Health care organizations still struggle with how to address one of medicine’s biggest problems.
Physician burnout in recent years has gone from a taboo topic to one of great concern in the health care industry. In the past, doctors would avoid even talking about it for fear of being seen as weak by their colleagues, but thanks in part to a greater emphasis on mental health and physicians willing to speak out about it, the problem and its solutions are being openly discussed.
COVID-19 focused further public attention on burnout as overworked doctors suddenly found themselves working even longer hours while simultaneously worrying about their own health and that of their family members. This attention brought a renewed focus to burnout, and has many health care leaders talking about solutions, but doctors often see little progress.
And when solutions are presented, it can often be in the form of yoga classes or wellness programs that focus on the individual rather than the institution and systems that are often at the root of the problem. These classes take up even more physician time, making the problem worse. Health care organizations struggle with burnout because it can be difficult to quantify, and its effects can’t always be directly linked to costs.
Make ‘cents’ of burnout
Some costs are easier to measure than others. A burned-out physician that quits or retires early, for example, has a direct effect on the employer through turnover costs in recruiting and training a replacement.
“If we can decrease the rate of turnover, then that’s a huge cost avoidance factor for the organization,” said Terrance McWilliams, M.D., FAAFP, director and chief clinical consultant, HSG, a national health care consulting firm. “There are some estimates that indicate that due to gaps in coverage and the direct costs, recruiting a single physician can cost as much as $1 million. If we have physicians out of commission due to burnout, then we have to look at other forms of coverage, which either decreases efficiencies within the system, or you bring in temporary coverage like locum tenens.”
And then there is the risk to patients. “When physicians are burned out, they are much more likely to make mistakes,” said Christopher Porter, Ph.D., professor of management, and chair of graduate business programs in medicine at Indiana University Kelley School of Business.
Those are just the direct costs. McWilliams pointed out there are secondary costs to the organization. Having a disgruntled and burned-out physician interacting with patients and staff has its own price. “It can lead to staff dissatisfaction and a higher staff turnover rate, but also can affect the patient experience and lead to a loss of patients with its associated patient care revenue,” he said. “The financial impact is huge.”
With physician shortages projected for the coming decades, health care companies will be competing for an increasingly shrinking pool of candidates, who in turn may have to do more work to cover for fewer doctors, creating a rapid downward spiral.
Personal resiliency or institutional problem?
Most health care executives recognize there is a burnout problem with physicians, and that it likely hurts their bottom line, McWilliams said. “Unfortunately, I think there’s a little bit of a disconnect in some organizations between realizing there could be a problem or might be a problem and implementing a comprehensive program to address the problem,” McWilliams said. “There clearly are some organizations that are making great efforts to not just mitigate burnout risk, but to promote provider and staff wellness.”
But leadership must meet the challenges of daily operations while staying profitable, and when part of the problem is physicians working too many hours, wholesale changes may not always be possible. Organizational aspects contributing to burnout might require a full cultural transformation. “It’s one thing to promote individual resiliency, but it’s another to allow the practice of resiliency,” McWilliams said. “Do we expect our physicians to always be plugged in? How can we balance timely patient access and timely response to patients when there are only so many hours a day?”
Health care leaders often start by thinking the problem is a matter of personal resiliency. Physicians are sometimes expected to be superhuman, putting all patient needs ahead of their own, and this can contribute to unrealistic expectations from themselves and management. Leadership might begin with yoga, mindfulness, or other classes that can help a single person.
“They see it as a defect of the individual, because the system is perfect,” McWilliams said. “What they think they have to do is make it so all the individuals can deal with the system better.”
But with more and more studies identifying the problem as the system and not the person, no amount of resiliency programs aimed at the individual are going to solve the problem.
“The things that get implemented, at least in the health care organizations I’ve worked for are things that are on the ledger on the budget, and burnout isn’t on there,” said Gabe Charbonneau, M.D., a family medicine doctor in Stevensville, Montana, and an advocate for physicians fighting burnout. “It’s never been in the conversations that I’ve been a part of other than, ‘Here’s a wellness program that we’re trying,’” Charbonneau said. “I’m concerned that if it doesn’t get into those budget conversations, and it’s not reflected on our organizational balance sheet, it will continue to be this thing that we know so much about but aren’t really making any difference in it.”
Some organizations are progressively addressing the burnout issue and dialing back expectations, but this in turn leads to concerns about financial sustainability because if all the staffers are doing less, then the organization either needs more staff or less volume. “It’s hard in today’s system, which is still more volume-based than value-based, to be sustainable with the same number of individuals doing less work and therefore having less revenue,” McWilliams said. “It can put leadership between a rock and a hard place to find the right balance.”
How to measure and address burnout
Most health care organizations realize their physicians are at risk of burning out because it’s a high-stress job. Some leaders opt to take proactive steps to mitigate the risks without specifically assessing the scope of the problem, while others look to determine how bad the problem is, where efforts should be focused, and measure progress along the way.
