Experts Detail Proposals to Improve Clinician Well-being

Marcia Frellick

November 28, 2018

Physicians, nurses, and other healthcare leaders, speaking Tuesday before a committee of the National Academies of Sciences, Engineering, and Medicine, laid out what it will take to improve clinician well-being in the next decades.

Speakers touched on improving work environments and electronic record usability and easing recertification and documentation demands.

The meeting, conducted in Washington, DC, and livestreamed, was the committee's second open session on the topic this fall. Over the next months, the committee will continue to gather information and draft a report with conclusions and recommendations. The final report will be issued in the fall of 2019.

Changing the Culture of Blame

Marc Moss, MD, vice chair of clinical research at the University of Colorado School of Medicine (UCSM) in Aurora, noted that burnout is an occupational health problem and said it needs to be viewed that way.

"We would never blame the coal miner for developing lung disease and say that there's something they could do differently. This is a problem with our profession," he said.

One way that UCSM addresses mental wellness is its opt-out system for internal medicine residents to meet with a mental health counselor in a wellness center, which takes away the stigma.

The system also waves copays for mental health visits and makes the services much more available, which mimics efforts by police officers and social workers, for instance, Moss said.

Autonomy and Staffing Issues Feed Nursing Burnout

Matthew McHugh, PhD, JD, MPH, CRNP, RN, FAAN, associate director for the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing in Philadelphia, said that lack of autonomy and poor staffing are two key burnout drivers for nurses and other clinicians.

Addressing those issues may not require inventing a new model but looking to the Magnet nursing model, he said.

"We know that when nurses work in Magnet hospitals — hospitals that have these characteristics around more autonomy, effective leadership, adequate staffing and resources — nurses are less likely to be burned out. We also know that patient outcomes in these hospitals, accounting for differences in patient mix, are also better in Magnet hospitals," McHugh said.

He said that a question often asked is whether better pay can reduce burnout.

He answers, "Wages are important, but what we found when we account for wage differences across hospitals is that for nurses, differences in the work environment still really matter in terms of burnout. You can't pay away a bad work environment."

McHugh also urged more funding for researching burnout, a topic for which there currently is "not a huge appetite," he said.

Back Injuries and Assaults Should Figure in the Conversation

Laura Punnett, ScD, codirector of the Center for the Promotion of Health in the New England Workplace, said it's important to include certified nursing assistants when discussing clinician burnout, particularly because they perform much of the direct care in nursing homes.

"The work environment impacts them very much," she said. "We can use data from nursing assistants to get good understanding and insights as to what we want to be doing in terms of prevention."

Punnett said that burnout is not the only measure of staff well-being that should be considered.

For instance, "We haven't yet been able to put empirical data to the connection between having, for example, chronic back pain and how that may impact care of your patients," she said.

As to the best places to start in reducing burnout in nursing homes, Punnett said, "In addition to back injury, which is an enormous issue for the majority of direct-care providers in nursing homes, another issue that reaches almost epidemic proportions in some setting is assault by residents and residents' visitors."

"Institutions can do a lot more to make the workplace safer," she said.

Electronic Health Records

Several speakers pointed to problems with electronic health record (EHR) systems, and particularly documentation requirements, as a key factor in burnout.

David W. Bates, MD, medical director of clinical and quality analysis, information systems, at Partners HealthCare System, Inc, in Massachusetts, said that research he coauthored looked at how other countries use products from the EHR company Epic and studied their feelings about it relative to physicians in the United States.

"We've noted that physicians in other countries were far more likely to be satisfied with its use and they even cited it as improving its efficiency. Notably, the clinical notes in the US were four times as long as those in other countries. Physicians spend 44% of their computer-facing time on documentation and just 24% on overall time on communication with patients," he said.

Bates noted that use of medical scribes is often proposed as a way to ease the burden, but he sees that as only a temporary solution.

"We ought to be able to build electronic health records that just make it easier to document," he said.

His recommendation includes that the Centers for Medicare and Medicaid Services continue to ease documentation requirements and modernize payments to support virtual care.

"I believe that electronic health records will eventually deliver great benefit," he said.

Changes in MOC

Physician backlash over maintenance of certification requirement is well documented, and Mira Irons, MD, senior vice president for academic affairs at the American Board of Medical Specialties (ABMS), said that ABMS is addressing many of the concerns.

The largest changes in the past few years, she said, are the new ways to assess knowledge and clinical judgment.

"I'm happy to say almost all of the boards have now developed and are piloting alternatives to the 10-year, high-stakes examination that incorporate modular content that's more relevant to practice," Irons said.

Several of the boards are using more frequent lower-stakes exams that physicians can take at home. Some boards are also focusing on article-based assessment — reading a certain number of articles and being tested on the content.

ABMS approved convening an independent commission to hear testimony over 2018 and make recommendations to the board about a vision for the future of continuing board certification programs. The recommendations will come in December, followed by a public comment period, and a final draft will be shared with the board at its February 2019 meeting.

Irons is employed by ABMS. Other speakers declared no relevant financial relationships.

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