Doi: 10.1377/hblog20200110.543513

Physician burnout is a frontline challenge of US health care, with estimates suggesting a burnout rate approaching 50 percent among practicing physicians. The organizational drivers of burnout in modern medicine are myriad—daily documentation requirements, management of the electronic in-basket (the electronic medical record receptacle for physicians’ messages, prescriptions, test results, and so forth), maintenance of certification, and the inability to address patients’ non-medical needs, to name a few. In addition to posing a significant public health problem, burnout has consequences for the health care system, from poorer quality of care to reduced patient satisfaction.

While our understanding of how to best address burnout among clinicians is far from complete, we do know that perceived loss of control is a major contributor to burnout, with active coping mechanisms (skills and information acquisition, problem solving, decision making) associated with better stress tolerance and resilience to adversity. The phenomenon of loss over control in medicine has amplified over time as smaller practices have been acquired by larger health care systems, fewer physicians work for themselves, and physicians have become increasingly tied to the electronic health record. We also know that organization-directed interventions (those that change processes or the working environment) are more effective than physician-directed interventions in alleviating burnout. Both the literature and lived experiences suggest that structures that facilitate organizational improvement also have the potential to improve the clinician experience. Providing physicians with the tools and space to participate in organizational improvement and helping them regain a lost sense of control can help address burnout. Open communication, skill building, institutionalizing change, and robust measurement of intervention-related impact are crucial for success.

Democratizing Communication

Opening communication is a first step toward engaging doctors in organizational improvement. Team huddles at the practice level, for example, can simultaneously provide opportunities for participatory decision making, coordination of work, and impromptu troubleshooting of daily workflows. In a study of predictors of burnout among VA primary care physicians, greater perceived participatory decision making was associated with a lower likelihood of burnout.

Open communication at the system level can help address burnout by reducing perceived reporting burdens and enhancing representation. At New York City Health and Hospitals, leaders recently sought to revamp reporting by involving clinical providers and care teams across more than 70 primary care sites in a public voting process to select the measures that would be the focus of the entire ambulatory enterprise for the coming year. Together, ambulatory care teams reduced the total number of reported measures by two-thirds and replaced homegrown metrics with nationally validated measures that align with priorities identified by health plans, public health agencies, and other regulatory bodies, dramatically reducing the reporting burden facing New York City Health and Hospitals leadership in 2019. This inclusive approach also allowed clinical stakeholders who often have a lesser voice in negotiations to gain visibility and resources for their causes of interest. For example, resources allocated to pediatric primary care typically pale in comparison to those for adult medicine. However, because the above process culminated in pediatric measures being publicly discussed and included on the final scorecard, visibility of and resource allocations to New York City Health pediatric programs increased in 2019 and pediatric leadership felt better heard than previously.

Building Skills

To act on the pain points identified, physicians need training in basic improvement principles and support in testing these principles. While biostatistics, biochemistry, and anatomy are standard in medical curricula, few physicians emerge from training with the skills needed to alter their daily work environments in a systematic way. Lean and Plan-Do-Study-Act (PDSA) principles can serve as intuitive introductions to basic improvement methodologies. Lean, an approach that originated with manufacturing at Toyota, focuses on maximizing value and eliminating waste to enhance patient satisfaction and deliver superior care. When optimally adopted, it becomes embedded in an organization’s culture and its principles are carried out by every member; those who do the work are responsible for improvements. The PDSA Cycle brings Lean principles to life by helping clinicians test and refine their interventions.

We have witnessed standardized improvement training programming succeed in our own institutions. For example, Partners Healthcare’s Clinical Process Improvement Program (CPIP) is a six-day experiential learning course that provides quality improvement training for interprofessional front-line staff and trainees. Trainees are exposed to quality improvement content through didactic sessions, interactive exercises, and implementation of their own projects. As of 2017, 239 teams made up of 516 individuals had graduated from the CPIP with high self-reported participant satisfaction scores and sustained quality improvement activity. Author Lisa S. Rotenstein has seen front-line clinicians, ranging from social workers to attending physicians, empowered by the CPIP course to address challenges in their local work environments. 

However, classroom-based training in performance improvement is not enough to empower clinicians to implement these lessons in the real world. Practitioners require coaching and mentorship as they learn how to apply these tools to diagnose and treat sources of stress in their clinical environment. At Zuckerberg San Francisco General Hospital, participants in the two-day course in A3 thinking, a component of Lean, must identify a local mentor for their project, thereby strengthening relationships in the workplace. The course instructors also hold ongoing biweekly “Learning Labs” that connect individuals across the hospital working on performance improvement initiatives, creating a community for change makers, and a supportive space to reinforce their skills.   

Together, Lean principles brought to life by the PDSA methodology of improvement and dedicated coaching can help on-the-ground clinicians change the small points of pain in their systems, while turning leadership attention to larger sources of distress. A simple example of this from the Hennepin County Medical Center (HCMC) in Minneapolis, Minnesota, is highlighted by the American Medical Association’s module on burnout. At HCMC ambulatory practices, physician parents often had a hard time picking up children from school or daycare due to complex patients being scheduled at 4:30 p.m. After this was identified as a specific source of stress for providers, the practice re-engineered the schedule to ensure that complex patients were not scheduled later than 4 p.m. The simple change significantly improved providers’ ability to leave work on time, enhancing satisfaction.

At the Mayo Clinic, spurring improvement at the work-unit level is part of the organization’s strategic approach to burnout. Mayo’s standard process involves learning about local challenges in a work unit, conducting focus groups to hone-in on specific, local challenges and the burnout driver of greatest concern, and empowering local leadership to implement changes accordingly. After seven work units went through Mayo’s standardized improvement process, all seven experienced improvements in burnout (a median absolute 11 percent reduction in burnout), while five saw an increase in satisfaction (median 8 percent absolute improvement).

Institutionalizing And Measuring Change

Modern medicine undoubtedly creates barriers to the average physician engaging in health care improvement. The most potent of these is a lack of time. Thus, as suggested by Tait D. Shanafelt and colleagues, if improvement is encouraged, time for this work should be protected. We acknowledge that not every physician will have interest in driving improvement forward; nevertheless, involving them in the process of identifying workflow issues and considering their solutions may enhance their experience of providing care.

Regardless of how the problem is approached, an institution must be prepared to quantitatively measure the impact on its workforce. There are multiple validated tools, such as the Maslach Burnout Inventory or the Stanford Physician Wellness Survey (used by the Physician Wellness Academic Consortium), that can be employed. Too often, employee retention is used as a proxy for satisfaction, resulting in missed opportunities for intervention.

The solutions to alleviating burnout among physicians will ultimately involve multifactorial interventions focused both on individuals and organizations. Among the many strategies being tested, giving physicians back control over their environments through provision of improvement skills and opportunities to engage in improvement can not only be uniquely empowering but also enhance our systems of care.

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