Isolation and Burnout in Physician Culture: Innovative Solutions

Interview With Tait Shanafelt

Lidia Schapira, MD


May 29, 2018

Burnout is reaching epidemic proportions across medicine. As just one example, in the 2018 Medscape National Physician Burnout & Depression Report, 42% of physicians reported being burned out, and 15% admitted to either clinical or colloquial depression.

In this interview, Lidia Schapira, MD, an associate professor of oncology at Stanford University Medical Center, talked with Tait Shanafelt, MD, a nationally recognized expert in burnout who recently joined Stanford Medicine as associate dean and the institution's first chief wellness officer, about the causes of burnout and practical solutions at both the individual and system-wide level.

Is Burnout More Common or Are We Just More Aware?

Lidia Schapira, MD: Everybody seems to be burned out these days or talking about burnout. Have things changed, or are we just more aware?

Tait Shanafelt, MD: I think it's a little bit of both. There is definitely greater awareness of burnout in the medical community and at the societal level. Although everybody may be talking about burnout, we also know that the problem is not equally pressing in every occupation and discipline. National studies show that burnout is a more acute problem in physicians than in workers in other fields.[1,2] The field of healthcare has a high risk for burnout because of the nature of the work—caring for patients with complex health problems is challenging and often associated with emotional burden. Among healthcare professionals, studies show that the highest rates of burnout are in physicians; high rates are also found in nurses and advanced practice providers.[3,4] We also know from longitudinal work that the prevalence of burnout may be increasing in physicians.[2] It's a combination of greater awareness and a growing problem.

Big Contributors to Burnout: EHR, Emotional Burden

Schapira: We are hearing more about pressures in terms of documentation. Many people feel that the electronic health record (EHR) has contributed to job dissatisfaction or perhaps even accelerated burnout. How should we think about this? What are the greatest contributors?

National studies show that burnout is a more acute problem in physicians than workers in other fields.

Shanafelt: Burnout is a complex problem. We group the driver dimensions into seven areas: workload, efficiency, flexibility and control over work, work-life integration, meaning in work, alignment of values between healthcare professionals and the organizations for which they work, and community and collegiality. For physicians working in different systems and different specialties, some dimensions are a bigger factor than others. We load the EHR primarily into the efficiency category. It has certainly created changes to our workflows and care processes. In many cases, documentation now takes longer, and click and clerical burden have increased.[5] As organizations have ramped up productivity expectations, physicians also do not always finish documentation and clerical tasks during the workday because the visit lengths have been shortened. As a result, that work is waiting for them at night. Some of the best studies using EHR timestamp data[6] suggest that the average physician works 28 hours/month at night and on weekends when not on duty completing work they were unable to do during the work day.

The EHR has also fundamentally changed the work. Studies[7] indicate that almost 40% of the time physicians are in the exam room with patients is now spent typing and interacting with the computer, rather than interacting with patients. EHRs have fundamentally changed the human-to-human interaction between physician and patient that is at the heart of healing and a critical component of meaning in work. Those are at least two ways the EHR has contributed to the burnout problem. We have shown in national studies, however, that only about 20%-25% of burnout in physicians can be attributable to EHR-related factors.

Will the EHR Get Better?

Schapira: You bring up some great points. We have a lot to learn from the palliative medicine community in terms of how to support each other and form teams that work well. But let me just explore one more thing before we leave the EHR. Some smart people have said that the first 10 years of innovation can be really painful but will get better. Do you think we will look back and say, "Those were the dark days of EHR, but then it got better"? Do you think that the EHR will eventually work for us, or are we stuck in this current mode for the next generation or so?

Shanafelt: I am optimistic that EHRs will get better, but not because it's going to naturally flow in that direction. I think that physicians have reached a point where they are not going to tolerate the inefficiencies in our system and excessive clerical burden anymore. They are demanding improvements in workflow and how EHRs function so that they better serve professionals caring for patients. In today's pressured practice environment, we are asking physicians to maximize the volume of patients they can see due to societal need. Medical care is also now more complex and takes more coordination—do we really want the physician doing low-value tasks that others could perform? Innovative organizations have thought deeply about what tasks require the skill and time of a physician. Those are the ingredients that make people believe we are going to make progress.

