PISS on doctor burnout

The IHI Triple Aim is to lower per capita costs, improve the quality of outcomes and improve the patient experience. Add the doctor experience and you have the quadruple aim. And, don't forget the quintuple aim.

Some patient engagement and experience experts say there are 5 steps to making it happen:

1. Establish vision

2.Create a culture of engagement

3. Employ the right technology

4.Empower patients

5. Be ready to evolve.

Others have outlined how to get it done.

It's been demonstrated over and over again that happy employees make happy customers. Not only that. Happy employees yield happy investors too.

But the customer is only one half of the experience equation. The employee experience is similarly important, and it can often go overlooked.?EX — the sum of all interactions an employee has with an organization, from recruiting to an exit interview – also significantly impacts business performance. EX involves far more than human resources functions, including facilities, internal communications, IT, and even corporate social responsibility.?Research by Gallup shows?that work units in the top quartile in employee engagement outperformed bottom-quartile units by 10% on customer ratings, 22% in profitability, and 21% in productivity — and they experienced lower employee turnover, absenteeism, and safety incidents. Companies?that MIT researchers?classified in the top quartile of EX developed more successful innovations, deriving twice the amount of revenues from their innovations as did those in the bottom quartile. And their industry-adjusted Net Promoter Scores were twice as high.

Likewise, burned out, unhappy doctors make unhappy patients. The key to the patient experience is the doctor experience, yet employers and organized medicine have dropped the ball and don't seem to see the link. Physician burnout is now a public health crisis with more than half of doctors feeling the sting.?What/s more, no one has a lasting cure. What's more, while some factors that contribute to physician burnout among female physicians are similar to their male colleagues, it is important to identify and understand the gender-based differences, according to a National Academy of Medicine discussion paper. Focusing on the challenges women physicians face can lead to four high-level strategies to mitigate burnout and improve well-being.

Physicians between the ages of 40 and 54 experience a higher rate of burnout than older or younger doctors, according to a recent survey of more than 15,000 physicians who cited administrative tasks and work hours as key drivers of their stress.

In 1981, the?psychologist Christina Maslach, working with several colleagues, set out to create a test to measure occupational burnout. Eventually termed the Maslach Inventory, the scale assessed the risk of burnout by testing subjects along three basic dimensions: emotional exhaustion, depersonalization and personal accomplishment. The first set of questions, nine in total, measured the feeling of being chronically overextended or emotionally fatigued in the workplace. The second, with five items, tried to capture the feeling of becoming detached or disconnected from the recipient of your services: toddlers in the case of kindergarten teachers, or patients in the case of doctors (“I haven’t even?touched?a patient,” as the resident put it). The final dimension that Maslach identified, through eight questions, was a loss of personal accomplishment, a feeling that nothing was being achieved.

An online survey of doctors finds an overall physician burnout rate of 44 percent, with 15 percent saying they experienced colloquial or clinical forms of depression. Two new entries in the top six specialties with the highest rates of burnout compared with last year’s edition of the survey provide medical students and residents with new insight into their future careers.

Moderate to high burnout has been reported in 35% to 86% of OTO-HNS residents. Among other surgical specialties, resident burnout ranges between 58% and 66% in plastics, 11% and 67% in neurosurgery, 38% and 68% in urology, and 31% and 56% in orthopedics. Highest burnout rates were seen in postgraduate year 2 residents. Factors significantly associated with burnout included hours worked (>80 h/wk), level of autonomy, exercise, and program support. Reported resident work hours have steadily increased: 8% of OTO-HNS residents in 2005 vs 26% in 2019 reported averaging >80 h/wk. Practical implications of resident burnout include decreased empathy, moral distress and injury, poor health, decreased quality of life, increased attrition, decreased desire to pursue fellowship, and increased likelihood of medical errors. Structured mentorship programs, wellness initiatives, and increased ancillary support have been associated with lower burnout rates and improvements in resident well-being across specialties.

Burn out, of course, is not confined to the sick care workforce. A recent Gallup study of nearly 7,500 full-time employees found that 23 percent reported feeling burned out at work very often or always, while an additional 44 percent reported feeling burned out sometimes.

All health professonals, not just doctors, are at risk for burnout. Pharmacists are too as well as nurses.

In 2016, Carilion Clinic conducted a survey encompassing physician burnout and employee engagement. The survey was distributed to all physicians, residents and fellows, advanced care practitioners and medical students in the system.

The results were sobering. Fifty-nine percent of Carilion physicians were experiencing high burnout. Half of medical students, physician assistants and nurse practitioners also reported burnout, with burnout being worst among residents. The survey renewed Carilion’s focus on efforts to rectify widespread burnout. Leaders came up with these seven innovative ideas and initiatives, as outlined in an AMA STEPS Forward??module.

Burnout takes not just a human toll, but a financial one as well.

If nothing were done to address burnout, two Stanford researchers estimated, almost 60 physicians would leave Stanford within two years. The cost of recruitment for each physician—depending on the specialty and rank of faculty—would range from more than $250,000 to almost $1 million. And, for those 58 physicians, Stanford’s economic loss over two years would range from a minimum of $15.5 million to a maximum of $55.5 million.?

EMRs have become the burnout scapegoat, but there are 5 main sources of burnout ,which mostly have to do with the loss of control and authority and not having the right tools and support to do your job. Here are some others.

1. The practice of clinical medicine.

2. Your specific job.

3. Having a life.

4. The conditioning of our medical education

5. The leadership skills of your immediate supervisors.

To address the problem we need to PISS on it:

1. Prevention. Burnout prevention interventions are effective but tend to fatigue. They need to reinforced periodically. Here are some organizational resources to prevent burnout.

