Strategies for Reducing Physician Burnout

The fastest growing ailment seen in doctors' offices across the country very well may be the rising rate of physician burnout.

The American Medical Association (AMA) and the Mayo Clinic conducted multiple studies of more than 6,000 physicians in 2011 and 2014 on the topic of burnout. In just three years, the rate of physicians who reported at least one symptom of burnout went from 45.5 percent to 54.4 percent.

"This is the best evidence that the burnout rates are the highest they've ever been," says Christine Sinsky, MD, AMA's vice president of professional satisfaction.

This is not the only study that shows the seriousness of the issue. The Physicians Practice Great American Physician (GAP) Survey surveyed 1,314 physicians, who overwhelmingly reported the profession was more stressful and less financially lucrative than in years past. Respondents to the GAP Survey also said they were not happy with the direction healthcare is headed.

These metrics have been amped up, experts say, because of various outlying factors. Chief among them is the introduction of the EHR to medical practices. "What has made us more vulnerable [to burnout] in the past five to 10 years is some of the environmental changes. They are good changes, but some of it results in more work. Everybody loves EHRs … they give us information [at the point of care], but it takes more work to put the information in for physicians than it used to be. It adds like 25 percent more time," says Christy Sandborg, MD, vice president of medical affairs and professor of pediatrics at Lucile Salter Packard Children's Hospital in Palo Alto, Calif.

To this point, AMA partnered with Lebanon, N.H.-based Dartmouth-Hitchcock Health System for long-term observations of 57 physicians across four specialties in four states. What they found was that physicians spent nearly half of their time on the EHR and less than a third of their time face-to-face with patients. "In addition, the physicians were taking 1-2 hours of EHR and desk work to be done at home," Sinsky says.

What has likely driven the distaste for the EHR is that the government mandated physicians adopt them through the Health and Information Technology for Economic and Clinical Health (HITECH) Act. Lisa Roark, MD, family physician for a direct primary care (DPC) practice in Cassville, Mo., says Meaningful Use - the EHR Incentive Program, part of HITECH, mandating physicians to adopt a certified EHR or face a financial penalty- forced her to work longer hours for less money, while seeing the same amount of patients. When the health system she was working at offered a 5-year renewal contract that would force her to work even longer hours while still adhering to Meaningful Use, she decided to leave the fee-for-service world entirely.

Indeed, physicians responding to the GAP Survey said their number one frustration with healthcare was third-party interference. Not only has this come in the form of Meaningful Use and other government regulations, but administrative paperwork related to value-based quality metrics as well. Roark says by being a DPC doctor, where her patients pay membership fees and she does not take insurance, she doesn't have to answer to the government on how she's doing, for instance, with her diabetic patients. These administrative tasks have added to the overall sense from physicians, Sinsky says, that they aren't doing the work they were trained to do.  

The Different Cures to Burnout

Various healthcare organizations are trying methods to curing burnout. The AMA created the STEPS Forward program to refocus physicians towards spending more time directly caring for patients. The program includes several educational modules that tackle common practice challenges, often focused on increasing physician productivity. One such module, for example, focuses on optimizing staff performance.

"We have toolkits on increasing the responsibilities of our nursing and medical assistant partners, so that they can do more as they are rooming the patients in the pre-visit time, before the physician component of the visit, and so they can do more after the physician component of the visit," says Sinsky. Since introducing the STEPS Forward modules, Sinsky says AMA has seen 50,000 physicians complete at least one or more modules. 

Stanford's Department of Emergency Medicine is taking a different tact towards improving burnout and physicians' work-life balance. They created a process where physicians would ultimately log the time they spend doing extra duties, such as covering someone's shift, and accumulate credits that would allow them to "buy" certain amenities.

Sandborg explains, "If you … volunteer to cover someone else's shift, you get a certain amount of credit that you put in your bank. The banking is tracked and transparent to everybody … what you can withdraw from that bank are things … that will help [improve] their work-work conflict or their work-life conflict. Something that allows them to do better in their job and better in their personal life."

An example of a reward, she says, would be employing a service to clean your house or deliver you dinner. These amenities, Sandborg says, are more important to physicians than additional monetary compensation. It was a way of making physicians feel recognized in the work they do and to give them something meaningful, Sandborg says. "It promoted collegiality, satisfaction with the workplace, and made people feel they cared about each other," she notes. The pilot program in the emergency department was so successful, it's being considered for other areas of the health system. She also says it's customizable and adaptable for smaller practices

For Lisa Roark, the switch to DPC was her cure to burnout. She says switching to DPC has given her renewed life in medicine. "It's miserable to feel like you are working your tail off, seeing 40-plus patients per day, always be behind on charts, never caught up, and you have 20 different people telling you things that need to be done. You're always two steps behind. [Now], I'm two steps ahead," she says.

Not only does Roark see DPC as a cure to physician burnout, but it's good for patients too. Several patients she sees had great insurance but were never able to book an appointment with a doctor. If they did see a doctor, they were subjected to long times in the waiting room and "pushed to an [advanced practice provider]." DPC gives patients much better access to their primary-care physician and allows them to visit the doctor multiple times per month, if necessary.

Simple Things

Not everyone has to make a major employment shift to improve burnout. There are small things physicians can do to feel less stressed out and improve their work-life balance, experts say.

Taylor Foss, vice president of organizational transformation at Mission Health, a health system in Western North Carolina, says that physicians should literally take four deep breaths throughout each day. She also suggests they should try to meditate more often and shift their thoughts from negative to positive. "The simple method of saying what you are grateful for as you are pulling into work can be very powerful," she says. Mission Health runs wellness programs that focus on using these techniques to quell burnout among physicians.

At Stanford, Sandborg also buys into the simple things, such as personal coping techniques, to reduce stress. She also believes physicians receiving appreciation and recognition from practice administrators and fellow physicians can go a long way in improving their well-being.

A simple method Sinsky at the AMA recommends is taking a standardized approach to prescription management, such as automating the process in which medication is renewed. "By taking a standardized approach to manage prescriptions of the practice … practices can save 30-to-60 minutes per physician," Sinsky says. She says these incremental periods of relief will add up, allowing physicians to spend more time at home with their families.

DPC physician Roark advises physicians see fewer patients, schedule enough time to get paperwork done, and take a lunch break. She also adds, "Decide what time you are leaving that day and leave. If it's 5 p.m., shut down your computer, let the notes wait, and go home and see your family."

If burnout is not addressed, the consequences could be extremely unfortunate, experts say. According to one estimate from the American Association of Medical Colleges (AAMC), there will be a shortage of up to 60,000 physicians by the year 2025. Without turning around the burnout problem, this number could increase, if more physicians decide to leave the field. Beyond that though, the burnout issue could have a major effect on patient safety.

"We have found that physicians who are burned out can make more errors and have less satisfied patients and have patients who may not actually follow the instructions they are given by their physician. They don't have that close connection. That's the danger. It actually interferes with outcomes of that most important thing in healthcare … that interaction between the physician and the patient," Sandborg says.