Beating Clinician Burnout

Clinician burnout is pervasive in the healthcare industry, yet many healthcare leaders are unsure of how to solve the issue. If it is left unaddressed, healthcare organizations may experience quality, safety, and retention problems.

Signs of clinician burnout—a response to chronic workplace stressors—have become a reality in the healthcare industry.

"It's somewhere between 30% and 50% nationally in physicians and it is rising," says Mark Linzer, MD, FACP, director of the division of general internal medicine at Hennepin County Medical Center in Minneapolis, which includes a 484-staffed-bed safety-net hospital, downtown clinics, and a system of neighborhood clinics. "The data are pretty compelling depending on which instrument you use for measuring it."

A study published in the December 2015 issue of the Mayo Clinic Proceedings found just that. When researchers surveyed 6,880 physicians in 2014, 54.4% of them reported having at least one of the three components of burnout on the Maslach Burnout Inventory—emotional exhaustion, cynicism, and inefficacy—compared to 45.5% in 2011.

"With 50% of people experiencing at least one component of burnout nationally, you're looking at problems with morale and turnover. There are risks to patient safety, quality, and patient satisfaction, not necessarily from the burned-out physician, but from the adverse work conditions that led to the burnout," Linzer says.

The prevalence of burnout in healthcare should be cause for concern, not only for the clinicians experiencing it but for healthcare executives as well. Burnout is not, as many believe, a failing of an individual. Rather, it's a sign that something is amiss within an organization, and that systemic dysfunction can prevent an organization from achieving the desired outcomes of today's value-based care efforts.

To have success in the current healthcare environment, healthcare leaders need to do more than simply acknowledge that burnout exists. They need to uncover the root causes of burnout at their organizations and implement systemwide changes to fix it.

Measurement is key
Healthcare executives may be aware that burnout is common in the industry, but they seem to be less certain about the specifics of how it's playing out at their organizations.

Karen Weiner, MD, MMM, CPE, chief medical officer and CEO at Oregon Medical Group, a physician-owned, primary care–based multispecialty group of about 140 healthcare providers, with offices throughout the Eugene and Springfield area, received 151 replies for her survey of three of AMGA's leadership councils (Chief Executive Officer/Board Chair/President council; Chief Medical Officer/Medical Director council; and Chief Administrative/Chief Operating Officer council) in the fall of 2015. The survey results show that 86% of CEOs, 86% of CMOs, and 81% of COOs reported that they thought burnout was a problem within their organizations. But when asked if they were doing formal assessments of physician burnout at their organizations, only 21% of CEOS, 18% of CMOs, and 21% of COOs said yes.

Linzer, who has been researching physician work-life since the 1990s, says measurement is key to tackling burnout.

"You can't reduce burnout without measuring stress and the things that cause it," he says.

He advises that leaders distribute an annual wellness survey like the 10-item Zero Burnout Program survey, also called the Mini Z, which he and his colleagues at HCMC helped develop.

"They should measure some metric of wellness that they can report—satisfaction, engagement, stress, burnout, turnover—but they should have something to point to about the health of their workforce," he says.

Once leaders understand the extent of burnout at their organization, they need to dig deep and discover what is causing the burnout, and work to address the root causes.

"You have to intervene and have some sort of infrastructure in place," he says.

According to Weiner's survey, this is where many healthcare executives are struggling to find answers.

In response to the survey question "As a healthcare leader, do you think you have a sufficient understanding of the causes of physician burnout?" 57% of CEOs, 65% of CMOs, and 42% of COOs answered yes. As to whether they felt that they were sufficiently addressing the organizational factors that contribute to physician burnout, only 23% of CEOs, 16% of CMOs, and 6% of COOs said yes.

Weiner is one healthcare executive who has sought to tackle burnout at an organizational level. In 2013, after stepping into a newly created full-time medical director role at the medical group, she got to work evaluating burnout at the facility and uncovering its root causes.

"I have no information at all that it had anything to do with burnout, but the fact is one of our colleagues committed suicide the year before. We were all quite shaken. I thought it important to measure what was going on in our organization," she says.

Weiner used the Maslach Burnout Inventory to gauge physicians' burnout experience.

