Are practice investments to address physician burnout justified?

Editor’s note: This article was adapted from a paper submitted toward fulfillment of the requirements of Fellowship in the American College of Medical Practice Executives. Learn more about ACMPE certification.

The pace of change in healthcare is increasing rapidly, creating more pressure on physicians and practices. Changing government regulations, shifting payment models, higher patient expectations, expanding performance measurement and the use of EHRs and other technologies are driving physician practices to transform to stay current. With physicians at the center of many of these activities, the resultant pressures are affecting the entire care team.

There is an expanding body of evidence demonstrating increasing burnout levels in the physician workforce. Practices, health systems and medical societies are all bringing physician burnout to the forefront. Nationally there is a call to move from the Triple Aim — better individual healthcare, better population health and lower costs — to the Quadruple Aim, adding the well-being of the clinical workforce to the mix.¹

While many practice managers recognize that a more satisfied physician workforce will provide more engaged and better-quality care to patients, practice managers may not be implementing needed changes to enhance the satisfaction and well-being of the physician workforce. A clear business case is needed for implementing changes that may enhance the satisfaction of the physician workforce and the entire care team. Even physicians, many of whom maybe experiencing symptoms of burnout, may not fully understand the justification for addressing this issue. How do practice managers justify making investments to address physician burnout? Are investments to improve physician satisfaction justified in an environment of limited resources and competing demands?

What is physician burnout?

Burnout is a condition of being emotionally exhausted, having an increased level of depersonalization, and a feeling of less personal accomplishment.^2,3 As burnout can be caused by workplace influences, solutions in the workplace can have a positive effect on physician and staff burnout.

While burnout can be experienced in all healthcare professions, there are unique causes particular to physicians. Physicians have ultimate responsibility for their patients’ care, including the interactions of the care team collaborating with them to deliver that patient care. Overall, providing patient care is stressful; physicians are likely to underestimate these stresses and delay self-care.⁴ Having been trained to care for others, physicians may be unaware of how stress affects their own physical and mental health.

Physician burnout is extensive, with 54% of U.S. physicians experiencing at least one symptom of burnout in 2014, up from 46% in 2011, while rates of burnout remained stable for U.S. workers in other fields during that time.⁵ All physicians, regardless of specialty, experienced growth in symptoms of burnout during this three year period. Physicians experience levels of burnout nearly twice the rate compared to the general U.S. working adult population, with physicians also experiencing worse work-life balance scores.⁶ Physician dissatisfaction and burnout is a national problem for physicians in all specialties, practice types, genders, and career stages.

Causes of physician burnout

Most of the factors causing physician burnout are at the system level rather than at the individual physician level.⁷ Factors that contribute to dissatisfaction and burnout can fundamentally be categorized into areas related to a physician’s workload, the efficiency and organization of the practice, a physician’s autonomy in the work environment and their balance with home life, the physicians’ alignment with the practice’s values, the social circles and sense of community developed at work, and if they find meaning in their work.⁸

One significant contributor to burnout is the burden caused by EHRs and documentation. For every one hour a physician devotes to direct patient care, they will devote nearly two additional hours doing EHR and deskwork, including one to two additional hours at home each evening.⁹ This administrative work is often perceived as lower in value and not utilizing the physician at the top of his or her license. As a result, physicians become frustrated with the significant amount of time and effort devoted to clerical tasks within the EHR, resulting in an increased risk for professional burnout.¹⁰ Physicians working in EHRs with more functions and features had greater burnout than those physicians working in EHRs with fewer functions.¹¹

Primary care physicians are particularly vulnerable to the burdens caused by EHRs. Specifically, primary care physicians spend more than half their workday — “5.9 hours of an 11.4-hour workday” — in the EHR,¹² and more hours in the EHR than in direct patient care.¹³ Even for physicians who are aware of the value of using EHRs, they become frustrated by poor usability and the additional time it takes to interact with them.¹⁴

Addressing burnout

Decisions to address burnout, and whether those actions focus on making system improvements or on providing individual coping mechanisms (e.g., mindfulness, resiliency training, wellness programs), will determine how physicians perceive leadership’s actions.¹⁵ Addressing burnout primarily by implementing and promoting wellness activities, such as mindfulness and yoga, can be perceived as placing the onus of fixing physician burnout on the individual, rather than modifying underlying organizational causes of burnout. Thus, practices that implement interventions solely focused on the physician are not fully taking advantage of opportunities to create a better environment and these efforts may be conveying the message from leadership that the physicians, rather than the practice environment, are the problem.