2. Innovation: We need better ways to intervene and prevent relapse. For example, peer-to-peer network support systems provide peer supporters to those who have experienced an adverse medical event and need someone to talk to them.

3. Surveillance: Few health service organizations or academic medical centers monitor burn out or employee disengagement and usually depend on self reporting or flushing out the bad apples. It does not work. Doctors, like military personnel, have a warrior mentality that places stigma on those who won't man up.

4. Stewardship: We need better ways to shield harried doctors from adminstrivia and anything that prevents them from practicing to the top of their license.

Members of a recent AMA summit issued this call to action:

They committed to:

1. Regularly measure the well-being of our physician workforce at our institutions using one of several standardized, benchmarked instruments.
2. Where possible, include measures of physician well-being in our institutional performance dashboards along with financial and other performance metrics.
3. Evaluate and track the institutional costs of physician turnover, early retirement, and reductions in clinical effort.
4. Emphasize the importance of leadership skill development for physicians and managers leading physicians throughout our organization.
5. Understand and address more fully the clerical burden and inappropriate allocation of work to physicians that is contributing to professional burnout.
6. Support collaborative, team-based models of care where physician expertise is maximally utilized for patient benefit, with tasks that do not require the unique training of a physician delegated to other skilled team members.
7. Encourage government/regulators to address the increasing regulatory burden that is driving inefficiency, redundancy, and waste in health care and to proactively monitor and address new unnecessary and/or redundant regulations.
8. Encourage and support the AMA and other national organizations to work with regulators and technology vendors to align technology and policy with advanced models of team-based care and to reduce?the burden of the EHR on all users. Measure the new technology burnout impact factor as part of your vetting process.
9. Encourage and support the AMA and other national organizations in developing further initiatives to make progress in this area by compiling and sharing best practices from institutions that have successfully begun to address burnout, profiling case studies of effective well-being programs, efficient and satisfying changes in task distribution, and outlining a set of principles for achieving the well-being of health professionals.
10. Continue to educate our fellow CEOs as well as other stakeholders in the health care ecosystem about the importance of reducing burnout and improving the well-being of physicians as well as other health care professionals.
11. Support and use organizational research at our centers to determine the most effective policies and interventions to improve professional well-being among our physicians and other health care professionals.

Happy, productive doctors make happy patients and that drives revenue. Plus, the direct and indirect costs of burnout and turnover justify the investments and boosts the ROI.

Organizational behavior experts tell us that the single biggest cause of job stress is lack of control. Rules, red tape, interference, and IT mandates that don't help doctors take care of patients don't help and demoralize doctors. Creating a better attitude is about giving employees control, not wresting it from them.?

These workplace factors contribute to burnout in family physicians.

Physician burnout can be reduced by interventions at the individual and organizational level.

These burnout risk factors should be measured and addressed at an organizational level to help restore joy to the day’s work.

Workload: The demands of your job exceed the resources available to accomplish it.

Control: You have very little say over how you do what you do—and no one is interested in your feedback.

Rewards: Rewards are less about salary and benefits and more about recognition for a job well done. If the best you can say about your workday is that “there were no screamers today” or “nothing bad happened,” then you and your workplace are in trouble, Maslach noted.

Community: “Unresolved conflicts that fester over time into a socially toxic environment” may lead to anti-social behaviors, such as bullying and rudeness, Maslach said.

Fairness: A perceived lack of equity in the workplace—one in which success “depends on who you know” rather than experience and expertise—can result in anger and hostility.

Values Conflicts: A disconnect between the values that give meaning to your life and your day-to-day work realities can chip away at your sense of self, with long-range consequences.

What is missing is intervention and change at the systemic level or regulatory level.. If anything, top down rules, regulations and constant policy changes from Washington is causing change fatigue and making matters worse.

Here are some organizational strategies to reduce burnout:

1. Acknowledge the?problem and measure it.

2. Utilize the?power of leadership.

3. Focus on providing job resources

4. Minimize job demands and conflict

5. Promote work-life integration

6. Promote individual resilience

Here are some tips on building personal resilience:

1. To build and work your plan for greater resilience, strengthen your CORE.
2. Adjust your mindset
3. Practice resilience on the small stuff

Be sure you are measuring the right thing with instruments that are valid.

We need to rename the Triple Aim the Quadruple Aim and many professional associations are supporting the movement to restore the joy in medicine.

Note to administrators:Results indicated that organizational commitment had a more persistent influence on performance at the business unit level than vice versa. Consistent with prior research, this suggests that job attitudes may come first, and that practitioners might be well advised to aim to improve job attitudes in order to boost performance.

Employed physician engagement is not as high as their employers think it is, and conceivably, could drop even more in the future.

Health professional burnout will have to be addressed at 3 levels: individual, organizational and systemic. The last one is the most problematic given the conflicting interests and resistance to change. Here is an example. Although most physicians view the delivery of high-quality care as a professional imperative, performance-measurement activities face increasing resistance from physicians and some policymakers who believe that current measures are not meaningful.?In a recent survey, 63% of physicians said that current measures do not capture the quality of the care that physicians provide.?Yet U.S. physician practices are spending $15.4 billion each year — about $40,000 per physician — to report on performance.

Burnout and depression rates among U.S. physicians failed to improve in 2019, despite growing efforts by healthcare organizations, hospitals, and academic centers to address the issue through wellness programs and other interventions

Maybe, when all is said and done, doctors need to practice the Subtle Art of Not Giving a F@#K.

Did you get the memo?

Arlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs on Twitter@SoPEOfficial and Co-editor of Digital Health Entrepreneurship