Tackling Economic, Emotional Toll of Clinician Burnout Critical

Kerry Dooley Young

May 31, 2019

A former hospital chief executive argued Wednesday for promoting the potential economic benefits of reducing clinician burnout to win support from leaders of healthcare organizations for spending on initiatives like wellness programs.

"You frame it in a context that they can relate to" such as return on investment (ROI), said Ronald A. Paulus, MD, at a meeting held in Chicago by the National Academy of Medicine (NAM). "People always want to know about ROI. ROI is dramatic in this space."

Like his fellow presenters at NAM's Wednesday session, Paulus, a strategic adviser to HCA Healthcare and past president and CEO of Mission Health, also called for greater attention to the toll taken on clinicians and patients by the stresses of the medical workplace.

The meeting was part of NAM's ongoing Action Collaborative on Clinician Well-Being and Resilience. More than 50% of US physicians are estimated to have symptoms of burnout, including a high degree of emotional exhaustion, cynicism, and a low sense of personal accomplishment at work.

On Wednesday, Paulus presented findings from a report issued by the National Taskforce for Humanity in Healthcare, which he helped found. The taskforce last year estimated that the costs of burnout-related turnover may be as high as $1.7 billion annually among hospital-employed physicians, and $17 billion across all US physicians. For turnover of the nursing staff, the hospital cost might be $9 billion annually, with total national costs estimated at $14 billion.

Parsing these numbers at the NAM meeting, Paulus said it can cost 1.2 to 1.3 times the salary of a nurse to replace one, plus the expense for bringing on interim staff, often referred to as "travelers." Losing a physician can cost an organization about $1 million in revenue, plus another $300,000 in combined recruiting and startup costs, he said.

He contrasted the relative lack of focus on these costs from hospital executives with the attention they would pay to other financial drivers.

"If length of stay was costing that much, there damn well would be people all over that," Paulus said.

NAM started the Action Collaborative on Clinician Well-Being and Resilience in 2017 to spur healthcare organizations to take steps to reduce stress on their medical staff. At this time, more than 190 organizations and medical associations have issued statements through NAM's program outlining their intentions to try to ease the stress on medical staff.

Mission Health's statement to NAM's program, for example, includes a plan to boost the "resiliency development opportunities" for staff. It cited an intent to use programs such as Life XT to help people manage stress through cultivating more empathy and mindfulness.

"Pyramids and Copper Bracelets?"

At the Wednesday meeting, Paulus described how he overcame his skepticism about resilience training.

"I'm a data-driven guy," recalled Paulus, who also holds an MBA. "I was like 'What's next? Pyramids and copper bracelets?' "

But the research backing these approaches persuaded him to give it a shot. "The science around meditation, gratefulness, movement, it's as strong as most of what we do in medicine," he said.

In 2017, Mission Health issued a statement about results from a 4-month Life XT pilot program that included physicians, nurses, and administrative staff. It said participants' workplace performance increased by 19% and overall well-being increased by 15%.

NAM is seeking to present executives and leaders of healthcare organizations with more information this fall about how they might revamp operations to address stresses on their staff.

Charlee Alexander, MPH, who directs the Action Collaborative on Clinician Well-Being and Resilience, said at the meeting that a study of systems approaches will be published this fall. This work will consider the impact of electronic health records (EHRs) and the drive toward outcomes-based payments.

Speakers at the Wednesday meeting emphasized the need to allow clinicians time to make bonds with patients. The gathering was hosted by the Chicago-based Accreditation Council for Graduate Medical Education (ACGME), an active partner in the collaboration with NAM. ACGME's own efforts to combat burnout include its "Back to Bedside" program, which is intended keep residents and fellows engaged on a deeper level with their patients.

Several speakers at the conference emphasized the competition from administrative tasks, including documentation in EHRs, that can steal time that physicians would rather spend with their patients.

Results from the recently released iCOMPARE trial, for example, showed that first-year residents, or interns, spend almost five times more hours on indirect patient care than on face-to-face patient care, as Medscape Medical News has reported. Working on electronic medical records and documentation consumed much of the interns' workday. According to the study, interns might spend only 3.0 hours (13% of their time) on direct patient care and only 1.8 hours (7% of their time) on education over a 24-hour period.

"And the rest is noise, 80% of the time is noise," said Timothy Brigham, MDiv, PhD, chief of staff and chief education and organizational development officer at ACGME, at the NAM meeting.

He urged greater attention to what he defined as the "North Star" of medicine.

"It's all about the patient, it's all about connection to the patient and what we've done systematically in our clinical learning environment, in some ways, is take time away from that," Brigham said.

Restoring "the Human Connection"

Another speaker, Holly J. Humphrey, MD, president of the Josiah Macy Jr. Foundation, recalled her experience as the director of a residency program. Before joining the foundation last year, she oversaw undergraduate, graduate, and continuing medical education at the Pritzker School of Medicine at the University of Chicago.

Once she and other leaders of the program got acquainted with the new interns, they would poll them about their concerns about the training ahead.

"Each year we asked the interns what they were most afraid of. And for 14 years, the answer to that question never changed. For 14 years, they told us that they were afraid of two things," Humphrey said. "They were afraid of hurting a patient and they were afraid of losing themselves, losing their humanity in the course of their residency education."

Humphrey also spoke of a patient she remembered well from her own early days in medicine.

Around her second month as an intern, Humphrey cared for an elderly woman experiencing shortness of breath and bronchospasm. Humphrey and colleagues tried to determine whether these symptoms were related to the patient's congestive heart failure or to her asthma. They worked to avoid having to intubate her. Humphrey carefully weighed decisions about dosages of drugs such as aminophylline for the patient.

"I was so focused on all of the details of her management that you can imagine my surprise, after having been up all night with her, when the next morning her question for me was this, 'Doctor, do you have a Polaroid camera?' " Humphrey recalled.

Humphrey said she brought her camera to work the next day. During her presentation at the NAM conference, Humphrey showed a picture taken of her as a young intern with the elderly patient. The woman had wanted to get the photo because this was "the very first time in her life that she had ever had a lady doctor," Humphrey recalled. The patient wanted to send this picture to her two granddaughters in Alabama.

"That's the human connection, that goes beyond the aminophylline and the steroids and all of those things that I spent the night focused on," Humphrey said.

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