Many physicians and other staff members have gained their leadership roles based on tenure and may not have had training or experience in leadership. The leadership qualities of those individuals supervising physicians have a clear influence on the satisfaction of individual physicians working under their leadership. One study found that manager scores across 12 leadership dimensions are correlated with the burnout and satisfaction scores of those physicians they manage: “each one point increase in composite leadership score was associated with a 3.3% decrease in the likelihood of burnout and a 9% increase in the likelihood of satisfaction of the physicians supervised.”¹⁶  Proper leadership training is essential for any organization looking to create a positive work environment.

Another concern for physicians is how their personal views and values align with organizational leadership and how leadership supports a positive work environment. If physicians perceive their personal values are misaligned with management they will more likely be burned-out.^17,18 A practice environment that supports a participatory, group culture is positively correlated with improved physician satisfaction while a practice with a hierarchical and bureaucratic culture is negatively correlated with improved physician satisfaction.¹⁹ Creating an open, collaborative, and supportive team environment can go a long way in addressing physician burnout in a practice.  

In addition, a physician’s work quantity, the type of work, and the perceived control a physician has over his or her work all influence the risk of burnout. Research highlights that burnout is associated with working in an organization where one has limited control of their work setting.^20,21 A physician’s control over his or her work schedule is a significant predictor of work-life balance and level of burnout.²²

Physicians who reported spending more time on administrative tasks, such as prior authorization and clinical documentation, had greater levels of burnout.²³ However it is not the actual number of hours a physician works that drives his or her happiness, rather it is the perceived ability to manage their workload.²⁴

Finally, physicians are facing an overwhelming and growing administrative burden from tasks such as quality reporting and payer-required documentation.²⁵ Practices that increase support staff per physician and “shift from a physician-centric model of work distribution and responsibility to a shared-care model, with a higher level of clinical support staff per physician and frequent forums for communication,” can improve team function and professional satisfaction.²⁶ Addressing these workplace factors can be a positive step for a practice to improve physician professional satisfaction.

Why burnout matters

Today, practice managers may not be addressing the issue of physician burnout because they are unaware of the organizational and financial impacts of it and/or are not sure how to address it. There is evidence supporting the organizational, financial, and patient impacts of physician burnout and proven strategies that can address these issues.²⁷ This body of evidence is growing and there is a national call to continue to build practice-based science on effective interventions that improve the delivery of care while creating a better work environment for the care team.²⁸ Understanding the impacts physician burnout can have on the whole practice can help explain why investments to improve physician satisfaction are crucial in an era of limited resources.

There is significant evidence that physician burnout impacts the outcomes of patients and their perceived wellness. Physician stress is reported to increase errors and decrease patient satisfaction.²⁹ Stressed and burned-out physicians report making more errors and have more instances of providing patient care that is less than optimal.^30,31,32,33

Likewise, when physicians perceive they are providing high-quality care they report better professional satisfaction.³⁴ Physicians who are dissatisfied with their careers have reported having more difficulty in treating their patients.³⁵ Interestingly, emotional exhaustion was correlated with better patient communication scores, which is likely because physicians who give more to their patients in terms of time and engagement during patient visits may find themselves more emotionally depleted at the end of the day.³⁶

Furthermore, when physicians feel as if they have made a medical error it can result in significant personal distress and reduce the physician’s empathy; these factors are also linked with the increased probability of future self-perceived medical errors, creating a vicious downward cycle.³⁷ Research has shown that programs to reduce physician stress have the potential to decrease malpractice claims at an average of over $350,000 per claim.³⁸ Clearly a physician experiencing burnout has negative consequences on patient care.