The research tool was developed by Christina Maslach, PhD, professor of psychology at the University of California, Berkeley, who has studied burnout since the 1970s. It breaks burnout into the following three key dimensions:

• Emotional exhaustion—feeling tired and fatigued at work
• Cynicism—developing a callous or uncaring feeling, even hostility, toward others, including patients and colleagues
• Inefficacy—feeling like you are not accomplishing anything worthwhile or making a difference at work.

Because burnout is complex, the MBI does not give a single score that determines the overall intensity of burnout. Rather, each component is measured on a subscale that looks at the frequency of a person's experience ranging from every day to never. For example, "Working all day with people is really a strain for me," or "I feel I'm positively influencing other people's lives through my work."

"The burnout measure is designed only to really assess people's experience. It doesn't measure causes," says Maslach.

Though the MBI is widely used to assess burnout, she cautions against thinking of it as a diagnostic tool.

"We weren't saying burnout was a disease. We were saying clearly people in various kinds of places and occupations that we've been studying are going through an experience that is really difficult," she says. "They get depressed, they quit their job, they don't show up, but making it a disease puts it kind of within the individual. It says the individual really is responsible for taking care of this, and it basically ignores [the question of] what is the environment and situation in which this is happening."

Weiner, who has worked at the medical group since 1997, describes the MBI as an instrument to take an organization's vital signs.

"It takes the vitals, it gets the current state, and then you need to do the diagnostics," she explains. "You need to find out what is going on in your organization."

After using the MBI, Weiner uncovered that 58% of the medical group's physicians reported experiencing at least one component of burnout, and 10% of the physicians were experiencing all three components.

Morale at the organization was low. On a 2012 AMGA employee satisfaction survey, overall satisfaction among staff was at the 18th percentile.

Physician engagement was poor as well.

"Nobody was showing up to meetings," Weiner says. "There were no department meetings in adult primary care. There was just a disengagement across the organization, and any attempt to change or do anything different was met with resistance and resentment and frustration."

She then began to delve deeper into the situation.

"You need to find out what is going on in your organization, because it can vary from department to department. You really have to use your diagnostic skills to figure it out, and then you have to do an intervention based on what you found."

Part of the issue may have been what attracted Weiner to Oregon Medical Group in the first place: a large degree of physician independence. They had the autonomy to train their medical assistants as they saw fit, to set up their patient templates the way they wanted, and to see patients at their own pace.

Yet, as healthcare changed, the group struggled to come together.

"In the late 2000s, we started to feel some of the pressures of the changes in healthcare, of some of the health plans expecting us to improve quality," Weiner says. "They were giving us feedback and measuring, and we didn't quite know what to do with it."

The organization reached its tipping point in 2011 with the implementation of its electronic medical record.

"It really highlighted the lack of standards that we had. Everybody practiced differently, and everybody collected data differently. That created a lot of frustration," she says. "We have 140 intelligent clinicians who went about figuring out how to collect data and put it in the EMR in 140 different ways."

The results of Weiner's 2012 assessment of the organization was proof things needed to change.

"It was a way to make the case that we can't stay here anymore. That this was unsustainable, that we needed to change, and we needed to do something different," she says.

Jack Silversin, DMD, DrPH, a consultant whom Weiner calls the "grandfather" of physician-organization compacts, was brought in to speak to the medical group. The organization's leadership met with the clinics' physician practice leaders and began having meetings to describe the organization's current state and to describe the future state they wanted to achieve. From those conversations, a one-sentence vision was crafted: "We collaborate to provide the highest-quality patient-centered care."

The vision may have been succinct, but it was a far cry from the organization's starting point.

"We weren't collaborating. We were siloed," Weiner says. "We all thought we provided excellent care, but we weren't really measuring it. We weren't doing process improvement, and we were physician-centered."

A physician-organization compact was created to guide both the physicians and the leadership toward their new vision.

"The next step was to look around and see: 'Is our system set up to help people achieve what it is we said we want to achieve?' Namely physician engagement and the change process," Weiner says.

This led back to the whole issue of those meetings and committees that no one was attending.