Interventions like scribes, virtual scribes, and better team-based care models to improve efficiency, reduce documentation burden, and eliminate low-value clerical work are going to come much sooner than the artificial intelligence EHR systems that listen to our encounters, provide decision support, and complete our documentation and orders as we walk out of the room. That no doubt will come in the future; but, personally, I don't think it's right around the corner. Waiting for such technological advances can distract from the tremendous opportunities to improve workflow and efficiency tomorrow. A number of practices have deployed changes that dramatically improved physician efficiency. Their physicians now go home several hours sooner with their documentation done. They spend more time talking with their patients and feel like meaning and purpose have been returned to their work. The opportunity to disseminate those interventions that already exist is what gives me hope.

Schapira: You mentioned that one of the contributing elements for burnout in healthcare professionals and physicians may be emotional load. Does your work confirm that?

Shanafelt: In medicine, we are exposed to death, human suffering, and the limitations of our current therapy to help many patients. Most providers recognize this as a part of the work that we can't necessarily eliminate. We do, however, need to provide support as healthcare professionals deal with these occupationally related emotional burdens. As an oncology fellow, I remember rotating with the hospice team for 2 weeks doing in-home visits and in-home care. Once a week, at their team meeting, they would light a candle and read the names of the patients who had died in the last week. They provided an opportunity for team members to share a story or reflection about their interaction with that person and their family. Then they blew out the candle and moved on to this week's work. This is a tangible illustration of how professionals built into the workday a specific approach to support each other with substantive, daily emotional burden specific to their specialty. Every specialty and discipline has slightly different emotional burdens and challenges. Not all of us have developed and built in effective support mechanisms to address our unique challenges as strategically.

Innovative Practices for Efficiency

Schapira: Organizations need to be more responsive to this issue because, if not, they may lose part of their workforce, and that would benefit nobody. Can you name a few other innovative practices that could re-engage more physicians in their work, make them feel valued, help them "rekindle" their vocation, and reduce stress?

Shanafelt: The group at Mass General has a framework I like based on four principles: eliminate, consolidate, delegate, and assist.

Eliminate. We do work in our clinics and hospitals that should potentially be eliminated. It's low value. It shouldn't be transferred from one care provider to another. It is unnecessary and should be stopped. It's easy for us to think about many of the documentation requirements that we do in certain settings and circumstances right now that are there only to justify a billing code or imposed on 100% of physicians to try to prevent fraud in 0.01%. They are not there for any medical reason. We should eliminate such wasteful work.

Consolidate. Can things be consolidated? The example I like is the seemingly endless stream of required annual modules: HIPAA training, human subjects, compliance, safety, infection control, and so forth. They are usually done on personal time, and every other month another one pops up. A lot of those types of things can be consolidated into a single once-a-year format. Everything is teed up, integrated, put together, and delivered in a variety of formats: lectures before work or at noon, online. Make it efficient and flexible to complete. That is an example of consolidation.

Delegate. Then there is delegation. Who really needs to take first pass at answering things in your portal inbox? Many of those things are going to end up routed to someone else on the care team like the appointment person, a nurse, or a pharmacist. The doctor is still the first to touch those in many places, and that is something that somebody else should be doing.

Assist. Scribes are an example of assisting. Some things the physician has to be involved with, but they can be made more efficient using a more effective team-based approach that is revenue neutral or even net revenue positive.