A physician experiencing burnout creates stress that may negatively impact the entire care team.³⁹ More troubling is that physicians who have higher levels of burnout are less likely to recognize their career as a calling. This diminished sense of calling can have negative consequences across the practice as physicians become “less intrinsically and prosocially motivated.”⁴⁰ On the extreme end of burnout, some physicians turn to chemical dependence or abuse alcohol⁴¹ and can become depressed, including having thoughts of suicide.⁴²

As a coping mechanism to being burned out and stressed, physicians will likely decrease their clinical schedule or leave the practice altogether. Physicians who are highly stressed or experiencing burnout are more likely to decrease the number of hours worked, leave their practice, or leave the profession of medicine.^43,44,45,46 About 1 in 5 physicians in the United States intend to decrease their clinical schedule because of burnout, while about 1 in 50 intend to leave the profession.⁴⁷

When physicians reduce their work schedule it leaves the practice less physician time available for patients, creating potential patient access problems; about 20% of physicians will reduce their work schedule due to burnout.⁴⁸ Physicians who are compensated by a productivity-based model are more likely to reduce their schedules than those physicians in salaried compensation plans.⁴⁹ While evidence reveals reducing work effort will reduce burnout for the physician, it does result in reduced practice capacity.⁵⁰ This reduction in capacity creates stress for the remainder of the care team who must pick up the extra work left by the physician reducing his or her schedule.⁵¹ This reduction in work effort by a physician reduces the capacity of the practice, limits patient access and increases burdens on those physicians and staff that remain.

Beyond reducing his or her work effort, there is significant evidence that when physicians are experiencing burnout, they will leave the organization.⁵² Evidence highlights dissatisfied physicians leave at two to three times the rate of satisfied physicians.⁵³ Furthermore, physicians experiencing emotional exhaustion will also cause them to leave the organization.⁵⁴ Losing a physician from a practice results in lost revenues, increased recruiting costs, and increased training costs to orient a new physician, all of which negatively impact the bottom line.⁵⁵  Practices report the cost of recruiting a replacement physician when one physician leaves the practice is between $500,000 and $1,000,000.⁵⁶ These costs do not consider the increased workload and stress for the staff that remain. A short-handed team, turnover among any member of the team and too many patients all increase burnout; thus, teams not fully staffed and over capacity will lead to burnout for those staff that remain when a physician leaves.⁵⁷ Therefore, one physician departure can have negative ripple effects for the remaining physicians and staff. This can begin a vicious downward cycle for a practice.

Finally, physicians who are dissatisfied have lower patient satisfaction scores, impacting the scores for the practice.^58,59 Specifically, patients of primary care physicians who reported an increased amount of depersonalization and exhaustion had significantly lower patient satisfaction scores.⁶⁰ As patient satisfaction scores are an important indicator used by the practice and outside entities, these decreased scores can have meaningful negative impacts on the practice. 

Implementing an improvement plan

A physician practice can make a positive change in their environment to address physician burnout, increase satisfaction for the entire care team, and improve patient outcomes and satisfaction. A practice manager can create a simple plan by building consensus, measuring physician satisfaction, engaging practice leadership, creating a wellness team, implementing interventions, and then reassessing, adjusting and continuing their efforts.
 

Building consensus

Cumulatively, there is clear evidence physician burnout leads to increased risk of medical errors and poorer health outcomes, diminished quality of care, decreased professionalism and compassion, increased costs of care and decreased physician work effort by reduction in clinical time or departure. Presenting this robust body of evidence and explaining it to physicians, staff and leadership provides a compelling case for addressing physician burnout. A presentation of the frequency, causes and impacts of physician burnout in the practice to leadership, physicians and staff can be a persuasive call to action.

