The Business of Burnout: Boosting Physician Resilience Pays

Diana Phillips

September 26, 2017

Hospitals and health systems cannot afford to ignore physician burnout. That is the message from a new report outlining the business case for addressing burnout at the organizational level.

Previous research has estimated that half of all US physicians experience burnout, and studies have shown that physician burnout influences care safety and quality, as well as physician turnover and patient satisfaction, the researchers write.

Tait Shanafelt, MD, from Stanford University, Palo Alto, California, and colleagues report their findings in an article published online September 25 in JAMA Internal Medicine.

Despite awareness of the high prevalence and potential consequences of burnout, characterized by emotional exhaustion, cynicism, and reduced professional effectiveness, "little has been done to address this problem," the authors write. They attribute the "anemic" response to a lack of awareness of the financial burden that burnout exerts and uncertainty about what can be done to reduce or prevent it in today's healthcare culture.

Considerable Financial Burden

To address the first issue, the authors reviewed the available evidence, looking at the financial costs associated with physician turnover. These include direct costs tied to recruitment and indirect costs resulting from lost revenue during recruitment, onboarding, and training, as well as the costs associated with decreased productivity and those influenced by diminished quality, safety, and patient satisfaction on performance. Using the evidence, they developed a worksheet to project the organizational cost of burnout on the basis of the number of physicians in the organization, performance characteristics (safety, quality, turnover, and patient satisfaction), and standard financial calculations. They also developed a worksheet to estimate the return on investment of an intervention to reduce burnout on the basis of decreased turnover.

"Consider a hypothetical organization that employed 450 physicians, had an annual turnover rate of 7.5%, and which had typical replacement costs of $500 000 per physician. The annual organizational cost of physician turnover would be approximately $16.9 million/y," the authors write. On the basis of a national prevalence rate of 50% and evidence suggesting that burned out physicians are twice as likely to leave an organization as their more engaged peers, "the amount of turnover attributable to burnout for this organization would be approximately 2.5%/y," the researchers estimate. They note that the overall turnover rate comprises a 5% rate among physicians without burnout and a 10% rate of those who are burned out.

If an organizational intervention that costs $1 million per year could produce a 20% reduction in the relative risk for burnout, from 50% to 40%, "[t]he associated organizational cost savings would be $1.125 million per year," the authors write, noting that this 12.5% return on investment is conservative. "[I]t does not account for lost revenue due to decreased productivity among burned out physicians who do not turn over or consider the other benefits of reduced burnout with respect to patient satisfaction, quality and safety, and potential reductions in litigation risk." Additional financial benefits would be realized by associated improvements in clinical performance and patient satisfaction, they explain.

Organizational-Level Interventions More Effective Than Physician-Level Interventions

These estimates highlight the strategic importance of reducing physician burnout at the organizational level, and a review of the available evidence suggests that doing so is possible, the authors write. They reference two systematic reviews and meta-analyses that show organizational interventions can reduce burnout and are more effective than physician-level interventions. In one of the meta-analyses, reported by Medscape Medical News, organization-directed approaches that include consideration of the work environment were particularly beneficial.

Effective burnout reduction strategies require an understanding of the dimensions that drive burnout, the authors explain. These include workload, efficiency, flexibility and/or control, culture and values, work-life integration, community at work, and meaning in work. "Organizations can often make profound and effective changes in several of these dimensions (eg, flexibility and/or control, efficiency, community at work, and meaning in work) with limited investment," they write.

Although not necessarily costly, these changes "typically require a strategic plan customized to the local environment along with prioritization, commitment, and follow-through at the highest level of the organization," the authors stress. "Commitment from executive leadership is the prerequisite, assessment the first step, and frontline leadership a force multiplier."

"Downstream, Indirect Costs...Immeasurable"

The financial estimates in this report likely underestimate the actual cost of physician burnout by an order of magnitude, given that the they reflect just one of multiple consequences of burnout, according to Maria Panagioti, PhD, from the National Institute of Health Research School for Primary Care Research at the University of Manchester, United Kingdom, and lead author of one of the meta-analyses cited in the report. "The downstream, indirect costs, including the public health burden of potentially suboptimal, unsafe care, are immeasurable."

By looking at burnout from a cost perspective, "this report adds to what we know about physician burnout: that it is a serious and complex problem threatening those who give and receive care," Dr Panagioti told Medscape Medical News. "If we want to retain professionally competent physicians and ensure high-quality care for patients, the well-being of physicians has to be prioritized and supported."

Because physician burnout is multifaceted, strategies to address it must be multifaceted as well, Dr Panagioti said. "Burnout is driven by workload, imbalance between job demands, and prolonged stress. The only way to prevent it is through a combination of interventions that target these drivers."

Another important contribution of this study is that it makes "the need for more holistic assessments of the benefits of organizational interventions...apparent," Dr Panagioti said. "Future trials of organisational interventions for burnout should not only report health outcomes (improvements of burnout scores; turnover rates) but also economic outcomes (cost-effectiveness analyses using these formulas) if we want to achieve policy change."

Dr Shanafelt is coinventor of and receives royalties for the Physician Well-being Index, Medical Student Well-being Index, and Well-being Index, instruments for which Mayo Clinic holds the copyright and has licensed for use. The remaining authors and Dr Panagioti have disclosed no relevant financial relationships.

JAMA Intern Med. Published online September 25, 2017. Abstract

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