Experts report on efforts to change the workplace and the culture of medicine
The COVID-19 pandemic put working conditions into the national spotlight, so it should be little surprise that being overburdened often is an understatement for physicians, nurses and health care support staff. That new level of attention and awareness may be one of the good things to come out of the fight against COVID-19.
But physician burnout was a problem before the pandemic; if the virus were to disappear tomorrow, burnout would not. In a recent Medical Economics® survey, more than 93% of physicians report feeling burnout at some point and more than 73% say they feel it now.
Given this reality, what happens next? Medical Economics® spoke with physicians and executives about the latest steps in the fight against burnout. There is movement to add leadership, rewrite licensing forms, approve legislation that could improve the workplace, and remove barriers to mental health care for physicians.
“Change is possible,” says Tait Shanafelt, M.D., chief wellness officer at Stanford Medicine in California and a nationally recognized researcher on physician burnout. “There’s reason for optimism and it’s going to take all of us as physicians really engaging with leaders of health care systems and organizations to drive the change that’s needed to reshape the health care system.”
Although definitions vary, researchers have noted burnout encompasses three key areas: physical and emotional exhaustion; feelings of cynicism, negativity and detachment from work; and inefficacy, feelings of incompetence and lack of achievement and productivity. It happens when job demands — heavy workloads, time pressures and inefficiencies — fall out of balance with resources such as meaning of work, job control and social support from peers and supervisors, as summarized by the National Academy of Medicine’s 2019 volume, “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.”
For many physicians, burnout creeps in when they must devote time to interactions that are not of value to patients or what is needed in their care, Shanafelt says.
Such situations exist in doctors’ offices, hospitals and health systems across the United States and many physicians are feeling pain, discouragement and disillusionment. But the nation has reached an inflection point for medical worker burnout, so now is the time for physicians to engage health care leaders for a cultural shift in medicine, Shanafelt says.
Physicians can start fighting burnout by maintaining their physical health. Workforce training on personal resilience and stress reduction may be helpful. Shanafelt says large-scale change must be rooted in organizational values, priorities, culture and leadership, along with adjustments to reduce or streamline administrative burdens, preauthorizations, billing documentation, reimbursement models that transactionalize care, and numerous in-basket messages.
“How do we create more efficient systems? Eliminate that inefficiency, create more highly functioning teams and … a community of health care workers who are able to support each other due to the emotional demands that the work entails?” Shanafelt says. “If we really want to get at those more substantive things … we need dedicated leadership. We need a commitment at the highest level of the organization.”
Meet the chief wellness officer
There are leadership development programs to train and deploy health care leaders to start or expand physician wellness initiatives. Shanafelt leads the Stanford Medicine Chief Wellness Officer Course, a weeklong immersion program requiring written commitments of institutional support for future actions. Since starting in 2017, it has graduated 170 participants in four cohorts. A parallel, online Physician Well-Being Director Course has graduated thousands of leaders at the department and division levels for wellness efforts in units around the country.
Alumni include Nigel Girgrah, M.D., Ph.D., chief wellness officer for New Orleans-based Ochsner Health, the first health system in Louisiana to add a department dedicated to workforce wellness. Efforts started in 2017 with Girgrah chairing a well-being task force to survey staff and report to the executive team. Health system leaders announced the new Office of Professional Well-Being in fall 2018. Girgrah says the wellness team spent a year developing a strategy to focus on four areas: practice automation largely involving electronic health records (EHRs), promoting advanced team-based care, worker resilience, and enhancing provider communication.
Like the rest of the nation, Ochsner Health had to deal with COVID-19 starting in March 2020. Some of the wellness initiatives fit right in — executive communication reassured staff that their jobs were stable, and employees responded well to resilience training. Other initiatives were specific to the pandemic, such as setting up child care and ensuring adequate personal protective equipment for front-line staff. Some of the practice efficiency initiatives “sort of got paralyzed, for good reason” due to the pandemic, Girgrah says, but now Ochsner Health hopes to reboot those efforts.
Administrative burdens arguably are worse for physicians in independent practices or those in small towns and rural or underserved areas, says Sterling N. Ransone Jr., M.D., FAAFP, president of the American Academy of Family Physicians.