Furthermore, for those physicians, staff or management looking for the financial impact of burnout, research can be assembled to present a financial justification for addressing this issue.⁶¹ When a physician leaves there are costs required to recruit and credential a new physician, and time required to build his or her panel. An average of $500,000 per physician for replacement costs and lost revenue is a reasonable estimate when considering physician turnover costs.⁶² There is considerable savings if a practice needed to replace just one less physician per year.

However, the calculation does not account for lost revenue for those physicians who reduce their schedule as a coping mechanism, nor does it consider the positive benefits of reducing burnout on patient satisfaction scores, the quality and safety of care delivered at the practice, and reductions in the risk of litigation.⁶³ Furthermore, when a physician does leave a practice, those physicians and staff that remain have increased burdens and are more likely to see their levels of dissatisfaction and burnout increase.⁶⁴

The American Medical Association (AMA) offers an online calculator to estimate the organizational cost of physician burnout by inputting the number of physicians in a practice, rate of burnout of physicians, current turnover rate per year, and cost of turnover per physician. The AMA also offers a tool to calculate the return on investment for interventions made in the practice to reduce burnout.⁶⁵ These simple calculators help put the impact of physician burnout into financial information useful for planning and decision-making. As burnout can be contagious, none of these financial calculations fully address the savings attributable to the quality of patient care, patient satisfaction, and other team members not being burned out or leaving the practice.⁶⁶

Physicians are scientifically trained; presenting evidence-based data on the prevalence, costs and impacts of physician burnout can help build organizational consensus to take action on addressing the issues that cause physician burnout. In addition there is a small, but expanding amount of research on successful solutions that address physician burnout showing that investment and action can have positive outcomes. Putting together the research, calculating the financial impacts and providing evidence-based solutions creates a compelling case for a practice to address the issues that cause physician burnout.

Engage practice leadership

Executive leadership support of efforts to improve physician burnout is essential.⁶⁷ Management buy-in is the key to ensure changes are supported and sustained. Efforts to address physician burnout must be perceived by physicians and staff as legitimate solutions to the problems at hand. Without leadership buy-in, true practice transformation is unlikely to be implemented or sustained. Some organizations include physician satisfaction as one of their key organizational metrics, tracked on their data dashboard. Similarly, some CEOs have asked their boards of directors to hold them accountable for the physician satisfaction scores of their physicians, and in turn, hold their executive leadership teams accountable for these scores.⁶⁸

Create a wellness team

Create a wellness team whose focus is on improving the practice to ease burdens on physicians and staff. The higher the level of leadership on this team, the greater the chance of success. Some organizations have established a chief wellness officer, who serves on the executive leadership team and reports directly to the CEO. The wellness team should comprise a diverse set of stakeholders who are willing and empowered to identify opportunities to improve the practice. The wellness team can identify quality improvement activities that provide meaningful feedback to physicians, make workplace improvements in workflow or communication, or implement quality improvement projects that address physician and staff concerns. Evidence shows these types of changes can improve care and reduce physician burnout.⁶⁹ By implementing these changes as part of a team formed to address the work environment, promoting a more positive organizational culture and improving communication, the practice will have positive outcomes on physician satisfaction.⁷⁰

Even if the wellness team is not successful in every one of its suggested practice changes, there are benefits of physicians and staff getting together to discuss problems, share ideas and build comradery. Evidence indicates that when physicians come together and share experiences and reflect with their colleagues, it can have lasting impact on increasing engagement and reducing depersonalization in the practice.⁷¹

Working together, a wellness team can create a sense of community that works collaboratively toward an improved practice.

Implement interventions

Practice interventions can be categorized into two types: organizational interventions and individual interventions. Organizational interventions are changes in how the practice operates, such as staffing and role changes, process changes, or other operational interventions. Individual interventions are targeted at the individual physician, such as wellness programs that may include mindfulness, meditation, yoga and other self-care interventions.

