Strategies for physician burnout as healthcare emerges from the pandemic

 

Listen and Subscribe

While the nation continues to recover from the COVID-19 pandemic, healthcare workers — especially physician practice leaders, nurses and staff — report experiencing increased symptoms of stress and burnout, as well as dissatisfaction with their work situations.

Clinical and administrative workers at all levels have joined the “Great Resignation” of individuals changing employment, looking for increased wages and better working conditions, often prompted by growing feelings of stress and burnout.

The Coping with COVID-19 for Caregivers survey, funded by the American Medical Association (AMA), made headlines when it reported that burnout approached 50% in 2020 among medical disciplines, and one in five physicians and 40% of nurses plan to exit their practice in the next two years.¹

These changes are occurring while physician practices undergo substantial change. Another AMA study examining physician practice arrangements reported that the long-term trend toward larger practices and away from physician-owned practices has accelerated: For the first time, less than half of patient-care physicians (49.1%) reported working in a physician-owned practices, per the 2020 report. This is a drop of almost 5 percentage points from 2018 and a drop of 11 percentage points since 2012. The study also reported that by 2020, almost 40% of physicians worked directly for a hospital, or for a practice, at least partially owned by a hospital or health system.²

To help put these trends into context, I recently had the pleasure of speaking with two physicians:

• Michael Nochomovitz, MD, chief clinical partnerships officer, Devoted Health, and previously senior vice president and chief clinical integration and network development officer, New York Presbyterian
• Jessica Dudley, MD, chief clinical officer, Press Ganey, and former chief medical officer at Brigham and Women’s Hospital in Boston, where she was responsible for teaching development and oversight of physician-led efforts to improve the quality and efficiency of healthcare.

“Although it’s hard to see it as a silver lining of the pandemic, there’s now a real awareness of the challenges facing recruiting and retaining physicians and creating the opportunities for them to be professionally fulfilled and live up to their own expectations of why they chose a career in medicine,” Dudley said.

Dudley framed the issue of physician burnout with three main contributing factors:

1. The doability of the job: “Administrative burdens or regulatory requirements being piled on doctors ultimately gets in the way of them … taking care of patients.
2. Embracing team-based care: “Medicine initially was a very individual type of practice,” but that has evolved in recent decades, and organizations that have not invested or developed the support and infrastructure for physicians are struggling. “You really run better as a team.”
3. The burdens of perfectionism: Physicians are “wired” to strive for perfection, “which ultimately means sacrificing our own well-being to take care of those around us,” Dudley said.

Nochomovitz agreed with these key components of the growing burdens of stress and burnout, adding that the emergence of physicians’ duties with EHRs being “one of the biggest dissatisfiers” for the profession. EHRs added a lot of “pajama time” documenting in patient records after regular work hours, which diminished physicians’ sense of professionalism due to a loss of independence and added complications to doctor-patient relationships as physicians spent more time in the EHR compared to patient-facing clinical time. All these issues were then compounded by the stresses of the pandemic, Nochomovitz said.

The following abridged Q&A highlights key insights from Nochomovitz and Dudley from our discussion:

Q. Physicians plan to leave their organizations for many reasons, including retirement and just finding a new practice. Are there reasons beyond stress and burnout for this trend?

Nochomovitz: I don’t think there’s one answer, because this is very regional. … There are many more alternatives available for physicians to leverage their training outside of the doctor-patient interface. They can leave health system employment and go into large independent groups or groups owned by private equity, or with [retail clinics] such as Walgreens, CVS, or Walmart.

Dudley: I'm most concerned about the physicians who leave the medical workforce. … We are seeing an exodus of female physicians. We know how great an impact the Great Resignation has had, especially on women in general. … What I worry about is the compounded effects of women — who may have children at home or other home-based responsibilities, often called “the double shift” — who can't do it all anymore and step out of their practice to take care and manage non-work-related responsibilities. They may choose to do that when their work environment is unable to provide the flexibility. We must rethink the old ways of practice and the limited flexibilities that were offered. … There are ways for all organizations to create more flexibility, which I think will also give individuals more autonomy, even when they're in a larger practice setting.

Q. What recommendations can you provide to physician executives and practice leaders to minimize the effects of burnout in their organizations?

Dudley: Survey your physicians in a structured way. You are more likely to hear more voices and more likely to get honest responses, as long as you offer a survey that is confidential so that doctors feel comfortable responding. … Really understand how your physician workforce is doing, what the challenges are — it must be an in-depth set of questions so that you can tease out what the issues are, and then having board and executive support for responding to what the survey shows, using the data, leveraging the support of leadership, to begin to develop programs to make change.

Nochomovitz: This issue of listening to the physicians can't be a corporate exercise. It has to be something meaningful, recognizing the professionalism of the doctor and that it's really being done for change and for improvement. The culture of a physician organization is going to determine the degree of dissatisfaction and burnout; if an organization is paying attention to the workforce and adapting to change, they will do better than a culture that is sort of preordained.