Determining Your Biggest Hurdles

Shanafelt: The quality movement has taught us that challenges are unique to the work unit. We've seen the exact same issue when we have worked with different divisions, departments, and clinics to reduce burnout and drive engagement and professional fulfillment. You really have to go to the work unit and use, for example, the seven driver dimensions to think about the biggest challenge and identify things under local control related to that problem that could be improved. Once you identify which dimension is your biggest challenge and how it is manifesting itself locally, allow the team, the people in the practice, to design a strategy to improve it. Pilot it to see if it improves things.[8,9]

I'm always amazed at how much low-hanging fruit there is when I work with units. Most divisions or work units have figured some things out and shockingly neglected other things. I was recently talking to a physician in a large academic center where, in one specialty area with 20 people, they had one of the most integrated team-based care models of physicians, nurses, and advanced practice providers I have seen. The physicians never touched the computer to put in orders. But they didn't have a system to cross-cover their inbox when they were on vacation. This physician was complaining that they had to come out of the woods from their camping trip once a day to clear their inbox messages. One corridor over, in the same building, when someone was on vacation, colleagues covered them. That is an example of a local unit that has not prioritized that issue. There is an easy fix, but it has not been employed yet.

There are often a number of little things like that in every unit pertaining to scheduling, cross-coverage, triage, the rooming process, team-based care, workflow, and how things are delegated. There are almost always opportunities to improve those processes.

Building more collegiality and community and support of colleagues is a huge opportunity.

Physician Culture

Schapira: We know that the physician culture is one where many of our colleagues feel very isolated and may be reluctant to share how much they are distressed with other colleagues. Perhaps the reason things have gotten so bad is that, as a group, we have not known how to advocate for ourselves. Can you comment on temperament or the acculturation of physicians that may lead someone to feel very burdened or perhaps put them on a path to excessive stress and burnout?

Shanafelt: Some of the things that make us good physicians also make us vulnerable to burnout. Many of those qualities are strengthened and buttressed by our culture and system of training. We tend to be perfectionistic and often hold ourselves to unachievable standards. In studies, about 80% of us describe ourselves as either workaholics, type A personalities, or excessively controlling.[10] We believe that we are superhuman and that fatigue, illness, and normal human limitations do not apply to us. We generally don't reveal our vulnerabilities or the things we're struggling with to our colleagues. Many of these behaviors are reinforced as professional norms during training. Our training systems, even today, tend to be based on overwork and trial by fire and do not necessarily encourage vulnerability with colleagues.

How do we address these issues? Some of them are more challenging than others. Building greater collegiality, community, and support of colleagues is a tremendous opportunity. We, as physicians, are very committed to our colleagues. We care about them deeply and want to support them, especially when they are dealing with professional challenges. The busyness of today's practice environment has frayed or weakened some of those relationships and interactions that we have with colleagues.

This is an example where mindful organizations can engineer opportunities for colleagues to meet and have conversations about the virtues and challenges of being a physician—even if it's just a division, a department, or a group of physicians. Schwartz rounds or Balint groups have formats that some organizations have used in that way. I think that there are also opportunities to build smaller, consistent communities that may have even greater personal impact.

We conducted a couple of randomized trials[11,12] at Mayo Clinic led by my colleague Colin West exploring different ways to build physician communities. We created groups of colleagues who met every 2-3 weeks to engage in a conversation about a topic related to the virtues and challenges of being a physician so that they could share experiences, support one another, and enjoy one another's company. Two randomized trials have now shown that such groups not only reduce burnout, they also lead to improved meaning in work, and these benefits are durable for at least 18 months. It's a very low-cost intervention. At the heart of it, they are reconnecting colleagues with each other and reminding them of the many great things about this profession and the work that we do each day. This is a huge opportunity and one that is readily adaptable to all specialties and practice settings.

Schapira: Perhaps the younger generation will come into this more naturally because they are more used to connecting through social media and may feel more accompanied whenever they face a challenge. Do you think things will get better because they are so open and used to being more creative with how to engage with each other?

Shanafelt: I don't know. Being vulnerable, sharing experiences, and working through challenges face to face is different from an online experience. The types of things that are unlocked in these group conversations may not be as easily achieved electronically.