"We took all of the leaders of the committees and brought them into one think tank called the TIC—the tactics and implementation committee," she explains. "It takes a strategic plan, takes the feedback from what's going on on the frontlines, and synthesizes and prioritizes projects based on what we are trying to achieve strategically and what the pain points are out on the frontline."

When an issue "rises to the top," the committee calls a work group, which is headed by a physician who is knowledgeable about the issue. A charter is created so there is a beginning, middle, and end to the project, and there are deliverables and measurables to be met.

"There's an executive sponsor that's overseeing it and supporting it, and who's making sure it has all the resources it needs," she says.

The group's solution is piloted, and, if approved, it's implemented throughout the organization.

"The point is, it's results-oriented and it's prioritized based on pain points for physicians," Weiner says.

Other changes at the medical group include establishment of fair compensation practices and redistribution of workloads.

The changes seem to be having some impact.

On the MBI, 27 and above is considered high on the emotional exhaustion subscale. In 2013, the average emotional exhaustion number on the MBI was 27.7, and in 2015 it had dropped to 23.1, a moderate level (17–26 scores are considered moderate burnout levels on the MBI scale).

Reports of depersonalization dropped from 8.6 to 8.1 (between 7 and 12 is considered a moderate level on the depersonalization subscale) and a sense of personal accomplishment went up from 40 to 41 (39 and above is considered a high level of personal accomplishment).

Results on the AMGA employee satisfaction survey have showed improvement as well. Those reporting rewarding work went from the 8th percentile in 2012 to the 50th percentile in 2016.

In that same four-year period, AMGA employee engagement went from the 15th percentile to the 35th percentile, happiness with workload went from the 48th percentile to the 69th percentile, and growth opportunities went from the 30th percentile to the 65th percentile. Overall satisfaction among staff went from the 18th percentile to the 58th percentile, and staff satisfaction with physician interaction rose from the 8th percentile to the 50th percentile.

"It helped me to feel good that there's this ripple effect in what we're doing," Weiner says. "Our vision is of collaboration and pursuit of quality in patient experience so we have achieved a culture of collaboration. It's an expectation now, and it's what we expect of each other. It's how we do things around here. We have significantly improved our quality both on our internal measures and the feedback we're getting from our health plans."

But Weiner says the work isn't done, and realistically it may never end.

"Are we a culture of quality and safety yet? I think we're working on it. Are we a culture of being patient-centered? We're working on it," she says. "I don't think that there's an endpoint."

Demands vs. resources
When burnout occurs there's often an imbalance or mismatch between a person and his or her job. Decades of research by Maslach and her colleague Michael P. Leiter, PhD, have found these mismatches often occur in six key areas of the work environment:

• Workload—the amount of work to be done in a specific period of time
• Control—the opportunity to make choices and decisions
• Reward—the recognition (financial and social) received for job contributions
• Community—the social context of the work environment
• Fairness—the presence of consistent and equitable rules
• Values—the consistency between an employee's and organization's values

"Those are things that really put people in very difficult imbalances … and can predict burnout down the road," Maslach says.

Weiner says burnout is related to the ratio between demands and resources, and in today's healthcare environment, demands have grown faster than the resources needed to handle them.

"There's the workload of being a physician, the time demands, the intensity of the work—that's always been the case. But the inefficiencies and barriers to providing care have increased as well. In that ratio, when you're increasing those demands without increasing the resources, it contributes to burnout," she says.

And healthcare professionals need organizational support to bring that ratio back into balance. "It's not just a matter of if I, the provider, learn how to do this workflow, it's going to be OK," she says. "So what can an organization do to help? There needs be a framework to understand where the pain points are, and then how an organization can do something about that."

"One thing burned-out doctors reliably do is leave the practice. When people leave, it costs a quarter of a million dollars to replace them."

Linzer's own research has uncovered similar themes. In 1996, The Physician Worklife Study, a national survey of physician satisfaction funded by the Robert Wood Johnson Foundation, found that time pressure diminished physician satisfaction and that physicians were experiencing stress related to lack of work control.

The Minimizing Error, Maximizing Outcome (MEMO) Study published in Annals of Internal Medicine in 2009, looked at how organizational climate and work conditions affected clinicians and quality of care.