Independent physicians share some systemic inefficiencies with physicians in large health systems, such as user-unfriendly EHRs, prior authorizations and insurance paperwork, says Eileen Barrett, M.D., M.P.H., chair-elect to the Board of Regents of the American College of Physicians. Physicians in independent practices may have more control over workflow and workplace culture, but not all are trained or have tools to address those challenges, even though all deserve that, Barrett says. Physicians in larger health systems may have more of a financial cushion to address those issues if leadership is willing and able to prioritize them, she adds.
Ransone agrees. “When you’re in practice and you’re taking care of a small community, you’ve got so many people that you’re trying to take care of but you have to spend so much of your time doing paperwork that a lot of us feel is needless and doesn’t contribute to the health care of the individual,” he says. “And then (in) a smaller practice, you don’t have the resources that you can hire somebody to do a lot of this paperwork.”
In independent practices, finances can contribute to burnout or mental health distress. Young physicians begin their careers with debt totaling hundreds of thousands of dollars. For independent practices, especially solo practitioners trying to keep the lights on and the doors open, “you’ve got the issue of … how much can I work?” says Ernest R. Gelb, D.O., FACOFP, president of the American Osteopathic Association, who spent years as a private practitioner in rural Pennsylvania. Experts often suggest taking on more patients to make more money, but that can lead to overwork contributing to burnout and hurting marriages and family life, or to substance use issues, he says.
More patients mean more paperwork, which now means more time with EHRs. Ransone, a family practitioner in a town of 2,000, and Girgrah, overseeing wellness for 34,000 health system employees, both mentioned pajama time — work after work, when physicians are writing notes, reading in-basket messages, reviewing results and completing charts.
“Ideally for most, this should be zero,” Girgrah says. “But the goal is to reduce this, so folks are spending less time on a computer and are able to disconnect.”
The EHR was described as almost a panacea for improving patient care through faster, more efficient, informative records. “And what it turned out to be is just another bump in the road that we have to go over in our daily lives to see our patients and get paid for our services,” Ransone says.
His suggested solutions:
Progress has been made in streamlining evaluation and management code documentation requirements for outpatient care, along with reduced administrative burden in treating people for opioid use disorder and improved performance measurement requirements from the federal Centers for Medicare & Medicaid Services, Barrett says.
“More needs to be done in all these areas to help physicians in independent and smaller practices,” Barrett says. “But these are a start, and when we get changes done it will also improve patient experience.”
Apart from systemic solutions, Gelb emphasizes work-life balance. “It’s a concept that none of us physicians with gray hair were raised on,” he says, but physicians must learn it and integrate it into their practices.
Gelb and Ransone agree it is a privilege to serve a local community, but there is a risk of work and life imbalance. Many physicians feel responsible for their patients and that gets amplified in a community where it feels like everyone knows everyone else and can drop in on the doctor anytime. Ransone says when he was a young father, he at first felt guilty taking Saturdays off for family time.
“There’s a really weird feeling like you’re abandoning your patients,” Ransone says. “But I realized that if I wasn’t happy and I couldn’t take care of myself, I certainly couldn’t take care of my community.”
Keeping it confidential
Experts agreed mental health counseling could help treat distress associated with burnout, but physicians fear repercussion if they seek help. Confidentiality is key to changing that.
The University of California San Diego Healer Education and Assessment and Referral (HEAR) Program started in 2009 as a physician suicide prevention program. In 2016, HEAR expanded to nurses, then to all health professionals in the system, with the mission growing to include a support program to enhance the emotional and mental health of staff, prevent burnout, and help people access mental health care.
HEAR’s anonymous online questionnaire has led to 1,000 referrals for mental health care, and about 100 residents and fellows have ongoing, confidential, free therapy. UC San Diego Health has not had one physician or nurse suicide since the program started, says Director Sidney Zisook, M.D.
“We certainly cannot assume that we are the sole reason for that, but if we have helped save one life, the program is fully worth its fare,” Zisook says.
HEAR is guided by an interdisciplinary committee that meets as needed and is divided into task forces dedicated to research, education and other topics. Along with Zisook, HEAR has two licensed mental health counselors to work with staff, and the program was cited as a model for other health systems by U.S. Surgeon General Vivek Murthy, M.D., MBA, in his May advisory on health care burnout.
Confidentiality has become a goal for the Dr. Lorna Breen Heroes’ Foundation, which honors the life of Lorna Breen, M.D., a New York City emergency department physician who struggled to help patients with COVID-19 until her death by suicide in April 2020.
In March, President Joe Biden signed the Dr. Lorna Breen Healthcare Provider Protection Act, gaining attention, pledging resources and establishing national accountability for physician burnout.