Regardless of the format, it's important to create psychological safety so that participants feel that they can be vulnerable with their colleagues. Many physicians always have their "team leader" hat on when in the work environment with the multidisciplinary team. It's not until they are in a room of trusted colleagues that they can pull the curtain back and let their guard down. It would be nice to think that the younger generation will naturally do some of those things, but if we don't work on incorporating those qualities and behaviors into the professional culture, we might just acculturate them into the well-established professional norms the minute they exit training.

It's important to create psychological safety so that participants feel that they can be vulnerable with their colleagues.

Building a Safe and Supportive Community

Schapira: What are a few easy, specific ways of engaging folks in this effort to build a community that is supportive and safe over the long haul?

Shanafelt: Any physician can say, "I feel like I don't connect with my colleagues as much anymore, so I'm going to invite four or five people that I enjoy spending time with to go to dinner every fourth Thursday." That is worth doing. But if we really want to make inroads into this at a broader level, we need to think about these things from the systems and organizational perspective and at the professional level. We need to create such community if we are going to stay engaged, fresh, fully committed, and compassionate in what we bring to this over the course of a career. We often refer to this system aspect under the rubric of a "culture of wellness." A culture of wellness is not about encouraging people to pursue self-care activities or develop personal resilience (although those are good things). It's about the values and behaviors of the organization—the expectations, training, and accountability of the leaders; providing physicians the ability to co-create their work environment in partnership with peers. It includes values alignment between healthcare professionals and the organization, peer-support, flexibility, appreciation, and giving people voices, input, and the ability to fix the broken windows in their local work unit. It requires attention to system-wide initiatives and processes for community or collegiality to occur.

In the second trial of community groups at Mayo Clinic,[12] we had seven or eight colleagues meet for dinner every 2-3 weeks. They were asked to spend 15 minutes discussing one of the questions we provided, and then they enjoyed each other's company. We paid for the meal. Half of the groups were randomly assigned to begin meeting immediately and the other half to begin meeting 6 months later. After the first 6 months, the groups assigned to immediate start had reduced burnout and improved meaning in work. When we presented the results to the Mayo Clinic board, they recognized that the intervention was scalable, cost-effective, and made a difference. They immediately approved it to be a standard benefit for all Mayo Clinic physicians and scientists. We had no idea what the uptake would be. People registered their group, received the questions, began to meet, charged the meal on their corporate card, and Mayo paid for the meal. Everyone told us that no one would sign up because the last thing anyone wanted was another night away from their family. Fifty percent of the faculty in Rochester joined a group within the first 16 months or so. It was a bit shocking to us. We had tapped into a huge unmet need. People were getting something out of those sessions that was different from conversations they had in other settings that often focus on the day-to-day hassles and frustrations. They were able to reconnect with colleagues and the deeper meaning, purpose, virtues, and challenges of our work in this profession. The structure of the intervention also draws people in. When a couple of colleagues decide to form a group and invite a few colleagues, others who might not have formed a group on their own participate.

This is just one example of how an organization can create structures and processes to create a culture of wellness.

Organizations 'Need to Pay Attention'

Schapira: That is brilliant. I think what I'm hearing you say is that this is something that is not optional. Organizations need to pay attention, and if they do not, they do so at their own peril.

Shanafelt: That's true. There is a moral and ethical case for organizations that care about their people and recognize that most of the work they do is predicated on talented, engaged, and dedicated healthcare professionals. Other organizations care because of economic factors, recognizing the cost of turnover and the strong evidence of burnout on productivity and quality of care, patient satisfaction, lower professionalism, and the ripple effects of these factors on the whole care team. Sadly, some do not awaken until tragedy occurs, often in the form of a suicide of a faculty member, a resident, a fellow at their center. But at the end of the day, there are unequivocally effects on access, quality, cost, and patient satisfaction. All of our organizations claim that those are the things that we are pursuing, and we can't achieve them with a burned out group of physicians, nurses, and advanced practice providers.

