Physician burden — not just for physicians anymore
Colleen Grady, DBA
https://doi.org/10.37964/cr24721
It is well known that physician burnout is reaching epidemic levels, and this should be a critical concern for anyone in health care. Health care leaders are dedicated to environments where compassionate care is provided to patients; however, non-clinical leaders are often unaware of the gravity of physician burnout and the impact it has on patient care. A pilot study to explore strategies to achieve the quadruple aim and to understand leaders’ perceptions about physician burnout has provided valuable insights which are informing a larger, national study on this important topic. Through a better understanding of organizational barriers to physician wellness, a more comprehensive approach to addressing the crisis of burnout among physicians is possible.
KEY WORDS: physician burnout, organizational culture, joy at work, compassionate leadership
CITATION: Grady C. Physician burden — not just for physicians anymore. Can J Physician Leadersh 2020;7(1):10-13.
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Physicians are particularly affected, with burnout rates at an all-time high.3 The consequences of physician burnout are plentiful; in addition to the huge personal toll, there are issues related to patient safety and access to care.4 Leaders in health care are uniquely challenged to care for the carers and to foster workplaces that are meaningful, engaging, and built around a culture of wellness that can keep burnout to a minimum.5 A workforce that is engaged and feels part of the team is critical to organizational effectiveness.6
Care for providers is the fourth pillar of the “quadruple aim,” added to Berwick’s triple aim7 —better health, better care experience for patients, and better value for health care dollars. Bodenheimer and Sinsky8 posit that the absence of focus on the fourth aim “imperils the triple aim” and the Ontario Medical Association9 terms the fourth goal the “foundational element,” necessary for the first three objectives to be achieved. Leaders in health care are dedicated to environments where compassionate care is provided to patients; however, their awareness of the gravity of physician burnout and priorities to address it are largely unknown. Although an integral part of health care organizations, physicians are often not considered employees and have their own culture as professionals. They are accustomed to working long hours and putting high demands on themselves which can lead to burnout, high attrition rates, and even suicide.10
A pilot study to explore strategies to address the fourth pillar of the quadruple aim and understand leader perceptions about physician burnout is informing a larger, national study on this important topic. Eleven administrative leaders from health care organizations in southeastern Ontario, from family health teams, community health centres, and hospitals, participated in semi-structured interviews followed by inductive analysis. This study was approved by Queen’s University Health Sciences Research Ethics Board. Top
Leaders define the culture
From front-line leaders to boards, the value of investing in development and ensuring a collaborative team is crucial to influencing culture. Two-thirds of participants acknowledged that disruptive change challenges our ability to feel joy at work. Recognizing accomplishments, measuring satisfaction regularly, and prioritizing healthy workplace strategies were identified as very important by all leaders, but only three of them indicated that these applied to the physicians in their organization.
References to physician culture indicated a distinct separateness and the division increased in reference to strategies to achieve the quadruple aim. While acknowledged for commitment to patient care and admired when they interact well with staff, physicians were seen as autonomous professionals who were often approached “with kid gloves.” Factors related to physician burnout were not viewed in an organizational context, but seen as relative to systemic pressures and, in some cases, the fault of the physician themselves. Their inability to say no, their insistence on taking on more than one job, and, for physicians of advanced age, the lack of education about work-life balance were seen to be contributing to higher stress levels. Top
Burnout — the visible and the invisible
Burnout is described as a work-related syndrome that includes three elements: emotional exhaustion, depersonalization, and a decreased sense of accomplishment.11 Physicians are especially vulnerable to burnout as shifting priorities of government and productivity expectations have led to a work life filled with higher administrative demands. This leaves less time with patients, which was their purpose in choosing this profession.
Physicians are often viewed by the public as well paid, despite being expected to work long days, be constantly available, possess the most current knowledge, and remain healthy and competent to provide outstanding patient care. For those who admit to burnout, the stigma attached is far greater than for others in health care, with much of the literature suggesting that resilience and self-care are the obligation of the physician. Physicians are held to a different standard, generally expected to heal themselves and blamed for ignoring the signs.12 Framing wellness as an individual responsibility only blames the victim.10 Top
Participants were able to identify what burnout looks like and knew of its effect on others, although most were not aware of any physician in their organization currently suffering (“those things are really personal”). Increased patient demands and administrative workloads, unrelenting expectations from government, and burdening by peers who ask physicians to cover for them when taking time away from work were seen by the administrative leads as the biggest frustrations for physicians.
