Want to Reduce Burnout? Tackle System Problems, Experts Say

Diana Mahoney

January 26, 2018

Clinician burnout is a systemic, multifactorial problem that requires a systemic, multifactorial solution and an industrywide call to arms, key opinion leaders and experts stress in a pair of articles published January 25 in the New England Journal of Medicine.

A recent Medscape survey, for example, found that 42% of physicians report burnout. The new reports, however, suggest healthcare organizations and advocacy groups are beginning to take action.

Tackling the burnout crisis effectively requires an aggressive, concerted effort of key influencers, Victor J. Dzau, MD, and colleagues from the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience, write in a new perspective published in the January 25 issue of the journal. "[N]o single organization can address all the issues that will need to be explored and resolved."

Yet, no mechanism currently exists for "systematically and collectively" gathering and analyzing clinician burnout data, the authors explain. "The problem is not lack of concern, disagreement about the severity or urgency of the crisis, or absence of will to act," they write. "Rather, there is a need to coordinate and synthesize the many ongoing efforts within the health care community and to generate momentum and collective action to accelerate progress."

The authors believe the National Academy of Medicine (formerly the Institute of Medicine) is well suited to coordinate the efforts of a wide range of stakeholders (organizations, clinicians, information technology vendors, payers, policy makers, and patients) whose input will be essential to achieving sustainable solutions. "Nearly 20 years ago, the [Institute of Medicine] report To Err Is Human identified high rates of medical error driven by a fragmented care system. The report spurred systemwide changes that have improved the safety and quality of care," they explain. "Today, we need a similar call to action." 

The charter of the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience is to achieve just that by curating available research, facilitating knowledge sharing, and spurring action. To date, more than 100 national organizations have joined the collaborative and support its four central goals:

  • increase the visibility of clinician stress and burnout,

  • improve healthcare organizations' baseline understanding of the challenges to clinician well-being,

  • identify evidenced-based solutions, and

  • monitor the effectiveness of the solutions' implementation.

Because the current body of knowledge suggests burnout is largely driven by external factors, such as inefficient work processes, long work hours, heavy workloads, work–home conflicts, and organizational culture considerations, "the collaborative will focus initially on promoting solutions and progress at organizational, systems, and cultural levels," Dr Dzau and colleagues write.

One of the first key deliverables from the collaborative, expected sometime this year, will be an online knowledge repository, or hub, of available data, models, and toolkits, which will be available for other organizations to use in their own endeavors.

The commitment of the organizations participating in the collaborative indicates that clinician well-being is a high priority for healthcare decision makers and provides "reason to be optimistic" that the efforts will stem the tide of clinician burnout, the authors write. "Through collective action and targeted investment, we can not only reduce burnout and promote well-being, but also help clinicians carry out the sacred mission that drew them to the healing professions — providing the very best care to patients."

Local Efforts Underway

Many health systems have begun testing programs to reduce burnout among their clinicians. Stanford University's School of Medicine, for example, pilot tested a "time banking" program to compensate physicians for some the time they spend on work-related activities that fall outside their caregiving duties and that contribute to their feeling overburdened, according to the authors of the second perspective published in the January 25 issue of the journal.

In exchange for time spent on such tasks as mentoring, serving on committees, and covering shifts for other providers, Stanford's pilot program allowed faculty members to receive work- and home-related services: meal delivery, cleaning services, or grant-writing support, for instance, New England Journal of Medicine national correspondents Alexi A. Wright, MD, MPH, from Harvard Medical School and the Dana Farber Cancer Institute, and Ingrid T. Katz, MD, MHS, from Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts, explain.

The initiative was successful, particularly among female faculty members, who in a survey conducted by the school were most likely to report feeling unsupported or undersupported in their career development. "Though this initiative was meant for all physicians and basic scientists, women used these services more frequently than men, and the number of female faculty members who reported 'feeling supported' had nearly doubled by the end of the pilot program," the authors write.

Programs such as time banking signify an important cultural shift in medicine, according to Tait Shanafelt, MD, who joined Stanford Medicine in September 2017 as the organization's chief wellness officer. Stanford is the first academic medical center in the country to create an executive-level position of this kind focused specifically on clinician well-being. But many more will likely follow as the true cost of burnout — medical errors, poor clinical outcomes, high turnover, low engagement — becomes increasingly obvious, Dr. Shanafelt said in an interview with Medscape Medical News. "Physician burnout is eroding the soul of medicine. Organizations need to constantly gauge the well-being of providers and develop and implement research-based interventions to address the practice considerations that contribute to clinician suffering."

At the Mayo Clinic, measurement of physician well-being has become a strategic priority "to identify divisions and departments that need help," Dr Wright and Dr Katz write. "Physicians are also asked to evaluate the leadership skills of their immediate supervisors, since a 2013 study demonstrated that every 1-point increase in a 60-point measure of leadership was associated with a 3.3% decrease in physician burnout." Coaching and other support services are offered to leaders, as needed, to address performance gaps.

In some organizations, clinical care models are being redesigned to reduce clinicians' noncaregiving workload, with an eye toward burnout reduction. One example is a team-based model adopted by the Department of Family Medicine at the University of Colorado. The group has implemented a system called APEX, for ambulatory process excellence, whereby many of structured processes involved in a visit (data collection, medication reconciliation, patient education, and visit documentation, for example) are handled by a medical assistant, freeing up the primary care provider to focus on the exam and medical decision making. The team-based approach, the authors write, required adding staff, training, and new communication systems.

"Within 6 months after the APEX launch, burnout rates dropped from 53% to 13%," the authors report. Additional benefits included improvement to multiple preventive health measures (mammogram, colonoscopy and vaccination rates), reduced wait times, and more patient visits per day. The success of the initiative has led to expansion plans across other clinics in the organization.

Although effective, these examples "may not address the fundamental question of how physicians can reclaim joy in the practice of medicine," Dr Wright and Dr Katz state. "Such a transformation will first require investments from senior administration in academic medical centers and individual practices to recognize and measure the extent of the problem." The fruits of those labors can then drive policy changes and innovative solutions targeting clinician well-being, they note.

The article authors and Dr. Shanafelt have disclosed no relevant financial relationships.

N Engl J Med. 2018;378:309-314. Wright full text, Dzau full text

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