Among 422 physician respondents, 48% said their office environment was tending toward or, frankly was, chaotic, while 49% said their work was stressful; 27% noted burnout symptoms; and 30% said they were at least moderately or more likely to leave their jobs within two years.

"One thing burned-out doctors reliably do is leave the practice. When people leave, it costs a quarter of a million dollars to replace them," he says.

Even a modest investment in burnout prevention can yield positive results, says Linzer.

"It doesn't take too many folks to leave to easily pay for a wellness program. Certainly, that's more than our budget for just one person leaving," he says.

Linzer is speaking of HCMC's Office of Professional Worklife, a program that focuses on offering wellness services to improve the work lives of HCMC providers.

"Our task is to oversee the work lives of almost 800 providers here," says Sara Poplau, assistant director of the Office of Professional Worklife. "They engage with us in different ways. Every new provider that comes in gets a presentation from either myself or Dr. Linzer."

Poplau's office is in a busy area of the hospital, which allows for high visibility and easy access for providers.

"I will get some foot traffic from people who come by and say, 'I need help with this.' But then you talk to them and find out it's maybe this other thing that's causing stress," she says. "We can help connect them with someone who can advocate with them for changes or connect them with another department that had a similar challenge."

There is also a "reset room," a small, inviting space (there are flameless candles and a sound machine) where providers can go if they need some quiet time.

In addition to these types of programs, an organization must have policies, procedures, and protocols that create a healthy work environment where providers thrive.

In The Healthy Workplace Study published in 2015, Linzer and his fellow researchers identified three categories of effective interventions in regard to burnout: workflow redesign, communication improvement, and quality improvement projects.

For example, giving physicians control over how they balance their workload is one way to help control chaos and decrease burnout. And according to the "demand-control model" of job stress, a greater amount of demands calls for greater amount of control on the part of an employee.

"They need to get more control to figure out how to get that work balance and still get out at the end of the day," he says.

"How you organize and how you manage your personnel and how much you let it just be random motion will determine the difference between a hectic, chaotic place and a well-organized one."

Some interventions Linzer recommends are:

• The use of scribes for alleviating stress from electronic medical records
• Allowing for flexible scheduling that gives physicians the ability to work outside the 9-to-5 time frame
• Scheduling uninterrupted "desktop time" for physicians to complete charting
• Scheduling visits with more complicated patients earlier in the day

"How you organize and how you manage your personnel and how much you let it just be random motion will determine the difference between a hectic, chaotic place and a well-organized one," Linzer says.

Engagement is contagious
Around 2012, Thomas Jenike, MD, senior vice president and chief human experience officer at Novant Health, a not-for-profit, integrated system with 14 medical centers, 1,380 physicians in 530 locations, and numerous outpatient centers headquartered in Winston-Salem, North Carolina, experienced what he recognizes in hindsight as burnout.

"I was just stretched too thin, and I got to the point where I didn't feel, personally, like I was doing anything right or even up to my level of good," he says. "I'm not certain that anyone else would have said that. I still had great patient experience scores and no issues and everyone else said I was doing great, but I just didn't feel like I was."

When Jenike started his practice in 1998 he had no patients. But that soon changed.

"Part of that was I was always accessible and I was very attentive to all my patients and my partners. I was willing to work in extra people and extend my hours, and that really worked well to help build my practice pretty quickly," he says.

"I was just stretched too thin, and I got to the point where I didn't feel, personally, like I was doing anything right or even up to my level of good."

Even after he had built a successful practice, Jenike continued to work in the same way and at the same pace.

"I just kept running the same play over and over again even when I had a full practice and then started having administrative obligations and duties," he says. "That same model of saying yes to everything and trying to be responsible for everyone and everything, that just became overwhelming."

He says he felt a constant level of stress because he "wanted to make sure everyone was OK, but didn't feel like I was doing that."

Even though he was supposed to be practicing half-time as a clinician and half-time as a Novant Health physician executive market leader where he oversaw the health system's practices in a specific region of Charlotte, he still carried over 4,000 patients in his panel.

When he was at his administrative job, he was worrying about his patients. When he with his patients, he was worrying about the administrative job.

"The amount of joy and fulfillment from the patient experiences, which I loved so much, started to diminish," he says. "My patients would tell me how great I was and how much they loved me, but basically I got to the point where it was going in one ear and out the other. I just didn't believe it, so I didn't even take it in."

