMD on April 9, 2018.
Physician burnout rates hover around 50 percent and the adverse consequences are serious. Burnout is associated with increased medical errors, suboptimal care, turnover, and personal costs, including substance use, depression, and suicide. The financial cost to healthcare organizations is significant: replacing a physician is estimated to cost at least $500,000. Plus, physician turnover results in care disruption, patient access issues, and lost revenue for hospitals to which the physician referred patients for specialist care and other services.
What fuels burnout? Contrary to popular belief, burnout is not due to personal weakness or increased susceptibility to stress. Professional burnout is a predictable response to stress in the workplace.
It can be helpful to think of the underlying causes as falling into four interrelated categories:
- Individual level: Stresses inherent to the practice of medicine or that the individual physician brings with him or her to the workplace, such as untreated depression and a perfectionistic temperament.
- Practice level: Frustrations and barriers to providing care that sap the physician’s energy and enthusiasm for the profession. These include changes in the practice environment, documentation burden, and inefficient administrative and care processes. Practice-level issues also adversely affect the organizational performance measures that leaders care most about.
- Organizational level: Factors that adversely affect the entire hospital, health system, or physician practice, including unsupportive leadership, lack of effective communication between top leaders and frontline clinicians, and an organizational culture that condones disrespect and rewards constant personal sacrifice.
- External factors: Regulatory, economic, and social factors that put pressure on healthcare organizations, which is in turn transmitted to leaders and clinicians, such as increasingly complex and diverse patient populations, well-intentioned policies that have increased the clerical burden, and increasingly onerous payment restrictions.
In our interactions with medical students, residents, and practicing physicians, we often hear about the intense stress in practice today, insufficient time with patients, and the negative effects on personal life. Too many physicians are discouraged and looking for ways to cut back on clinical time or leave practice entirely.
To ensure its viability, a healthcare organization must maintain a healthy workforce. Leaders need an effective, comprehensive approach to addressing physician burnout—one that considers all four levels of burnout drivers.
Individual level: Since many stressors of medical practice cannot be eliminated completely, physicians throughout their careers must take personal responsibility for boosting their coping skills and resiliency. Professional coaching and leadership training can empower physicians to transform mindset and behavioral patterns in positive ways. By enhancing self-awareness and self-management skills, coaching and leadership training can help physicians to identify stress triggers and proactively plan ahead to reduce the likelihood of becoming overwhelmed or burning out.
Physicians may benefit from coaching and training on time management, task delegation, team building, and verbal and non-verbal communication skills. Stress management techniques, such as mindfulness meditation and controlled breathing, can further help them to navigate stressful situations with poise and equanimity. While these approaches at the individual level may be necessary for preventing burnout, they are usually not sufficient. Coaching and training programs cannot substitute entirely for implementation of broader practice and organizational changes to ameliorate physician stress and prevent burnout.
Practice level: It is essential to address the practice level drivers of burnout. However, it can be helpful to use coaching and other individual-level strategies first to build the capacity to address the practice issues. A workforce that is acutely burned out cannot engage in the tasks required to fix the inefficiencies and broken processes. Physicians and other frontline clinicians must be included in any practice-level fixes. Using a structured, team-based system to conduct this work is an effective way to address immediate problems and build process improvement skills. The specific fixes will vary based on the clinical unit, but might include new rooming strategies, dyad staffing (for example, a physician paired with a medical assistant), previsit lab testing, medical scribes, and team-based care.
Organizational level: Physician burnout risk can be reduced by open and effective communication between physicians and organizational leaders. The communication needs to occur in a context of psychological safety, with everyone in the conversations empowered to speak candidly and without fear of retaliation. Physician leaders, such as chief medical officers, sometimes can facilitate these conversations, because their leadership roles span the clinical and organizational realms.
Dialogue groups, perhaps led by external coaches or facilitators to ensure neutrality and balance, can promote direct, relevant exchanges between clinicians and organizational leaders that may not otherwise occur. Open-minded listening on everybody’s part is essential. When physicians and organizational leaders better grasp the stressful challenges that their counterparts are facing, empathy and collaboration on creative solutions can deepen. This process can not only reduce physician burnout but also enhance clinical care, organizational functioning, and quality of life for everyone in the organization.
External factors: Although external factors, such as Medicare reimbursement policies, can seem too large to change, individual physicians and organizational leaders can influence these factors. For example, a common barrier for physicians needing mental health services is the presence of questions about past mental health treatment on applications for board licensure, despite the fact that such questions are not recommended by the Federation of State Medical Boards. Physicians and state medical societies can advocate for the removal of such questions and for access to confidential treatment. Organizational leaders can proactively consider the downstream implications of reimbursement and other regulatory changes—and take steps to mitigate the adverse effects on physicians.
As the complexities of modern medical practice multiply, physician burnout has become an urgent problem facing our healthcare system. Physicians can and must take personal responsibility for their own wellness, stress management, and prevention of burnout. The practices and organizations in which they work can support them by providing coaching and training, while also implementing changes in how the organization functions and promotes dialogue aimed at stress reduction. Wider societal changes would also reduce the likelihood of physician burnout and bolster the functioning of the healthcare system.