Measuring and Managing Physician Burnout

Measuring and Managing Physician Burnout

Physician burnout is widely recognized as a challenge not only for physicians, their families, and their colleagues, but also for the US population that depends on access to engaged and effective healthcare providers. The World Health Organization recently defined burnout as 

A syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: 

1) Feelings of energy depletion or exhaustion.

2) Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job.

3) Reduced professional efficacy. 

Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.”  

Despite near-universal awareness, the problem is poorly quantified.

Measuring Burnout

Quantifying the prevalence and severity of burnout is inherently difficult. First, burnout is an internal experience that can only be described by the person suffering from it. Second, burnout is a continuum rather than a binary state.  

The Maslach Burnout Inventory (MBI) is the most commonly used measure of physician burnout. The MBI delineates burnout according to three components: emotional exhaustion, depersonalization, and reduced personal accomplishment. However, the cutoff criteria of what constitutes burnout and where to delineate low, medium, or high severity is subjective and varies widely in academic literature.

Other measurement tools have emerged to improve upon the MBI, whether by framing some of the questions negatively or by addressing the high cost of the MBI materials. Alternative approaches include the Copenhagen Burnout Inventory, Oldenberg Burnout Inventory, Patient Health Questionnaire-9 (PHQ-9), Stanford Professional Fulfillment Index, and the Well-Being Index.  

The vast array of diagnostic tools and cutoff points can be dizzying, but they all point to the same high-level conclusions:

#1 Burnout affects healthcare providers at higher rates than the overall population

In a 2014 study, approximately 54% of physicians reported at least 1 symptom of burnout, almost twice the rate of the general U.S. working population. Physicians explain that an heavy load of bureaucratic tasks and excessive work hours (especially take-home work) are the primary contributors to emotional exhaustion, depersonalization, and reduced job satisfaction.  After all, they “didn’t go to medical school in order to enter data in the EHR.”  

#2 Burnout affects primary care providers at higher rates than specialists

In an Archives of Internal Medicine article, researchers noted “substantial differences in burnout were observed by specialty, with the highest rates among physicians at the front line of care access (family medicine, general internal medicine, and emergency medicine).” Confirming this result year in and year out, the annual Medscape survey across 29 specialties consistently places Family Medicine and Internal Medicine in the top 5 for burnout and bottom 5 for happiest at work. 

#3 Burnout is reported at higher rates for women than men 

Among US physicians, women report burnout at 25% higher rates than men. Researchers note that women may be more likely to admit to psychological problems and seek help than men. Women also disproportionately assume childcare and family responsibilities, increasing the cost of challenges to work-life balance.

Healthcare executives must seek solutions to the root causes of burnout – excessive clerical tasks borne by the provider and the take-home work that results. Without a change, provider turnover will continue to climb and patient access will continue to erode.

What is Physician Burnout?

What is Physician Burnout?

Physician burnout has become a national epidemic with multiple studies proving that about half of all doctors suffer from at least one of the three common symptoms associated with this condition. Physician burnout negatively impacts quality of care, patient safety, physician and patient turnover rates, and patient satisfaction in addition to increasing the number of medical errors that have become common in the United States. According to a Mayo Clinic Proceedings study by Daniel Tawfik, MD, medical errors are responsible for 100,000 to 200,000 deaths each year. However, research connecting physician burnout to these errors is limited. 

Up until pretty recently, the most prevalent approach to reducing medical errors was to fix the workplace safety by adding in more checklists for physicians to complete and adding in “solutions” like yoga and breathing exercises for the physicians. Tawfik’s study shows that this is insufficient, comparable to placing a Bandaid over a large gash. Fixing these medical errors starts by addressing physician burnout, understanding what it is, how to identify it in yourself and your colleagues, and finding ways to prevent it. 

Defining Physician Burnout

An accurate comparison for physician burnout is that energy is like a bank account that can have a positive or negative balance. Every time a physician engages in the activities of their life and medical practice, he or she withdraws energy and the balance decreases. During times of rest and rebalance, energy is deposited, causing that balance to increase. The problem comes when it dips into a negative balance. The account doesn’t close; instead, energy is still spent (in this case working) despite the fact that the currency (energy) is, in fact, depleted. 

Burnout is a long-term stress reaction characterized by a series of symptoms we will later discuss that is a result of a constantly depleted energy account and with a negative balance over time. Yes, a physician can continue to function and work in this state but as only a shadow of the doctor that he or she is when the account has a positive balance. 

