Executive Session: Identifying causes of physician burnout and building support to mitigate them

In this month’s Executive Session podcast, David N. Gans, MSHA, FACMPE, senior fellow, MGMA, talks to Dea Robinson, PhD, FACMPE, CPC, to share her insights on the burnout crisis among healthcare providers and what practice executives should know and can do to reduce the effects and mitigate the causes.

Robinson has 25 years of practice management experience in hospitals and primary care practices and serves on the Society of Hospital Medicine’s Practice Management Committee and a newly formed subcommittee on hospitalist well-being. She previously was director of MGMA Consulting, and her recent PhD dissertation topic was on physician burnout, engagement and social support for hospitalists.

“Emphasizing how important relationships are in the workplace has been shown to be very protective against feeling isolated,” Robinson said. “As our health systems get bigger and bigger, we can feel like we’re lost in that system, and some of these physicians in this study felt lost.

“The communication was very disconnected. Form letters are not how to build a relationship of trust,” she noted. “In the leadership space, it’s very important to touch base and have that playground where you can just talk about all kinds of things.”

There’s also a hurdle of physicians acknowledging to themselves that there is a clear need to address burnout. Some physicians are dismissive of burnout resilience programs and may respond derisively: “Let me get my yoga mat.”

While many organizations measure burnout with survey tools, Robinson says it requires going beyond survey data. “If you really want to help curb burnout, you have to understand the sources of burnout,” Robinson said. It also requires knowing that physicians do not always define engagement the same way that a healthcare system defines engagement.

“Some hospitals and health systems will define physician engagement as how many committees they’re serving on. Physicians do not necessarily define engagement” the same way, she noted. “It was all connected to patient care.”

In Robinson’s study, one physician recounted leaving for the day and getting a call from the nurse on his way home: A terminal issue was revealed in a lab result for a patient. “He turned the car around, and he went back to the hospital and he said, ‘That’s what I live for,’” Robinson said. “We have to do whatever we can from that perspective to keep that behavior going.”

Q&A

Gans: How much of a problem is burnout, and who is most likely to be affected?

Robinson: Burnout has been identified as three major categories: emotional exhaustion, depersonalization and decreased self-efficacy. So, what does that really mean? It means that I’m really tired, it means that I don’t feel like I’m making a difference at work with whatever I do, and I depersonalize people. In other words, I don’t see them as people. And so we can see from a healthcare perspective, this is an issue because we don’t want our healthcare workforce tired, we don’t want our patients treated as if they’re not humans, and we want our physicians feeling like they are making a difference. So it is a big issue.

Gans: You have an extensive management understanding of practice organizations. Why did you choose burnout as the topic of your dissertation?

Robinson: I actually didn’t decide on burnout; it evolved. I originally did a pilot study on organizational fairness with physicians, where I went out and asked them to tell me about an unfair situation that’s happened in your workplace. Out of the organizational fairness came burnout, simply because there are a lot of factors that contribute to burnout that were connected to organizational systems. That’s how I landed on that topic, that and there’s been a lot of quantitative work done on burnout. The other thing that concerns me as a former medical practice administrator was even with all this data that we had, the needle wasn’t moving in the right direction.

One thing that is really missed in [conversations about] burnout … is how it originally started. Dr. Herbert Freudenberger first observed this phenomenon in a healthcare setting. What he first recognized was this extreme fatigue of the healthcare providers — sitting there with this dazed look on their faces, like the flame had gone out. And that’s exactly where the term burnout came from. Connected to that was identifying that these folks who were feeling burned out experienced a loss of trust with their leaders first before they got to that emotional exhaustion piece. It’s a very important factor when we talk about burnout, this connection to leadership.

Gans: When I talk to physicians about what brought them to medicine, almost inevitably, there is a spark that shows what caused them to move into this career path. When I’ve talked to physicians who are tired of their jobs, who don’t like being a physician, the flame is gone — in the context of burnout, it’s been around forever, we just haven’t recognized it. And we haven’t appropriately examined the causes and how you can help resolve the problem.

Robinson: In fact, the gold standard — Christina Maslach’s survey tool — was really only created in the mid-1980s. So, this hasn't been something that we’ve been able to track and measure for 100 years. This has evolved as healthcare has evolved.

Gans: Burnout affects almost all doctors at one time or another. Why might one doctor feel overwhelmed while another physician in the same environment is not affected at all?

Robinson: In the study that I conducted, I had 15 physicians. I administered the Maslach burnout survey, an engagement survey and a social support survey so I could compare the qualitative answers and the quantitative stuff. What medical practice administrators have to consider when they look at things like this is you can have a physician who is highly engaged and also burned out. This is one of the problems with some of the research that’s going on: The data that’s coming out of burnout is that just because a physician is burned out does not mean he or she is not highly engaged, as long as we’re using the same definition of engagement. [As Dr. Freudenberger observed], even though these physicians were technically, observationally burned out, they were still engaging with patients. They were still doing their jobs. We have to be careful as we go into the next phase of looking at this phenomenon, that when we use these terms, we agree on what these terms mean.