Organizations have to be committed to this if they want to achieve their mission. It's very much analogous to the quality movement. There was a time when the quality movement was at its nascent stage, and nobody evaluated quality. They assumed that they had good quality because they had dedicated, well-trained professionals. Then organizations started measuring quality and being honest with themselves. "Maybe we're not as good as we think we are." Many initiated quality programs as a necessary cost of "doing business." At some point, vanguard institutions realized that the quality journey is not a cost center. It's a fundamental core strategy that is the vehicle for their organization to achieve its goals. I think that we're at a similar inflection point where the vanguard institutions have recognized that we're really at the same place with the well-being of healthcare professionals. Having an engaged, committed, compassionate workforce that is not burned out is a core strategy for the organization to achieve its mission. We have to think about how to create an organizational system and culture to achieve that outcome.

Paul Harvey came on the radio and talked about a study from the University of Washington showing links between burnout and quality of care.

A Budding Interest in Burnout and an Unexpected Shout-Out From Paul Harvey

Schapira: What got you interested in this?

Shanafelt: It was a little bit of a fluke. I was on a research rotation as a senior resident at the University of Washington with Dr Tony Back, who has been a career mentor to me. Tony was asking me what I wanted to work on, and I said that I wanted to study the experience of residency. Being the great mentor that he is, Tony asked a number of questions about what I was observing and what my hypothesis was. I relayed that, now that I was a senior resident, I was observing residents I was supervising behaving in ways that were inconsistent with who I knew they were as people and incongruent with their dedication and altruism. "Why do you care?" Tony asked. I said, "It's affecting the patients we are caring for." He said, "I think you're talking about burnout. I’m not an expert in that field or a survey researcher, but I know some people who are. Let me help put together a team, and let's develop a project."

We did that small, pioneering study[13] almost 20 years ago. It was one of the first studies looking at the links between physician well-being and quality of care. It was a lightning rod when we published it. I remember it vividly. I was in fellowship when the paper came out and was riding a shuttle bus from one hospital to another hospital on the Mayo Clinic campus. Paul Harvey came on the radio and talked about, "a study from the University of Washington showing links between burnout in physicians and quality of care." I was sitting there dumbfounded on the bus, like, "Oh, my gosh, that's our study!"

It was an eye-opening moment. A small, unfunded, but rigorously conducted research study led by a resident created a national dialogue. [Editor's note: That study has now been cited by more than 750 other peer-reviewed manuscripts.] Education leaders at Mayo and several professional societies around the country approached me, asking, "Would you help us do a study to explore this further?" It snowballed, and eventually we moved into clinical trials testing interventions. I had the good fortune to have two amazing partners, Drs Colin West and Lotte Dyrbye, join me shortly after I arrived at Mayo Clinic. We have subsequently published over 120 peer-reviewed manuscripts on this topic. But I remember that initial epiphany. Approaching the problem in a methodologically rigorous way using the scientific method had the potential to change the world. Just like in my leukemia research, that approach would provide the evidence to understand the problem and address it. Over time, studying the work-life of physicians and other healthcare professionals became an increasingly larger focus of my professional research life.

Walking the Walk

Schapira: We are all happy that you followed that instinct and found the right mentor. I imagine that you are incredibly self-aware. Do you have a special way of checking in to make sure that your work-life balance is where you think it ought to be? Do you monitor yourself for signs of excessive stress?

Shanafelt: I do. I have a variety of ways to "self-calibrate." I have established practices and rituals I use to disconnect from work and to make sure I'm taking care of myself and keeping engaged in the things that give meaning and purpose to me, both personally and professionally. I am really good at saying "no" and limiting the things that are not the highest priority for me. My wife is a great partner and keeps me accountable, too. She will jokingly say, "Hey, you'd better walk the walk on some of these things," if I have been traveling too much, burning the midnight oil writing a manuscript, or letting work spill into personal life too many nights in a row. She reminds me to take time to recharge. She has been a wonderful partner in helping me monitor myself.

Schapira: We are delighted that you have her. It's been fun chatting. We may want to connect back to you and hear about your vision for correcting some of these trends [in burnout]. I'm incredibly thankful to you for your time.


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