A recommendation for a youth hitting coach for his son was instrumental in turning things around. It turned out that Nicholas Beamon, the hitting coach, worked at a leadership development firm that specialized in personal and professional development. For six months, Jenike worked with Beamon, meeting with him twice a month for a few hours.

"We started around me getting more clear about how I got to the position I was in, what was working, what wasn't working, what adjustments I wanted to make moving forward to bring the fulfillment and joy back to my professional life, personal life," he says. "It was hard reflective personal work but well worth it."

Jenike discovered that he had committed himself to doing a number of things that didn't align with what was most important to him and what he was most passionate about.

"I knew that I wasn't alone, so I got very committed to creating something to help my partners and my colleagues," Jenike says. "I had read all about burnout. I have experienced it to a certain extent. This is very important to me that we create something with more of a proactive approach to physician resiliency and wellness."

Jenike started talking with Novant's system leaders, its CEO, and medical group president about their interest in him trying to develop a program for the 1,400 providers at Novant.

"Our CEO is very physician-friendly. He gets a lot of phone calls from doctors around things like burnout and he didn't know what to do for them," Jenike says. "He understands the business case that we could not grow our company to where we wanted to go if nearly half of our physicians are burned out. It was easy to convince him to give me a shot to try to resolve this. And our medical group president was the exact same way."

Together with Beamon, Jenike created a pilot program specific to physicians. He targeted influential physician leaders in the system and enrolled 32 physicians in the pilot program.

"Our theory was that they were experiencing some of the same things I was in terms of juggling practice and juggling leadership positions," he says. "If we could show value to these folks starting at the very top, they would be the best champions to drive the work down."

Unlike, Weiner and Linzer's approaches, there was no statistical assessment of participants prior to enrolling in the program.

"We certainly did some survey questions on how they were experiencing their job, how they were experiencing their personal life, their level of fatigue, things like that, but it was not intended to be a data statistical–driven questionnaire. It was really more of a self-reflection questionnaire," he explains.

Jenike describes the two goals of what is now the Novant Health Leadership Development Program.

First, Jenike wants those who participate in the voluntary, three-day intensive program to have an enhanced experience of his or her life. The second goal was for those around the participants—colleagues, family members, friends—to have an enhanced experience of that person.

A good litmus test for whether the second goal has been achieved is when others start saying, "I don't know what it is about you, but it's just better to be around you."

Since the pilot project in 2013, about 500 physicians have been through the program, with more waiting in the wings.

Jenike says that while the program benefits its participants, it also benefits the organization as well.

"People start to care more and more about the organization, because they feel cared for by the organization. We see the people that go through our program step up into new leadership positions," he says.

Engagement rates at the organization have been on the rise since the program began. In 2015, through a team-member engagement survey, Novant Health was able to compare the engagement scores of providers who went through the leadership program and those who did not. Those who participated in the program scored 50% higher than nonparticipants on measures such as personal fulfillment and alignment with Novant Health's mission and vision, as well as engagement and positive attitudes toward the organization. In 2016, the program's participants were in the 97th percentile for both engagement and alignment. For all employees in the medical group, engagement is in the 86th percentile and the 90th percentile for alignment.

"So remember, the second outcome is: We want people to have an enhanced leadership experience of you. We find that when you go back to your hospital and you go back to your unit and you go back to your office and you are more engaged, you're more positive, you're more aligned, you're feeling more joy, and that is contagious," Jenike says. "People around you start to act the same way. We didn't get to 86th and 90th percentile for the whole medical group because we put that many more people through the program. It's just that the culture has changed."

Burnout as fuel for improvement
Burnout affects not just physicians but registered nurses as well.

A 2011 study by nurse researchers at the University of Pennsylvania School of Nursing found that 34% of nurses scored higher than the average for healthcare workers on the MBI emotional exhaustion subscale.

Though she didn't have a label for it at the time, Elizabeth Scala, RN, MSN, MBA, the founder and owner of Nursing from Within, a consulting business focusing on burnout prevention and career enjoyment, experienced burnout as a new graduate psychiatric nurse at a large urban teaching hospital.