Breen’s sister and brother-in-law, Jennifer Breen Feist, J.D., and J. Corey Feist, J.D., MBA, have a new target: state licensing boards, health system administrations and insurance companies that ask invasive questions about whether physicians and other licensed clinicians have sought mental health treatment. Apart from being potential health law violations, those questions may be lumped with queries about criminal convictions or moral fitness to practice medicine, says J. Corey Feist, a 20-year health care administrator.
“So, there’s a message that’s given to the health care worker, doctors and nurses: You can’t get help. And if you get help, it could cost you your license to practice, it can cost you your job at a hospital,” Feist says.
Before her death, Breen told her family about her fears of losing her professional license and reputation because she sought mental health treatment.
Because the questions effectively are a barrier to seeking care, the strategy is simple: Stop asking, Feist says. Other options include a single, inclusive question that complies with the Federation of State Medical Boards with no asterisks or fine print, or an attestation model with supportive language around mental health, according to the federation’s new Licensure & Credentialing Strategy Tool Kit.
Credentialing committees easily can audit documents, remove or revise questions regarding mental health treatment, approve the new paperwork and communicate it to physicians and staff. Feist said one health system amended its forms in less than a week.
“It’s very important because health care leaders are in this unique position to actually make the changes that are needed,” Feist says. “This is starting to take hold because organizations are looking for something tangible that they can do right now, and this is perfect. And literally this can take days. It’s not hard to do.”
Confidentiality is a key part of other programs and strategies with potential for relieving burnout by creating access to mental health care. In May, the Ohio State Medical Association (OSMA) launched the Well-Being Checkup And Referral Engagement Service, or Well-Being CARE, for physicians and health care professionals. The goal is twofold: connect physicians and staff with services if needed while creating another resource to normalize the conversation about mental health in the profession.
Physicians find it easy to talk about physical ailments and ways to fix them, says Todd Baker, OSMA CEO. “If you see a colleague struggling with mental health or burnout, that conversation is not so easy or not so normalized,” he says. Offering an independent source also helps because physicians or medical staff may be reluctant to seek treatment within the health care systems they work for, says OSMA President Brian J. Santin, M.D., FACS.
In the service’s first month, 105 individuals completed the anonymous, web-based assessment, and almost 30% requested information or referrals. “But just making sure the conversation never stops about this issue is really our marker, in terms of how we want to define success,” Baker says.
In Virginia, physicians have a new level of confidentiality set in law. The Medical Society of Virginia (MSV) advocated for creation of the SafeHaven program, which has a partnership with a physician-focused national behavior health consulting practice.
Melina Davis, MSV executive vice president and CEO, agrees physicians are reluctant to seek counseling because if they must reveal it, they fear they could lose licenses, have referral networks dry up, or get fired. But physicians enrolling in SafeHaven gain legal privilege that forbids release of any records, reports or communications originating in the program — even in malpractice lawsuits, barring a court order that meets a high standard of proof, according to MSV.
State lawmakers unanimously approved the program in March 2020. It was coincidental timing with the spread of COVID-19, but the pandemic spurred the program’s beginning and physician enrollment started in July 2020. State lawmakers were unanimous a year later in expanding SafeHaven for physician assistants, nurses, pharmacists and students of those protected professions.
Now SafeHaven has 4,400 members, with 48% using the program and 17% in coaching and counseling. Davis argues that rate is unprecedented for physician usage of employer-sponsored wellness programs in the United States. “It’s unprecedented because they feel safe,” she says.
SafeHaven will expand into Michigan and MSV wants to serve as a consultant to take the program across the country. Primary care physicians can do their part by advocating for the same legal protection in every state, Davis says.
“More people need to be asking for this,” Davis says. “More people need to be advocating that it be a normal part of your legal system and your service system for health care workers. They need it, they deserve and it’s here. It makes a big difference.”
At the state, system or individual level, change may not happen quickly, but physicians cannot afford to ignore symptoms of burnout. There are resources to help physicians, Gelb says.
“Burnout is something that should not be ignored. It’s going to affect you,” Gelb says. “It’s going to affect your family. It’s going to affect your performance as a physician and the liability issues that potentially may need to be addressed as well. So, this is something that is important to your health. And if you’re not healthy, how can you take care of somebody else? That’s my big take-home message right now: Get the help that you need, get the help that you deserve. It is out, it is available — all you have to do is reach out.”