COMMENTARY

Beating Burnout: Advice From Physician Experts

Arthur L. Caplan, PhD; Carol A. Bernstein, MD; Christine Sinsky, MD; Robert W. Brenner, MD, MMM; Richard I. Levin, MD

Disclosures

August 22, 2016

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Medscape held a panel discussion called Beating Burnout: An Essential Guide for Physicians on July 28, 2016. Following are excerpts from that summit.

Arthur L. Caplan, PhD: Managers, chaplains, all kinds of folks are involved here in trying to understand the phenomenon of burnout. While we won't solve the problem tonight, I hope we come away with an understanding of what it is, what are some of the ways to cope with burnout, what are some of the causes of burnout, and what are some of the systematic organizational problems that create burnout?

You may be feeling, "I didn't go into medicine for this to be managed or told I have to see x number of patients in y amount of time," or "I don't have the kind of interaction that I wanted." What can you do to start to personally cope with these feeling or the reality of burnout? I'll go to Carol first. Should we all do yoga?

Carol A. Bernstein, MD: For some, it's really helpful. One of the challenges about burnout is how to deal with it; how to build resilience in ourselves is a very individual thing. It is important for people to sit and think about the kinds of things that they can do that make them feel better, whether it's going out for a nice meal or doing yoga. Or it might even just be having an opportunity to have time off.

One of the biggest problems that we face is time compression. More and more has to be done with less and less time, even for yoga. So we can't think about that unless we can think of some way to decompress what we do. It may be related to the system issues you raised, Rob, but we have to figure out, within the systems that we work, how we can provide opportunities for us to have both meaningful interactions with patients and to feel better about ourselves without adding another layer on, another regulation—another thing to do.

Christine Sinsky, MD: I would actually suggest that about 80% of burnout is driven by organizational and systems factors, and a smaller minority, on the order of 20%, is driven by individual factors. It's good for all of us to be mindful, to do appreciative inquiry, and to take care of ourselves with exercise to get some distance from our work. But the most effective thing we can do to reduce burnout is to improve workflow. And Mark Linzer's work at Hennepin demonstrates that.

At Hennepin County in Minneapolis, they have found that by improving workflow, you can have an odds ratio of 6 of reducing burnout. It's the most potent intervention to reduce burnout. For most primary care physicians, we can save 3-5 hours a day by reengineering how the work is done and by building stronger teams around the physician. And that goes a long way toward reducing burnout.

Dr Caplan: I just want to note, by the way, before I let Rob jump in, that very few people want to take the option of leaving, so they are trying to find ways to either personally cope or do some of these workflow shifts and so on.

Robert W. Brenner, MD, MMM: There are some elements that we may miss that I don't want to exclude in terms of workflow, which is key. It's one of the most important things to deal with. But there's something else that is really important, and that is that a lot of physicians feel that they are unheard. They have lost control in their organization. Let's face it: A lot of physicians in this country are now in employment models or working for healthcare systems, and they feel a lack of control and are not being heard.

That's a critical element. The way to tackle that—and it's not easy; we all agree that it is complex—is to look at the culture, to look at how invested the organization is in tackling this problem, in dealing with it, and not just setting up a yoga or a wellness committee (which are all very good, because these things will start to address the problem and bring more awareness). But it's having a culture where a physician who is experiencing burnout will feel very comfortable about coming forward and saying, "I think I'm burned out," or will be more comfortable with a colleague coming up and saying, "I think you're burned out; let's talk about that." And having a means of addressing that.

Dr Caplan: So, I heard two things there. One is that it's not necessarily a matter of shame if one responds to tough working conditions with burned-out behavior, so to speak. And then I also hear you say that if you could incentivize the opportunity to make your feelings known, and Rob said this too, if the organization will do that, that gives pathways to at least starting to drill into the problem.

Dr Bernstein: Change can happen. It's critically important for it to come from—I hate to say this but—the top down. Leadership has to be genuine and authentic if they're going to say, "We really care about how you feel." We care about the system.

Dr Caplan: Let me jump in. So, should boards and trustees be expecting that from leaders?

Dr Bernstein: Well, I certainly hope so. Again, I don't want it to be just another cog in the machine, but authenticity and proof of concept in leadership are critical if this is going to succeed. If the people at the top don't believe in this and they don't care about it, I don't care what institution you're in, it's not going to happen.

Dr Caplan: In coping with organizational change, are there natural allies? Are there people to go to? I mentioned the trustees as one example for the leaders. But should we be thinking about involving patients in helping us struggle with burnout? What do we do to find allies beyond self-management types of solutions? (Which I'm not against.) And, clearly, streamlining that workflow is drawing attention off of this question.

Dr Bernstein: I'm always a believer that if people come together and voice the concern collectively, then we'll make more of an impact. That's the best way that I can think about it. The other thing that I've noticed is that as we've started to have this conversation about both burnout and depression, everybody wants to talk about it. So if everybody wants to talk about it, it's clearly an issue of concern. And we do better in groups trying to bring it up the chain and whatever institutional organization that we're in. I mean, that would be something I would think about off the top.

Dr Sinsky: One takeaway is that care of the patient requires care of the provider, and we need to focus on health professional well-being, on reducing burnout, improving the opportunities for joy in practice, if we want to reach all of the other goals. The other thing is that clinical excellence depends on operational efficiency, and if we focus on operational efficiency, we'll get clinical excellence, which is what also drives professional satisfaction.

Richard I. Levin, MD: Many of the solutions that have been described and the observations made have to do with the fact that, as physicians, we need to organize in novel ways nationally and speak up in a way that we haven't done since Medicare was passed in 1965. The purpose of that is to reestablish the relational aspect of medicine, which simply requires time, and that is why the entire audience responded to the notion of streamlining workflow.

Dr Caplan: Are we putting doctors in the position where their training doesn't match the kinds of tasks that they're being asked to do?

Dr Brenner: With the burgeoning tasks that we have now to accomplish, something has to change. You have heard about "top of the license." Why are physicians putting in data that can be put in by a nurse's aide or a nurse? And front-desk staff should be part of the team. A team-based care model is most effective, and you have it in your office personally.

 
We have to act like chief executive officers. We can no longer feel that we must take every single click and task upon our own shoulders.
 

[Dr Sinsky answers a question from the audience]

Dr Sinsky: You're absolutely right that the solution has to involve relief from doing work that doesn't require 11 years of education. Right now, particularly in some fields, physicians are spending the majority of their day doing work that does not require their education and training. We have to change that.

One of the things we're doing at the American Medical Association is creating a series of practice transformation toolkits. They're free and online. You can go to them now. One is on shared documentation—we call it team documentation. It's a portion of advanced team-based care in which a clinically trained person stays with the patient from the beginning to the end of the appointment and does a lot of work around care coordination and patient engagement, and helps with data entry. That has been one of the more powerful ways of letting physicians do physician-level work. You're absolutely right: We have to act like chief executive officers. We can no longer feel that we must take every single click and task upon our own shoulders.

Dr Caplan: Let me thank all of you for coming out tonight. Let me thank all of the people who are with us electronically in the Facebook and Twitter worlds. I'm sure that Medscape will continue to try to grapple with this issue. I can't promise you that I know exactly what direction that will take, but it's obviously a major issue for the audience that works to appreciate Medscape's products and activities.

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