Signs & Symptoms of Physician Burnout

The industry-wide accepted standard for burnout diagnosis is the Maslach Burnout Inventory that was developed in the 1970s by Christina Maslach and her colleagues at the University of San Francisco. She described burnout as “an erosion of the soul caused by a deterioration of one’s values, dignity, spirit, and will.” The three distinct symptoms most commonly associated with physician burnout:

Symptom #1: Physical and Emotional Exhaustion

The physician is feeling both physically and emotionally drained, depleted, worn out, and unable to recover during non-working hours. This is by far the most common symptom of burnout and is the one most physicians identify with when taking burnout prevalence surveys. A thought process that the physician suffering from physical and emotional exhaustion may identify with is, “I’m not sure how much longer I can go on like this.”

Symptom #2: Depersonalization

When physicians display this symptom, it often comes in the form of cynicism, a need to vent about their patients or their job, and a negative or callous attitude. Doctors in this stage are feeling so emotionally drained that they are not emotionally available for their patients or anyone for that matter. 

Symptom #3: Reduced Sense of Personal Accomplishment

In this stage of physician burnout, you may begin to doubt the meaning and quality of your work and see yourself as incompetent. A piece of internal dialogue commonly associated with this symptom is thinking, “What does it matter? My work doesn’t really serve a purpose anyway,” or even, “I’m afraid that if I don’t change something, someone is going to get hurt and it’ll be all my fault.”  

Effects on patients, practice, and physicians

Physician burnout affects all parties involved: the physician’s patients, the practice, the physician’s family, and, of course, the physician him/herself. Physician burnout is directly linked to a series of unsavory consequences that you definitely want to keep out of your practice:

  • Lower patient satisfaction due to poorer quality of care
  • Higher physician and staff turnover
  • Higher and more severe medical error rates and malpractice risks
  • Physician alcohol and drug abuse and addiction
  • Higher physician suicide rates

There is a higher risk of death by suicide for both female and male physicians relative to other professionals but goes widely underreported. 

Physician burnout fits with the old adage “death by 1,000 paper cuts.” It can happen slowly over time, each day and each task exacerbating the physician’s condition until it comes crashing down with a trigger like a lawsuit, a tragic circumstance in one’s personal life, a significantly damaging medical error, etc. If left untreated, physician burnout will only erode the mental health of doctors and threaten patient care. 

Our Love/Hate Relationship with Provider Productivity

This is the first in a series of communications on productivity and its far-reaching effects on our individual futures and the future of healthcare. In upcoming blogs, we’ll examine the link between productivity and an effective medical home, discuss some of the impediments to greater productivity and then see what it looks like in the exam room.

The driving factor in lack of access

There’s always talk about improving access, but low productivity, the driving factor behind reduced access, doesn’t get much respect. It should. It’s estimated that 38 percent of primary care visits in 2015 were unnecessarily diverted from the PCP office to the ED, urgent care centers and retail clinics. That’s a lot of lost visits, to the detriment of the practice – and especially to the patient because fragmented, limited care is no substitute for the kind of cost-effective quality that comes with continuous, comprehensive care.

What’s to love about productivity?

Getting back to our love-hate relationship with productivity, the “love” part is a matter of economics. While there are some exceptions, compensation has historically been based on the number and intensity of services provided. Metrics and methodologies can vary, but for the most part, the more patients seen, the more the likelihood of financial success. Although we continue moving toward fee for outcome-based payment models and next-era indicators for productivity, the wRVU standard remains in place for the majority of employed physician and physician owner practices.

And what is it that we hate?

As it turns out, there’s a darker side to this straightforward work-pay relationship. For primary care providers who already feel maxed out, it’s the vision of the hamster wheel. You hear the word “productivity” and you think of an industrial age assembly line, complete a conveyor belt, bringing endless numbers of patients in and out of the exam room. This scenario may be a bit extreme, but a system that incentivizes volume without supplying support staff with the specific skills need in primary care exam rooms can end up creating a negative impact on the missions of preventive medicine, wellness, education and basic patient care itself.  As a result, productivity is not only distinct from, but may also be anathema to quality and service.

If that isn’t bad enough, increased productivity carries the threat of overwhelming the already fragile work-life balance that providers often struggle to maintain. That’s why discussions of productivity can create concerns in the areas of both professional and personal satisfaction.

Why greater productivity is a necessity

In recent blogs, we’ve talked about how pursuing the Institute for Healthcare Improvement’s Triple Aim remains critical for maximizing overall health system performance and a reliable constant in the ever-changing map of healthcare. We’ve also discussed the value to primary care providers of capturing more acute care patients who might otherwise seek to have their medical needs met at retail clinics or urgent care centers due to limited access at their provider’s practice. The common element in both of these objectives and the most effective way to achieve this improved productivity.