Organizations have several tools available to help take the pulse of an organization and track the trends. These run the gamut from a single question “How burned out do you feel?” ranked on a scale to multi-question surveys that dig into the details. The Maslach Burnout Inventory is considered the gold standard for assessing burnout, but there are also options from Mayo Clinic and the American Medical Association.
The challenge is that the results aren’t always tangible. “OK, our burnout factor is seven, but to someone running a health organization, what does that really mean? How do you translate that into something that affects the bottom line?” Charbonneau said. “It’s hard to translate because the cost is long-term, and you have to retroactively look back over time to see it.”
An organization that is serious about tackling burnout has to be willing to commit resources toward structural change. Adding a wellness officer or mindfulness program is not enough to make a meaningful difference in systemic burnout. “It doesn’t mean they are bad things, but if your commitment to addressing burnout is to try and bolt something to what you’re already doing, but not be willing to change the environment people are practicing medicine in, it’s kind of a nonstarter in terms of actually making a difference,” Charbonneau said.
If reductions in workload can’t be made, focus on ways to give people more control over their work life. While system-wide standards may be in place, doctors can still have team meetings to discuss what is and is not working within their domain that can be improved. It might be the way patients are scheduled or how they prepare for visits, for example.
“I think creative, caring organizations will find ways to continue to use telemedicine to the extent possible and will think about creative ways to allow people to have a little bit more flexibility in their work arrangements,” Porter said. “There may be constraints in what they can do as it relates to workload, but that doesn’t preclude them from making improvements in terms of workflow. Certain doctors are going to spend the majority of their time with especially demanding cases — is there a way to balance that out?”
It’s also crucial to consider the opinions of physicians who are feeling the burnout. “I think the mistake that is sometimes made is that health care organizations tend to jump to the solutions without really having a full understanding of the problem, and without perhaps going enough to the actual individuals who are affected to get their feedback and even input in solutions,” said Adam Perlman, M.D., M.P.H., chief medical officer and co-founder of meQuilibrium, a software company that measures and tracks employee well-being. “One of the things I’m a strong advocate of is listening sessions, and actually gaining feedback and garnering more detailed information about what the pain points are.”
Charbonneau agrees, but said leaders have to be committed to actually hearing what’s being said. “If you are an executive, and even if you can’t change a damn thing, do your very best to listen to people to make them feel heard, because it makes such a difference,” he said. “I’ve experienced leaders where even if they can’t fix the problem, you know they are doing the best they can and want to hear what you have to say and that you matter to them. And there are others who are just waiting for you to stop talking so they can go back to business as usual and make you go away.”
Leaders also need to look at building more efficiencies into the electronic health record and anything else that can lighten the administrative burden. “These are the things that allow us to spend more time doing what we went into medicine for — really caring for patients and connecting with them,” Perlman said.
Physicians looking to enlighten leadership about the challenges of burnout can start by being a general advocate for provider wellness. This can help create a culture where physicians can seek help for a variety of issues without being stigmatized as weak, McWilliams said. “You can work toward an environment with realistic expectations and also one with well-accepted interventions for individuals who are experiencing difficulties.”
No matter the rank within an organization, a physician can model the behavior he or she wants others to demonstrate, which includes being open to being vulnerable and starting conversations about the challenges of the job, Porter said.
“Part of the problem is that people don’t always feel safe to talk about what their concerns are,” Charbonneau said. “It’s like for the doctors that complain, the answer is to make that person feel like a troublemaker rather than trying to understand what’s going on.”
A Turning Tide
Burnout didn’t become a major problem overnight, nor will a magical solution banish it from medicine. Volume still plays a huge role in how physicians are reimbursed, and as a result, workloads are likely to remain high. But the question that remains is how health care leaders will respond now that they have a better understanding of its scope and effect on physicians. The outlook is mixed.
“I’m hoping that over the next decade, we develop balanced, realistic expectations of each other with mutual accountability, to be able to recognize issues earlier, to be able to intervene with issues earlier, but also have more comprehensive programs more readily accessible to individuals,” McWilliams said.
To be successful, health care organizations are going to have to settle in for a long commitment to cultural change. “It’s not like everyone will look around and say, ‘Yes, we’ve ended burnout,’” Perlman said. “It’s going to take an ongoing effort to continue to create and support a culture that values the well-being of our employees as much as it values the health and well-being of patients. A number of interventions can get us there, but it’s a matter of implementing them and staying on them and being able to pivot as the moment changes.”
Porter is not optimistic health care is up to the challenge. “Hospitals had not done a great job managing physician burnout before the pandemic, and I don’t really have any reason to believe that they’re going to be doing better going forward,” he said.
And while the evidence may suggest burnout has gotten worse, Perlman said he’s optimistic that the focus on mental health and the efforts to streamline technology will create a world where there is less burnout. “Prior to the pandemic, we were on a trajectory that wasn’t probably sustainable,” he said. “This traumatic moment has facilitated us taking a deeper look and coming up with some solutions.”