Building Burnout-Proof Culture In Your Medical Group

By Andis Robeznieks

With physician burnout on the rise, new strategies and technologies are being tested to help support clinical teams while also driving growth

There is growing recognition that physician burnout is a significant problem that can have tangible implications for patient care and staff turnover.

Major reasons for burnout include lackluster performance of many electronic health records (EHR) systems that complicate rather than simplify clinical tasks and record keeping and increasing regulatory burdens imposed by the government or insurance companies.

Burnout, as defined by the American Medical Association, is a long-term stress reaction, and its characteristics include depersonalization, a feeling of decreased personal achievement and cynical or negative attitudes toward patients along with a loss of empathy for them.

Fifty-four percent of physicians reported their morale as somewhat or very negative in a survey of 17,236 physicians. The survey, commissioned by the Physicians Foundation and conducted by the Merritt Hawkins physician recruitment and search firm, also found that 48 percent of doctors plan to reduce the number of patients they see and the hours they work or look for a nonclinical, administrative role.

“There is no amount of yoga that will compensate for having to do two hours of EHR work after the kids go to bed.”

Another recent survey found that rates among physicians reporting at least one symptom of burnout increased to 54.4 percent in 2014 from 45.5 percent in 2011 compared to rates of 28.4 percent and 28.6 percent for those years among the general U.S. population. The survey, conducted by researchers with Mayo Clinic and the AMA, also found increasing physician dissatisfaction with work-life balance growing to 48.5 percent from 40.9 percent during the same period.

“Given the extensive evidence that burnout among physicians has effects on quality of care, patient satisfaction, turnover and patient safety, these findings have important implications for society at large,” concluded the researchers in their survey report published last December in the Mayo Clinic Proceedings journal. “There is an urgent need for systematic application of evidence-based interventions addressing the drivers of burnout among physicians.”

There are positive aspects to build on. The researchers noted that the negative findings of their survey were offset somewhat by the nature of the profession, which included meaningful relationships with patients, intellectual stimulation and “the satisfaction of helping fellow human beings.”

Christine Sinsky, MD, AMA vice president of professional satisfaction and one of the co-authors of the report, also sounded a positive note.

“I am optimistic that most of the drivers of burnout can be overcome by rational people of goodwill coming together,” Sinsky said in an interview.

Also boosting Sinsky’s optimism are statements by Andy Slavitt, acting administrator for the Centers for Medicare & Medicaid Services (CMS), and others expressing recognition of how complex and overlapping regulations are contributing to the problem of physician burnout.

Sinsky, who is an internist with Medical Associates and Health Plans, a 170-provider medical group in Dubuque, Iowa, cheered how a time-consuming regulation with no patient value was going away on January 1. This regulation, part of the federal Meaningful Use program, which subsidizes EHR purchases, penalizes physicians if they have non-licensed professionals, such as a receptionist, to type in orders for routine tests into the EHR.

“For most physicians, it could save an hour a day to delegate that task to a non-clinical member of the team,” Sinsky said. She added that, at her practice, identifying when a patient’s next visit should be scheduled and what tests will be required in the interim takes a doctor about three to five seconds. But entering it into the EHR takes two to three minutes.

“It turns out that order entry is one of the biggest drivers of dissatisfaction,” Sinsky said.

Physicians only spend 27 percent of their day in direct clinical contact with patients and 49.2 percent on “EHR and desk work,” according to an AMA-funded time-and-motion study Sinsky co-authored that was published September 6 in the Annals of Internal Medicine. The study also found 37 percent of time spent in an exam room with patients involved non-face-to-face EHR and desk work and that many physicians in the study spent one to two hours a night completing these tasks at home.

“I used to be a doctor, now I’m a typist” is a battle cry emerging from this workload, Sinsky said.

In her own practice, Sinsky said much of this has been eliminated by making nurses active members of the care team and having nurses “take ownership of standardized practice elements,” such as administering vaccinations, being the first responder to lab results and obtaining preliminary patient histories. Afterward, nurses, physicians and patients than have a three-way conversation. When Dr. Sinsky leaves the exam room, the nurse stays and continues to discuss next steps and provides patient education as required.

“That’s made a tremendous difference in my satisfaction and joy in practice,” she said.

In an earlier study published in a 2013 edition of the Annals of Family Medicine, Sinsky and a team of researchers observed how 23 high-performing primary-care practices found innovative ways to mitigate burnout.

These included extending prescriptions from 12 months to 15 for patients with stable chronic conditions. This reduced unnecessary appointments and avoided repeating the same tasks multiple times throughout the year.

Extending prescriptions from 12 months to 15 for patients with stable chronic conditions reduced unnecessary appointments and avoided repeating the same tasks.

