On Christmas Day, an article was published in JAMA that confirmed what many of us had suspected for a long time. When hospitals are penalized for high 30-day readmission rates,...
15,000 physicians responded to the annual Medscape Physician Lifestyle Survey. A component of this survey is in the Medscape National Physician Burnout & Depression Report for 2018. Of these 1,500 physicians, 42% reported being burned out. My own specialty of critical care medicine led the way with 48% reporting burnout. Women were more burned out at 48% than men at 38%. Burnout was most common in the 45 – 54 year old age group – this is the age group that normally is the most productive. The most important contributions to burnout were (1) too many bureaucratic tasks, (2) too many hours at work, (3) lack of respect from administrators/colleagues/staff, (4) electronic medical records, and (5) compensation.
Burnout is expensive. When a physician (or nurse) quits, it costs a lot to replace him or her. There is lost productivity while you are waiting for a replacement. There is the cost of recruitment. And then there is the lost productivity while the replacement physician ramps up in productivity. Overall, it costs about $250,000 to replace a physician ($350,00 – $500,000 if that physician is a critical care physician). Then, if you bring a new physician into an environment that is conducive to burnout, then you are just going to lose another physician in short order.
So, how do you fireproof your physicians against burnout? I’ve attended a lot of presentations on burnout and often, they get mired in a lot of psychological generalities, resulting in me drifting off into daydreams about what I’m going to have for dinner and where I’m going to go on my next vacation. Here are some tangible things that we can do to prevent burnout:
- Learn to identify it. Every doctor knows that the best way to cure a cancer is to diagnose it in an early stage. The same goes for burnout. But the only way that a medical director is going to recognize burnout early is to interact with the members of the medical staff on a regular basis. That doesn’t mean sitting in your office firing off emails, it means having face to face conversations with each physician. Doctors usually won’t just say, “Hey, I’m burned out”. Instead, they’ll be rude to patients, get angry with the nurses, get behind on their charting, submit their charges to the billing office later, and stop coming to staff meetings.
- Make wellness resources available. At the Ohio State University, we have the STAR program (Stress, Trauma, And Resilience) and we also have an Employee Assistance Program. I make sure that our doctors know about these program – with our Employee Assistance Program, physicians (and staff) can meet with counselors without anyone else knowing and at no cost. Wellness programs like these are common in academic medical centers, large hospitals, and governmental hospitals but they are not always available in smaller hospitals or clinics. But almost every hospital has chaplains and social workers who can be utilized for wellness of not just patients, but also doctors.
- Look for excuses to pay compliments. Bad things happen in healthcare all of the time. People get sick. Patients die. Families get angry. Medical errors occur. Doctors get sued. We can’t stop all of these things from happening. As physicians, we are faced with life and death decisions every day and we are the often the ones who are most critical of our own medical judgement. This creates a heavy weight on our souls and that weight has to periodically be counter-balanced with some recognition of the good things that we do. When a surgeon comes to the hospital in the middle of the night to operate on a patient with a bowel perforation, send the surgeon and the anesthesiologist an email thanking them. Or if a cardiologist comes in to do a heart cath on a STEMI patient or a gastroenterologist comes in to do an endoscopy on someone with a GI bleed, then thank them the next day. When it comes to being a medical director, compliments are a more powerful tool than money. Ideally, every physician should leave the hospital each day with a sense of accomplishment.
- Be willing to be flexible. Maybe the hospitalist who is a new parent wants to reduce their number of shifts for a few months. Maybe the radiologist who is a single parent wants to read x-rays from home on certain days of the week. Maybe your critical care physician wants to be off duty on Friday nights and Saturday to go to Synagogue or be able to have a quiet place with the pager turned off to do Islamic prayers 5 times a day or to be off on Sunday to attend Mass. We all draw great emotional strength from our families, our religions, and our hobbies. Having flexibility with scheduling in order to preserve the ability of our physicians to draw this strength can build resilience.
- Yoga (but only for the millennials). There are two ways to get me to run for the door in a committee meeting or workshop: role-playing and yoga. But then, I’m a baby boomer and baby boomers hate doing yoga (or at least doing it in front of one’s peers). But millennials all seem to love yoga and so it can play a fireproofing role for your doctors under age 50. For those of us over age 50, pizza at committee meetings is more effective.
- More is not always better. Hospitals and physician group practices are under enormous pressure to increase productivity by seeing more inpatients/ER patients per shift and by scheduling more outpatients per hour. But being a doctor is not like being a mechanical assembly line robot. It is those interpersonal connections that we make with our patients through conversation that build the doctor-patient relationships that makes us feel good about the work that we are doing and drives us to continue on. When doctors feel they don’t have enough time to do a thorough job of caring each patient or enough time to just talk with their patients, then job satisfaction flies out the window. By keeping patient workloads reasonable, the hospital can save money in the long run by reducing physician turnover.
