A Responsibility to Address Physician Burnout

Alan Rosenstein has pondered physician burnout for more than a decade. In between practicing internal medicine in San Francisco, he has been very active in research, speaking, and consulting in the areas of physician behaviors, physician engagement, and physician well-being. While identifying feelings of burnout in your team is important, Rosenstein says that it is just as important to take steps to moderate physician distress. In fact, he says that it is the practice's responsibility to proactively address burnout by listening to physician concerns, showing empathy to their frustrations, providing customized support, and offering coaching or counseling when possible.

Recognizing that independent physician practices often do not have the resources at their disposal that large health systems do, Physicians Practice spoke with Rosenstein about the impact of stress and burnout on physician behaviors as well as strategies that smaller practices can deploy to support their team members. The following is part one of this interview:

Physicians Practice: Why is physician burnout becoming a more urgent problem in recent years? Or is there just more dialog on the subject?

Alan Rosenstein: It is a combination of both. I think it has always been around. But I think with the changing healthcare system, mostly through reform, it has changed a lot of the idealism around practicing medicine. But at the same time, [it's] also changed some of the economic models and delivery models. So physicians who have traditionally been autonomous and not really worried about someone looking over their shoulder, and working independently, are now being told they have to live by X, Y, Z metrics. They are being asked to do more in the way of electronic documentation, to spend more time on administrative tasks, and what's happening is everyone is telling them what they want them to do, but not one is listening to what is going on their world and what they need to do. 

The changing environment has exacerbated the stress and burnout, and you are dealing with a profession that is overworked, they are fatigued all the time. This is just another thorn in their side. So some of the frustrations are: "I'm going to have to change my model of practicing medicine," particularly the independent practicing physicians. And begin to look more to a group practice or a salaried model or some other vehicle than what they are traditionally doing.

PP: Why is it that physicians are not very good at recognizing stress in themselves?

AR: First of all remember physicians are super-ego people, they're task driven, they will work all hours to do what they really need to do. And their obvious concern is best patient care. So they constantly have these demands on their shoulders and they want to do it. That's what they were bred to do. So the first problem is that they don't even know that they are under stress. They just continue to work, continue to work, they get worn down both physically and emotionally, and they just don't even recognize what's happening to them until it's too late.

So the second thing is once they recognize they are under stress, they've worked under stress their whole lives. "Well I guess I am under stress. But I've been under stress all of my life. I can handle it." And of course, you ask them "How's that going for you?" And then finally, when they realize it's not going so well, they say, "Well maybe there's more to it. I'm going to take more vacation, or spend more time with the family. Or I'm going to spend more time on hobbies." But then the next patient call or administrative call pulls them away from what they planned to do.

And the last part is that even if they do know that they need outside help, there is a concern, a sort of super-ego. They don't want to admit that they need some help because they are supposed to be these stoic individuals. And then if they do ask for help, is it going to be confidential, are people going to worry about their competency? It may potentially have a backlash. And none of those assumptions are really true, but there is that reluctance to seek help. One of the things that I've talked about is, even if they recognize it and they say they are going to do it, they don't do it. So you can't leave it up to them to do it. We, meaning the organizations that they are affiliated with, need to take a more proactive stand and try and help the physicians set limits and take the necessary time to do what they need to do to relax.

PP: What are some of the things that those organizations can do to support their physicians? 

AR: There are a couple of things. There's a whole thing on providing the necessary services to participate in. But I believe the first thing is to give the physicians an opportunity to talk about what is on their mind. Now a lot of this leads to physician engagement, not just stress reduction or burnout reduction. But physicians are tired of being told what they can and cannot do. Particularly when no one wants to listen about what is going on in their world. The first thing that organizations need to do is to set up a vehicle to listen to what the physician says. No whether that is a town hall meeting, a department meeting, you do it through certain task forces, or do it one on one with some senior official (that's always a capacity issue). But the thing is give them the opportunity to talk about what is going on in their world, explain to them why the world is changing, what we (meaning the organization, the physicians, the staff) have to do in return.

And then most importantly, be responsive. You can't just listen and nod your head, and not make any effort to try respond to the physicians' concerns (even if you are not able to provide a solution.) So the first thing is to open up an avenue of input, let them vent, give them an explanation on why this is occurring. Build a mutual approach and align along mutual goals, which is of course, patient care. And show that you are responsive to their needs. I think that is the first step.

Then the second step is to actually provide them support services. A lot of organizations have tried to do this with wellness committees, they'll do it through certain programs, stress management, conflict management, anger management, time management programs, diversity training - and all that stuff. All of that is good. It has marginal improvement I believe because it is not tailored to the individual. But what we are finding is particularly valuable after someone has talked to them, is to provide one on one, customized either coaching or counseling, and just give them the tools to help them get through. And then you can move into relaxation techniques, mindfulness and so on. 

PP: So when you say coaching what do you mean?

AR: Its more behavioral coaching. It's really [acknowledging] this is the world around us, these are the restraints that are facing us. We are here to help you. ... We are going to try to give you logistical support. We are going to give you scribes for the EHR. We'll free up your schedule by giving you nurse practitioners or physician assistants, or cut down on your committee responsibilities. We are definitely going to schedule time off for you, it's mandated time off. And that is sort of the first step to get them to move in the right direction.

Then the individual coaches, it doesn't have to be a physician. Sometimes physicians are reluctant to talk to [physician] coaches. And sometimes they are mentors (coaches is a generic term). But the whole idea is someone to listen to them and someone to give them advice. And when it is really on stress management, there is some common advice that you can give. The problem is with that there is always an intention gap. They say, "I'm going to do this, I'm going to do this," but many people don't really follow through. So the role of a coach is to get them to commit to a schedule and not to deviate from that track. Whether it is turning off your cell phone or not looking at the computer. There are certain tools that they can give them that will prevent them from becoming distracted.