One example cited in the report involved how a Denver-area medical group created standing orders for common conditions such as sore throats, ear infections, head lice, sexually transmitted diseases and Warfarin management and gave nurses the authority to make a diagnosis and treat the problem.

Sinsky said there is developing evidence that the most effective burnout-mitigation interventions involve improving workflow and reducing the chaos of the work environment.

Other interventions included in the AMA’s Steps Forward burnout-mitigation program that have been found to be effective include supporting physicians in a research or quality-improvement project of their choosing (as opposed to having a project imposed on them), improving communications between physicians and administrative leadership and increasing opportunities for collegiality and reducing isolation.

To advance the last strategy, Sinsky said the Mayo Clinic pays for monthly meals where physicians meet in small groups where they discuss one set question and then spend the rest of the time socializing, discussing cases or talking about new developments in medicine.

“This used to happen organically during hospital rounds,” Sinsky said, “but now fewer office-based physicians do hospital rounds and those that still do are often focused on their computer screens.”

While EHRs are often cited as a source of physician burnout, IT solutions can also serve to mitigate against it as well.

Emory Healthcare in Atlanta is partnering with the Royal Philips technology company and the Macquarie University Health Sciences Centre in Sydney, Australia, on a study to mitigate burnout among the intensive care unit night staff. Emory doctors and nurses are remotely monitoring patients during the night shift, but they are doing so during daylight hours in Australia.

Emory doctors and nurses are remotely monitoring patients during the night shift, but they are doing so during daylight hours in Australia.

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Closer to home, hospitals are using IT to help reduce the burnout caused by scheduling issues.

“Hospital scheduling is like solving a Rubik’s Cube or a 10-dimensional Sudoku puzzle,” said Suvas Vajracharya, founder and Chief Executive Officer for Lightning Bolt Solutions, a physician-scheduling software provider. “The resulting schedule is not often how it should be.”

Software such as Lightning Bolt’s has been found to be particularly helpful for scheduling during the traditional September to December busy season for hospitals and for the seven-days-on, seven-days-off 12-hours-a-day nature of hospitalist physicians’ work.

“It individualizes the way doctors want to work, because they are not all the same,” Vajracharya said. “Some prefer night shifts, some want to avoid nights altogether. Some can’t work weekends, some can only work weekends. How do you keep track of everyone’s needs? It’s super hard.”

Romil Chadha, MD, said these problems were happening with the hospitalists division he led at the University of Kentucky HealthCare system, which had tripled in size in less than six years going from a roster of 18 physicians to 52 hospitalist physicians and 14 nurse providers and physician assistants.

“Not getting enough time off or not getting requested time off was one of the biggest factors of why people got upset or why morale was down,” said Chadha, medical director of the system’s telemetry and observation units. “We were seeing signs of fatigue.”

“Not getting enough time off or not getting requested time off was one of the biggest factors of why people got upset or why morale was down”

This was particularly true when some physicians wound up working 12-hour shifts for 14 days in a row. Chadha said he used to receive five to 10 scheduling complaints a quarter, but he recently celebrated a complaint-free quarter, for which he gives credit to Lightning Bolt.

In addition to scheduling, however, the University of Kentucky hospitalists also recently sought to combat burnout with a “Mission, Vision, Values” group exercise in which three main problems were addressed.

First, clinical efficiency and effectiveness were addressed, and a process was set up to disseminate knowledge and to have the group’s “super performers” serve as mentors to new physicians or those who were struggling.

Second, they looked at how to enhance its mission as an academic medical center or, as Chadha put it, “how do we develop junior faculty to be the person they want to be?” To this end, they developed pathways for senior members to mentor new staff in establishing themselves as future administrative leaders, researchers or top clinical teachers.

And third, like Mayo, they created ways to get to know each other in a way that enhanced the work-life balance.

“When we were an 18-physician group practice, we knew everyone,” Chadha said. “We knew their spouses, and we knew their culture and their background.”

Now, once-a-month offsite gatherings are held in which the group and their families meet. The events can be indoors or outdoors, at physicians’ homes or at a restaurant.

“The idea is to create collegiality outside the hospital,” Chadha said. “These are activities designed to increase enjoyment and decrease burnout.”

Sinsky said another path being taken to reduce burnout is a new focus on physician health and wellness. This includes making efforts to eat better, sleep and exercise more, quit smoking and reduce stress. It also includes recognition that these activities alone cannot prevent burnout.

“My observation is that about 80 percent of burnout is related to system factors and about 20 percent to individual factors,” Sinsky said. “Important as it is, there is no amount of yoga that will compensate for having to do two hours of EHR work after the kids go to bed.”

The nature of the problem makes her both optimistic and troubled at the same time.

“The practice of medicine is inherently meaningful,” she said. “So it’s bothersome that the rate of burnout is almost twice as high as the general population.”