- Beware of night shifts. Critical care physicians who work night shifts are more likely to be burned out. These physicians are especially vulnerable because a lot of the usual wellness support resources close up at 5:00 PM. Hospital leaders need to make the effort to stop by the hospital at night to just check in with the night shift physicians and let them know that their work is valued and appreciated. In many physician groups, as physicians get more senior, they do fewer night shifts. I think this is dangerous because it forces younger physicians to do disproportionately more of the night shifts and creates a culture of the night shifts being perceived as something bad, as something less important, and as something to be avoided. The medical director of our emergency department is my age and does night shifts just like any of the other emergency department physicians and I think that is one of the reasons that he is so effective of a leader of his ER doctors.
- Women physicians are different than men physicians. That sentence will probably get me into a lot of trouble but nevertheless, women physicians report being burned out much more than men physicians and this is a fact that we cannot ignore. Women also deal with burnout differently. According to the Medscape National Physician Burnout & Depression Report, The most common strategy to fend off burnout for men is exercise but the most common strategy for women is talking with family and friends. Therefore, offering free gym memberships may be effective to fireproof many of your men physicians whereby promoting schedules that are conducive to social functions and family time may be more effective to fireproof many of your women physicians.
- Reduce conflict between physicians and nurses. 23% of physicians reported that reduced conflict with nurses/administrators/physicians would lessen their burnout. By promoting interdisciplinary team-based approaches to quality improvement, hospital governance, and nursing unit management, conflict between nurses and physicians can be reduced. But maybe even more important is for medical directors and nursing directors to lead by example; in other words, the medical directors need to publicly show respect and support for the nursing staff and the nursing directors need to publicly show respect and support for the physicians. Over the decades, I’ve too often seen physicians blame the nurses or vice versa when something goes wrong in the hospital. Medical and nursing leaders must rise above the “blame game” and set an example of interdisciplinary respect.
- Ensure that non-physician staff are working at the top of their license. What doctors do uniquely best in the hospital is doctoring. But there are a myriad number of other tasks that go into the care of patients that non-doctors can do. Make sure that there are other hospital staff who can line up home healthcare, fill out home oxygen forms, complete FMLA applications, and schedule outpatient appointments. Thirty-four years ago, as an intern, I had to draw all of the blood cultures, do the EKGs, and even transport patients to radiology to get a chest x-ray after 5:00 PM – it is amazing to me that I didn’t go up in flames of burnout back then. Your physicians should spend most of their workday doing physician work.
- Make your electronic medical record work for the doctors rather than make the doctors work for the EMR. Electronic medical records were identified as the 4th biggest contribution to burnout in the Medscape survey. It shouldn’t have to be that way because the EMR is just a tool and the purpose of any tool is to make a given task easier to do, whether that tool is a wrench or a garden shovel. Too often, we design our EMRs around meeting governmental regulations and billing requirements first with the physician experience being second. This should really be the other way around and we need to design our EMR software to be as easy to navigate as possible. Hospitals need to put resources into information technology support in the way of 24-hour telephone help lines, periodic EMR optimization education for physicians, and staff who can do a lot of the basic data entry into the EMR.
- Ensure compensation equality. This doesn’t mean that the family physician should make the same salary as the neurosurgeon. But it does mean that there is a compensation plan that is transparent with respect to the rules that go into salary determination. Almost every human being on the planet thinks that they should get paid more for what they do. But most of the time, getting paid more is not as important as knowing that you are getting paid fairly.
- Be optimistic. As physician leaders, if we show optimism for the future, it can be infectious. Every doctor has had a department chair, division director, or medical director who seemed like Eeyore from Winnie the Pooh and the Hundred Acre Wood. When physicians know about all of the good things that are happening or are going to happen at the hospital, it can go a long way toward dousing the flames of burnout.
- Promote interaction with other physicians. In past years, physicians drank coffee with each other in the physician lounge, ate together in the physician dining room, sat with each other during grand rounds, and spoke face to face about patients as attending and consultant. Now, coffee is usually drank in the nursing stations while staring into a computer monitor, we watch grand rounds remotely over the internet, and consultants leave their recommendations in the electronic medical record. As a consequence, we have less human to human interactions with our colleagues. By having (good quality) coffee and snacks in the physician lounge, doctors will aggregate there. By putting the surgeon’s workroom in the same location as the anesthesiologists’ break room, you can foster communication. Look for ways to create opportunities for physicians to be together in the hospital.
- Changes should not come as surprises. Burned out physicians often feel like they are just “another cog in the wheel”. One thing that fosters this feeling is if the physicians feel like the hospital administration is making all of the decisions for the future without involving the physicians. What physician wants to learn from an article in the local newspaper that the hospital is building a new surgical unit or radiation therapy building? By updating and involving the physicians with future plans for the hospital at every step in the planning process, the physicians will feel more engaged – that engagement is one of the chief defenses against burnout.
Burnout among physicians has always been there but it is more prevalent now than ever before and we are more aware of it than ever before. Fortunately, there are tangible things that we can do to make our hospital environments less combustible and thus prevent it.
November 16, 2018