For the practice, the evidence is clear that burnout is a system issue and that organizational interventions will have more of an impact than interventions solely targeting the physician (e.g. wellness or mindfulness programs).⁷² Evidence shows that dedicated and focused commitment by an organization can and will make a difference on physician burnout rates.⁷³

Many practices have already identified interventions that improve the organization and efficiency of a practice. Some practices have added staff to perform administrative functions which results in less physician time dedicated to administrative tasks and higher patient satisfaction.⁷⁴ Other practices have advanced team-based care with an enhanced role for medical assistants or nurses that increases patient-physician face-to-face time.⁷⁵ These organizational steps can improve physician satisfaction, as well as increase patient satisfaction and quality of care delivered at the practice.

It is important to note, any practice changes must provide physicians with control over their environment. Evidence reveals that high work demands can be mitigated when one has control of their work.⁷⁶ While a practice may look to standardize activities, this standardization must allow physicians some ability to customize their schedules, work space, and other activities to their practice style and preferences.⁷⁷

In the end there are four essential elements that will likely increase the chances of creating successful changes in the practice: leadership, teamwork, communication, and metrics.⁷⁸ Thus, getting leadership support, involving the entire care team in the practice improvement effort and measuring and communicating progress are integral to successful practice changes. Practice managers may be surprised by the positive outcomes created by physicians and other care team members implementing practice improvement ideas.

For the individual physician, professionalism should include self-care; as an unhealthy physician cannot optimally care for patients.⁷⁹ The Code of Medical Ethics for physicians states “physicians have a responsibility to maintain their health and wellness” including following a healthy lifestyle, having his or her own physician, and seeking appropriate help as needed.⁸⁰

Physicians need support and resources to stay healthy; as physicians who do not live a healthy lifestyle are less likely to recommend healthy habits to their patients.⁸¹ Programs that promote healthy living can help a practices’ physicians and their entire staff. In addition, mindfulness and resiliency training can be provided. There is evidence that mindfulness programs provide benefit to participants.⁸² These programs may be in-house, through partnerships, or with community providers.

Many physicians benefit from opportunities to contribute to the practice beyond their role in direct patient care. Opportunities to provide leadership, formal and informal, are important. Practice managers can develop opportunities for physicians to take on leadership roles and other opportunities to provide input on the way the organization is run. In addition, practice managers would be well served to support various career opportunities, as well as part-time schedules, including job-sharing.⁸³ Overall, for physicians to thrive, they need some degree of control over their environment, comradery with their peers and staff and an opportunity to contribute to something meaningful to the organization and their patients.⁸⁴ Individual interventions, such as mindfulness or wellness programs, can be considered an adjunct to organizational interventions.⁸⁵ 

Reassess, adjust and continue

Implementing practice changes to address physician burnout is not a onetime activity. Measuring physician wellness should be done yearly, as well as soliciting open feedback on the success or failure of tactics to address physician burnout. Through measurement and reassessment, programs and interventions can be adjusted to continuously improve the practice for physicians and the broader care team. Practices that pay attention to work conditions within their organization will increase their success at recruiting and retaining physicians, while likely providing better quality patient care.⁸⁶ After assessment, continuing to adjust and moving forward is important. Celebrating small wins or other progress milestones will keep the team motivated to continually identify and implement opportunities for improvement. Practice managers that support these ongoing efforts will likely see numerous beneficial improvements in their practice. 

Challenges to implementation

While both individual or practice interventions can be beneficial, it is likely that both are needed to have maximum effect.⁸⁷ Practice transformation is difficult; practices should be aware that not all changes will be received positively and some may feel negative about the process. While there is extensive literature on organizational development, applying these principles in practice takes effort and commitment. No practice should embark on this effort without the organizational leadership’s support and the willingness to make changes identified to improve the practice. In addition, more evidence-based solutions are needed; further research on optimal practice design, staffing, workflow, and use of technology is required.