"I felt like I wasn't making a difference in my patients' lives, and in hindsight, I had a diminished sense of personal accomplishment," she says.

Over the span of about four years, these feelings worsened until, after a sleepless night of uncontrollable sobbing, she resolved to take action.

"I realized I wasn't doing anything for my own well-being," she says.

She changed her work environment, began seeing a counselor, and read books to shift her perspective to one that was more solution-oriented.

And it worked.

Today, Scala works with healthcare organizations to teach nurses how to identify signs of burnout as well as strategies to prevent or cope with the issue.

"I think it's really helpful to get some support and to get some help, because when you're experiencing burnout, you're so wrapped up in what's going on that it's really hard to get out," she says.

Vanderbilt University Medical Center in Nashville is one organization that has developed its own resources to help nurses cope with the stressors they face on a daily basis.

"I think that nurses are experiencing great waves of change. Changes in models of care. Changes in economic rules and regulation. Changes in the way people come in out of hospitals or are seen in clinics, pay for performance," says Marilyn Dubree, RN, MSN, NE-BC, executive chief nursing officer at Vanderbilt University Medical Center. "I think the external environment changes actually impact our clinical staff and leadership, but I also think that nurses, in a special way, are impacted by compassion fatigue and by the real expenditure of the emotional and physical energy in caring."

In 2002, to better provide its nurses with psychological support, Vanderbilt launched the Nurse Wellness Program, headed by Margie Gale, RN, MSN, CEAP, a nurse wellness specialist, at the Work/Life Connections-EAP Department part of VUMC's Health and Wellness Division. The program offers services such as counseling, workplace outreach, and the promotion of wellness activities.

The program's advisory council is the Nurse Wellness Committee, a group of leaders and staff nurses who meet monthly to advise Gale and her colleagues on what the nurses' greatest needs are and what problems need to be addressed.

"We then work on projects on how we can improve conditions to create a positive work environment," says Gale.

For example, Gale partnered with another committee to establish a workplace violence prevention nursing task force. In 2016, she launched a workshop on burnout and compassion fatigue that will be offered every three months.

"We are teaching them about what burnout is and how to recognize it. We're teaching them about compassion fatigue, and then we're talking about self-care techniques," Gale says. "How to develop hobbies, how to set boundaries, how to take breaks."

Gale has even done things like bringing a yoga instructor to the pediatric ICU to teach nurses how to take a 7-minute yoga break during their shift.

Health and wellness information is also disseminated by a group called the Nurse Wellness Commodores.

"We push information out to them to take to their units," Gale says. "They help deliver that information by ways of their staff meetings, newsletters, and unit boards."

VUMC also offers a monthly program called Bedside Matters, where staff, including nurses, talk about the social and emotional issues of caring for patients and families. The group may discuss a case where a patient wanted to die with dignity but the family wanted to continue with invasive medical treatments.

"They talk about a difficult case," says Gale. "How did we deal with it? What impact did it have on the staff? How did we handle it? How did we support our staff?"

Ethical challenges like the ones discussed during Bedside Matters rounds can be contributing factors to burnout among nurses, says Cynda H. Rushton, PhD, RN, FAAN, the Anne and George L. Bunting Professor of Clinical Ethics in the Berman Institute of Bioethics and the School of Nursing at Johns Hopkins University in Baltimore.

"One of the things that I've spent a fair amount of time looking at is how ethical conflicts and all the stress surrounding them contribute to burnout," she says. "I think that creates a condition for people to then become emotionally and physically exhausted, trying to reconcile that difference between what they ought to be doing and what they're actually doing. You add onto that organizational factors like workload, which also lead to physical exhaustion, and it tends to intensify the feelings of stress that people are feeling at the bedside."

When this stress occurs, Rushton says individuals and leadership should see it as an opportunity rather than a failure.

"It's a signal that something is off-balance. We don't get burned out because we failed. It's because we've been trying so hard to address issues, some of which are not solvable in our skills and resources and abilities," she says. "I think leaders have to really take stock of the organizational processes, policies, and structures that are contributing to burnout and to allocate resources to support diverse strategies for clinician well-being, recognizing that one size doesn't fit all."