Joy in the workplace
Although recruitment of physicians was identified by each of the participants as the “biggest crisis in this area,” no connection to workplace culture was acknowledged. Having a full complement of physicians in the organization was seen as critical, but a lack of focus on joy in the environment where physicians practice was clear. “Recruitment is a challenge. We are sitting at a bit of a melting point, there’s not a doubt.”
We know that physician burnout is at epidemic proportions, and the consequences of burnout affect not only physicians’ health but the health of patients and their access to safe care. The health care system is also impacted as it must deal with high turnover and costly departures from the profession. Another crisis of this magnitude would accelerate the time it takes for an organization to find the resources necessary to turn this situation around.4 Top
Few studies exist that demonstrate the value of reducing physician burnout. One randomized controlled trial demonstrated that providing supports for physicians had significant impact.13 Results indicated that when physicians were given an hour of protected and paid time biweekly, they experienced fewer symptoms of burnout. Those given an hour of protected and paid time spent in small peer group learning (also biweekly) showed even greater decreases in burnout and an increase in job satisfaction that was sustained for a longer period. Top
Call to action
Further research related to team environments and the leader role in achieving the quadruple aim for everyone in the organization, physicians included, is needed. Compassionate leadership presents a model that can provide insightful discussion among leaders to encourage making the connection between caring for the carers and caring for the patients.
Health care leaders who underestimate the importance of an engaged and supported workforce that includes physicians do so at the expense of patient safety and quality care. Along with external threats to the organization, leaders must consider exhaustion, cynicism, early retirements, and disengagement of physicians, as these internal threats seem abundantly clear. Stemming the erosion “from the inside”5 should be a priority for organizational leaders so that physicians can continue to provide compassionate care to the sick and vulnerable. After all, compassion is the essence of health care. Top
References
1. Pink D. Drive: the surprising truth about what motivates us. New York: Riverhead Books; 2009.
2. Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI framework for improving joy in work (white paper). Cambridge, Mass.: Institute for Healthcare Improvement; 2017.
3. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med 2018;283(6):516-29. https://doi.org/10.1111/joim.12752
4. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 2017:92(10):129-46. https://doi.org/10.1016/j.mayocp.2016.10.004
5. Lister ED, Ledbetter TG, Warren AM. The engaged physician. Mayo Clin Proc 2015;90(4):425-7. https://doi.org/10.1016/j.mayocp.2015.02.005
6. Kouzes JM, Posner BZ. The leadership challenge: how to make extraordinary things happen in organizations (6th ed.). Hoboken, N.J.: John Wiley & Sons; 2017.
7. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health and cost. Health Aff (Millwood) 2008;27(3):759-69. https://doi.org/10.1377/hlthaff.27.3.759
8. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med 2014;12(6):573-6. https://doi.org/10.1370/afm.1713
9. A healthy Ontario: building a sustainable health care system. 2nd report from the Premier’s Council on Improving Healthcare and Ending Hallway Medicine. Toronto: Ontario Medical Association; 2019. https://tinyurl.com/y5alxthu
10. Vogel L. Reducing physician suicides requires system change, not just self-care tips. CMAJ 2018;190(14):E447-8. https://doi.org/10.1503/cmaj.cmaj-109-5575
11. Maslach C, Jackson SE, Leiter MP. Maslach burnout inventory manual (3rd ed.). Palo Alto, Calif.: Consulting Psychologists Press; 1966.
12. Epstein RM, Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Acad Med 2013;88(3):301-3. https://doi.org/10.1097/ACM.0b013e318280cff0
13. West CP, Dyrbye LN, Rabatin JT, Call TG, Davidson JH, Multari A et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med 2014;174(4):527-33. https://doi.org/10.1001/jamainternmed.2013.14387
Author
Colleen Grady, DBA, is an assistant professor in the Centre for Studies in Primary Care, Department of Family Medicine, Queen’s University, Kingston. She has a special interest in physician leadership and health systems, and her current research focuses on psychological stressors in the workplace for physicians, medical education, physician leadership, and engagement related to health system transformation.
Correspondence to:
Author attestation: The author assumes full responsibility for analysis and interpretation of these data. She has no competing interests in the completion of this study.
This work was supported by a Social Science and Humanities Research Council institutional grant through Queen’s University.
Informed consent: As this study was approved by Queen’s University Health Sciences Research Ethics Board, informed, written consent was obtained from all participants to enable publication of this article.
This article has been peer reviewed.