However, without a corresponding increase in the kind of efficiency that supports productivity – and in turn leads to greater access – our ability to attain the Triple Aim, along with our hopes for meeting the needs of acute care patients will never reach fruition. And as we will discuss in the next blog, neither will our ability to bring the medical home to an effective reality.

Uncommon Bedfellows: Access, Expanded Hours, and Provider Wellness

In the first installment in this two-part look at the role of acute visits in primary care, we focused on the benefits of building this capability. In this continuation, we’ll discuss what needs to be in place in order to get there.

Improving access for acute, same day patients offers important benefits to practices and patients alike, but it takes a little thought and effort. The good news is, the mechanics are well within reach. I promise not to delve into queuing theory, wait-time metrics or any elements of what can be the surprisingly complex subject of medical scheduling. But I will share with you a bit of my own practice experience.

Opening up an adequate block of time at the end of the morning and another at the close of the afternoon…

…allowed us to better balance acute patient needs with organizational resources. What’s amazing is that these blocks were the easiest and most pleasurable part of patient visits for my clinical staff even though there could be 6-8 patients scheduled for each hour-long block.

This approach, which did not include a move to a true open access model, enabled us to stay on track with our scheduled patients and then see acutes collectively. Generally, it offered enough choice to accommodate individual patient schedules. If not, we could usually bring them in whenever they could make it and adapt accordingly because of the efficiency of our exam room process.

Utilizing high-functioning assistants who are empowered with the specific skills needed inside the exam room…

…is the single most important factor contributing to timely and consistent access for acute care patients. By building a more effective team in the exam room, providers can focus on direct patient care, those things that are commensurate with training and skills – and not the non-provider activities that can represent up to 60% of the patient encounter.

For example, in the typical routine (non-acute) primary care visit, the provider spends 10-15 minutes with what would be considered exclusively provider responsibilities and 10-20 minutes with non-provider responsibilities. Now, with the staff handling all the non-provider responsibilities inside the exam room, the provider is free to move on and see the next patient much more quickly.

I’ve seen improved exam room protocols work effectively in my own practice and in scores of other primary care and specialty practices with which I’ve been involved on an educational and training level. However, it’s important to note that the kind of transformation needed for more acute care capacity as well as all other patient visits isn’t simply a function of adding personnel. It involves true process redesign and a commitment to culture change, with a bit of professional flexibility and patience thrown in.

Expanded hours…

…have to be part of the solution if a patient’s need for access is going to be truly met by a familiar primary care provider. By building a more efficient team inside the exam room, increased productivity will allow for shortened shifts as well as fewer shifts per week. The result is that a small group of providers will have evening and weekend access collectively for their patient panels while promoting a very healthy work/life balance for providers individually.

Extended weekday and weekend hours and greater flexibility in overall scheduling are providing additional options and removing more of those times when, as the urgent care promotions put it, “your primary care provider is unavailable or you’re unable to make a timely appointment.” It’s not always easy, but an improved exam room process and the productivity that goes with this make expanded hours eminently doable.

Realizing that the time and energy spent on seeing more acute visits is not a distraction…

…but rather an opportunity with a range of inherent benefits is the most important step in preparing a practice for increasing acute visits.

Despite ongoing uncertainty in the direction of health reform, the four legs of the primary care table continue to be competence, continuity, accessibility, and affordability. A practice without timely access to a familiar provider when a patient perceives an urgent need is like a table with only three legs. Missing that access leg doesn’t make for productive quality-based primary care any more than it forms a solid, reliable and well-functioning table.

And speaking of tables, we’re leaving too much on them if we’re not ready to increase access for same-day, acute care patients.

All in Good Time (Management): Reprioritizing Exam Room Goals

There’s a prevailing opinion among providers that time is equal to care; the more time a provider gives a patient, the greater the level of care or genuine compassion he or she has. That’s just not true. The quality of care we provide to our panel is what determines success—not the amount of time we spend in the exam room.

Starbucks hasn’t come to the exam room

Our inappropriate focus on socializing with patients has led many of us to prioritize the unnecessary goal of what I call a “Starbucks moment.” We’re under the impression that patients want and deserve unlimited time to relax, catch up and discuss anything that’s on their mind during a visit, regardless of how long it takes. And perhaps some of us have come to believe we deserve a “break” too—a respite from the demands of our busy schedule, spent in the company of a patient with whom we have a genuine, enjoyable connection.

We must remove this idea of socializing from the context of appropriate medical care. The strength of a provider/patient relationship isn’t dependent on the amount of time spent with patients, it’s founded upon and maintained by the right balance between personal connection, timely access, and competent medical care. Personal involvement is critical for a provider to know the patient and make the right decisions for his or her care. But unlimited time not only fails to produce better health outcomes; it negatively impacts access for the rest of the panel.