Gans: In discussions I’ve had with doctors, they love their job, they love caring for patients, they love what they’re doing. And they can’t understand why they don’t like being there — it’s this cumulative effect of stress and environment, and perhaps lack of emotional support.

Robinson: Lack of support, period. … When you look at some of the research that’s been done on the social context of work, there’s been very little that’s been done on the physician workplace environment. We kind of forget that they’re social beings, too.

We have this collection of systems that people created, and we placed them on top of physicians and say, “practice.” But what we forget all too often is that the systems are connected to people. One of the things that came out of this research was understanding what physicians need in terms of social support.

A lot of [physicians], when I handed them this piece of paper and said, “write down who the really important people are and what their role is in your workplace in terms of support,” they really took pause and said, “no one’s ever asked me about that.” It really broke down to three things: They need clinical support, nonclinical support and leadership support.

Their clinical support is nurses, case managers. The second category was nonclinical support; this can be a spouse, it can be a friend, it could be a peer. In one case, the physician had a scribe. And he was one of those physicians who scored really high on burnout and also very high on engagement. And he said, “Surprisingly, I find that my scribe is one of my biggest support systems, even though they don’t really talk or interact a lot … I feel like I can say anything when I turn my back, and that scribe will listen, but no judgment is passed.”

Then the leadership support: All of these physicians said how much they need leadership support but they lack it. And it didn’t matter what employment model they were in, they all lacked or wanted more leadership support and a stronger relationship.

Gans: Whether it’s a physician executive or an administrator, how can they better support their doctors?

Robinson: Part of it resides in the employment model. When you talk about support, it could be business support, which was lacking in some cases. There’s nothing like a good, old-fashioned conversation with your physicians and asking them how’s it going? You can start with the most common factor that drives burnout, and that is exhaustion. “How is your schedule going? What can we do collaboratively to change that? How are things going at home?” Remember, they’re human beings, and there’s a great body of literature that says that the more we feel cared and supported in our workplace, the deeper our commitment is going to be to our workplace.

Gans: And it’s also appreciation — telling someone that their role is important and that they are important to the organization.

Robinson: Even going a step further, as we start to see younger and younger physicians come into the workplace, that piece is more and more important to them. They really want to have that connection.

Gans: They want to feel engaged.

Robinson: That is engagement to them — having that connection to their boss. … There is no substitute for showing your physicians that you care about them.

[There was] a physician who was talking about her experience in burnout, and it was related to her leader. Her clinical performance was declining. She was going through some personal issues with a very close friend she went to medical school with. The expectation, the unrealistic expectation, as she perceived it, was “my boss didn't care about me.” The doctor said, “She never asked me how I was doing. All she wanted to do is tell me what a horrible job I was doing.” I still get chills when I hear that … we have to show that we care for the physicians. She’s going through a hard time, but you’re not going to know that until you have that conversation and that back-and-forth relationship that makes it okay for you to ask that.

Gans: This is the role of the leader, and it’s an emotional support as opposed to giving direction. It’s giving that emotional support that brings out the best in their employees, their physicians or whoever you’re leading.

Robinson: People like to belong to things. They like to belong to a place where they’re cared for. It’s just that simple.

Gans: Which approaches to changing that environment either helped resolve burnout or at least let them recognize what was happening?

Robinson: What my results showed was putting our resources into that relationship that physicians had with their leaders. They already had a relationship with their nursing staff, they already had relationships in that circle where they do their clinical work and they also have that relationship with their patients, and they appreciate it when their patients appreciate them. But when it comes to having the support that they need, you have to look for the signals and ask, is there conflict between physicians and a leader? Is there conflict between peers? Does your group get along? Are things discussed in meetings? That kind of stress [suggests] that not everyone is getting the support that they need.

Other key takeaways

• Robinson notes that a recent meta-analysis of physician burnout found that physicians didn’t know who to talk to about issues they experience. “They didn’t know where to go,” she said. “When you onboard a physician, that should be a question: ‘Do you know who to go to if you’re struggling? Do you know the resources available?’ if there are resources available.
• In her research, Robinson talked to physicians who also worked in a leadership role, which prompted a deeper look into how burnout develops among individuals who may switch roles between clinical work and leadership. Three overarching themes came from this group that affected burnout:
  1. Lack of hiring authority: While the physician leaders often interviewed candidates in the recruiting stage, the hiring decision often was made at the corporate level.
  2. Lack of internal business support: Physician leaders often reported feeling the pressure of asking their groups to work harder and more despite an existing feeling of being overworked beyond contracted amounts. While benchmarking data exists to help make decisions on support staffing, physicians reported not having access to such analysis to make a case for needing more staffing.
  3. Dealing with disruptive peer behavior: It’s not easy to discipline a fellow doctor that a physician leader may share on-call duties the next day, and many physician leaders are not trained in conflict resolution.