Furthermore, many of the frustrations physicians experience are beyond the control of the practice. These include burdensome prior authorization requirements, which 75% of physicians describe as a high or extremely high burden.⁸⁸ Government regulation, the usability of EHRs, burdensome quality reporting requirements and confusing new payment models all are additional causes of physician dissatisfaction.⁸⁹ While practice managers can create some workarounds to offset these burdens, they will also benefit by staying informed and being involved in larger health policy discussions. Practice managers can be informed and have a voice by joining professional associations and supporting their physicians’ involvement in the national, state and specialty medical societies.

Conclusion

Physician burnout is a bona fide and growing problem with real impacts on the individual physician, the care team, the practice and patients. Evidence is available to justify investments in addressing physician burnout. When this body of evidence is compiled, a compelling case can be made for implementing evidence-based, actionable solutions to addressing the problem of physician burnout. When practice managers address physician burnout, physicians, other care team members, patients and the practice as a whole benefit.

Notes:

1. Bodenheimer T & Sinsky C. “From triple to quadruple aim: care of the patient requires care of the provider.” Ann Fam Med, 2014, 12(6), 573-576. doi: 10.1370/afm.1713.
2. Maslach C & Jackson SE. “The measurement of experienced burnout.” Journal of Organizational Behavior, 1981, 2(2), 99-113. doi: 10.1002/job.4030020205
3. Maslach C, Jackson SE & Leiter MP. Maslach burnout inventory manual. 1996. Consulting Psychologists Press, Palo Alto, Calif.
4. Wallace JE, Lemaire JB, & Ghali WA. “Physician wellness: a missing quality indicator.” The Lancet, 2009, 374(9702), 1714-1721. doi: 10.1016/S0140-6736(09)61424-0.
5. Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J & West CP. “Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.” Mayo Clin Proc, 2015, 90(12), 1600-1613. doi: 10.1016/j.mayocp.2015.08.023
6. Ibid.
7. Panagioti M, Panagopoulou E, Bower P & et al. “Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis.” JAMA Intern Med, 2017, 177(2), 195-205. doi: 10.1001/jamainternmed.2016.7674.
8. Shanafelt, T. D., & Noseworthy, J. H. (2017). Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc, 92(1), 129-146. doi: 10.1016/j.mayocp.2016.10.004.
9. Sinsky, C. A., Colligan, L., Li, L., Prgomet, M., Reynolds, S., Goeders, L., . . . Blike, G. (2016). Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties. Ann Intern Med, 165(11), 753-760. doi: 10.7326/M16-0961.
10. Shanafelt, T. D., Dyrbye, L. N., Sinsky, C., Hasan, O., Satele, D., Sloan, J., & West, C. P. (2016). Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction. Mayo Clin Proc, 91(7), 836-848. doi: 10.1016/j.mayocp.2016.05.007.
11. Babbott, S., Manwell, L. B., Brown, R., Montague, E., Williams, E., Schwartz, M., . . . Linzer, M. (2014). Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Inform Assoc, 21(e1), e100-106. doi: 10.1136/amiajnl-2013-001875.
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15. Shanafelt & Noseworthy.
16. Shanafelt, T. D., Gorringe, G., Menaker, R., Storz, K. A., Reeves, D., Buskirk, S. J., . . . Swensen, S. J. (2015). Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc, 90(4), 432-440. doi: 10.1016/j.mayocp.2015.01.012.
17. Linzer, M., Manwell, L. B., Williams, E. S., Bobula, J. A., Brown, R. L., Varkey, A. B., . . . Schwartz, M. D. (2009). Working conditions in primary care: physician reactions and care quality. Ann Intern Med, 151(1), 28-36, w26-29.
18. Linzer, M., Poplau, S., Babbott, S., Collins, T., Guzman-Corrales, L., Menk, J., . . . Ovington, K. (2016). Worklife and Wellness in Academic General Internal Medicine: Results from a National Survey. J Gen Intern Med, 31(9), 1004-1010. doi: 10.1007/s11606-016-3720-4.
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20. Linzer, et al., 2009.
21. Linzer, et al., 2016.
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25. Friedberg, et al.
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34. Friedberg.
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37. West, et al, 2006.
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