Trust is the intangible component that makes the provider/patient relationship unique and health producing, not the amount of time spent together in the exam room. Patients generally consider provider competency a given because of the amount of education and training every provider receives, but timely access and communication are the key to building trust. No matter how good the provider, if she/he is not available to the patient, the patient loses trust. What patients want and need, besides competency, is timely access to a provider in whom trust has been developed – a familiar provider.

(A small caveat here. There will be instances when unlimited time is the right solution for patients with special circumstances or emergency concerns. But those exceptions shouldn’t drive day-to-day operations.)

Priority management

As I’ve written previously, time management begins with priority management. And if we’re going to fix primary care, we must begin by rethinking our priorities. So what are the exam room priorities for providers?

  • Maintain personal involvement with each patient to create or sustain health
  • Create access for the panel (in other words, see all the patients in the panel who need to be seen on a particular day) [links to TCM schedule content offer]
  • Make the necessary medical decisions for patients when they need care rather than refer to another provider
  • Empower clinical staff to accomplish all the ancillary (or non-provider) work inside the exam room
  • Communicate with patients in a timely manner (accomplished with participation of the clinical staff)

None of the goals above challenge or threaten the personal connection between providers and patients, and they actually incentivize greater trust by giving patients the care they need when they need it. And all of these priorities address the concerns of the individual patient as well as the rest of the panel, leading to better population health and meaningful provider/patient relationships.

Keeping the main thing the main thing

Primary care providers must begin thinking in terms of time and work within appropriate boundaries to give patients the access and quality of care they need to become and remain healthy. This means reorienting priorities inside the exam room and elevating health-producing strategies over “feel-good” moments that don’t actually create health.

The value of this cultural change in the exam room has enormous potential to transform our primary care delivery. Reprioritizing the goals of the exam room will lead to the improved access, health outcomes and cost-effectiveness our patients, panels, systems and society so desperately need.

What is Needed for the Patient Centered Medical Home to Reach its Full Potential?

When the Pickup Truck Meets the 18 Wheeler

Let’s take a quick look at what we know or at least what we may have read or heard.  A Rand Corporation study, presented in JAMA in 2014, compared a group of practices that had achieved patient-centered medical home (PCMH) recognition from the National Committee for Quality Assurance (NCQA) with a similar number of control practices that did not receive any special training. What the study reported, is that the medical home model was associated with only limited improvement within a range of quality measures and virtually no improvement in cost reduction.

No sooner were these findings published that proponents of the model cited dozens of private and public medical home-based examples where improvements in cost and quality had, in fact, been achieved and documented. Advocates also noted that the Rand study was based on a review of 2008 standards that have since been updated and was narrow in its focus, a limitation that is being addressed in new research that’s currently underway.

My personal experience as a primary care practitioner in a certified PCMH along with a great deal of observation around practices I’ve visited in various parts of the country over the past four years leads me to believe that the PCMH is a cornerstone of accountable care. It’s also a virtual requisite for meeting the Triple Aim of improving population health, the individual care experience and per capita costs.  At the same time, I think the section of the Rand report that suggests that “medical home interventions may need further refinement” may be right on  the money.

As we work with practices in how to effectively adopt a team care approach to primary care medicine, one of the essential building blocks for patient-centered care, we sometimes see administrators, practice managers, physicians and other staff who believe in the value of the medical home model and even imagine themselves to already be there or at least on the outskirts. In reality, they remain tied to the physician-centric approach of a traditional practice.

What they still haven’t accomplished is forming the kind of team where patients are able to develop a strong relationship with their doctor, clinical and non-clinical staff are empowered and trained to take on more aspects of care, particularly in the area of coordination and education, and physicians are enjoying a better work-life balance.

With these groups, I sometimes use the analogy of a six cylinder, gas fueled pickup truck being sufficient to meet the needs of their current practice but not adequate to power a medical home. Truly transforming the practice to a team care model and, ultimately, a patient-centered medical home requires more horsepower.  It’s time to get rid of the pickup and move toward a 12 cylinder diesel. The good news is that while investments in technology and staffing may likely be necessary, the proportional increase is not nearly as much as trading up from the pickup to the big rig.

Becoming a PCMH isn’t a matter of natural evolution. It takes the kind of concentrated effort along with the financial commitment I mentioned – particularly when it comes to additional staff – as well as the will to make the changes needed to go from doctor as point person to doctor as leader of a well-trained and high-functioning team.  It also takes the understanding that no matter how much you believe in the concept of team care and the medical home, no matter how solid your implementation plan, you still have to execute on it. And for that you’re likely to find that you just may need a bigger engine.

© 2020 Team Care Medicine