Dudley: There’s another important issue, and it’s the concept of psychological safety and creating a culture where everybody on the healthcare team feels comfortable speaking out, speaking up. [We need to] make it safe for people to speak up and speak out without fear; we need people to be honest and transparent about where the challenges are if we're ever going to be able to fix them.

Three main programs that were important [at Brigham and Women’s]:

1. We saw the pain that our physicians were experiencing with the EHR, and we really leaned into that. We used the data to see who was struggling, and then delivered at-the-elbow support with experts who could make individual doctors faster in their ability to navigate and become more efficient in using the EHR as the tool.
2. Making sure that when physicians were struggling, they had a way to access mental health support in a very confidential, destigmatized way. We built a faculty training mental health program, so that when a physician was struggling, they could go directly — self-referral only — to a dedicated email and protected phone line that physicians could call and then have a consultation with a psychiatrist or a psychologist and then determine what was necessary to support that physician better. There wasn’t a huge percentage of physicians who needed ongoing mental health support but being able to have an entry point triage and then work to support their emotional and mental health needs was critical.
3. Create the camaraderie and team collegiality that gives physicians joy. Besides taking care of patients, we rely on our colleagues, we connect with them. At Brigham, we launched a project similar to one from the Mayo Clinic, enabling doctors to get together for dinner or other social activities. We had a script that they could use if they wanted to guide conversation. It was an opportunity to reconnect with colleagues, share the challenges, but also remember the kind of joy, respect and fun that we have when we're with each other. This camaraderie and collegiality often gets lost when people are so busy.

Q. While lack of autonomy and independence can influence physicians’ decisions to leave their practice, are there other issues that are contributing significantly to stress and burnout?

Nochomovitz: The actual practice structure and the resources available to a practitioner to practice medicine. These vary tremendously. The Cleveland Clinic, Mayo Clinic, Kaiser California — they may have people unhappy, but they don't have a lot of people leaving. And that's probably because people get used to the system, there's a good pension, and they don't really have to do anything besides see patients.

Dudley: The data is so important, because this will vary by specialty and by practice. I have yet to find any organization that I've spoken with that feels like they've cracked this. Across metrics for engagement, resilience, and safety culture — especially with the pandemic — we have seen dramatic decline in all these areas, across the workforce.

There are some organizations where [initiatives such as] scribes or team-based care is a way that people have really solved this. Resourcing practices so that they work efficiently is important. I do see organizations as reluctant, because adding more staff support is really challenging for many organizations right now. Even those that want to hire more people or even budgeted to hire more people can't find the people right now. That's why I think it's so important that we are looking at redesigning how we do things in the practice setting and figuring out are there things that we're doing that we don't need to keep doing and how to make those operations run more efficiently.

Q. What advice would you give to a physician who feels stressed or burnt out and is seeking a change to their situation?

Nochomovitz: An individual needs to be able to look inside themselves and determine why they are unhappy, because the unhappiness may or may not have to do with a medical practice. If it has to do with the medical practice, leaders need to isolate the most egregious characteristics and principles and see if they can resolve them: Is there any opportunity for improvement? Is anybody listening? Once they've gone past that, the good news is that there are alternatives.

Dudley: I wish that at the individual level, when folks are recognizing just how challenging it is, that they can have the dialogue with their leadership and work together to create a better, more doable job for themselves. It probably will involve creating stronger teams, it will involve training on how to lead a team and ensure things like psychological safety. … Try to connect and see if it's possible to evolve the environment that you're in. If you feel this way, it’s likely your colleagues in your practice feel similarly, and it would be a shame to not try to see if … you can work together to try to make this whole environment a better experience for patients and for our colleagues.

I don't see medicine going back to more isolated, smaller practices. I think things are only going to become more integrated. … Investing in integrating across the journey of the patient, creating connectivity both virtual and in person so that we function more as teams, even though we may not be all co-located in the same environment — these are things that I think all organizations need to be thinking about and focusing on developing right now.

Nochomovitz: The issue that we need to address is that there is too much being put on the plate of the physician. With the industry expanding, I think we're seeing resources grow and evolve that will assist the physician in the continuum of care, particularly once they leave the hospital, so that the physician follow-up isn't so difficult. It's one thing for a physician to see a healthy patient; it's one thing to see a patient who's had an acute event: They broke a bone, they had an infection. It's another story to take care of somebody with chronic disease, where the burden on the physician becomes increasingly greater. And I think we're being unfair to the profession to expect them to do all this work.

I anticipate more partnerships between hospitals, physician groups, and other sectors that can assist in making sure that patients don't fall through the cracks. A lot of this work that needs to be done —social determinants of health, chronic disease management, medication adherence — gets done, and it's not simply the physicians trying to manage this, because it's impossible.

There's no doubt that voice recognition in EHRs and technology that can prompt the doctor on things that need to be done — I think that could go a long way to easing the burden of the overburdened doctor.

Notes:

1. AMA. “Coping with COVID-19 for Caregivers Study: National Comparison Report.” May 2021. Available from: bit.ly/3wiBIX6.
2. Kane C. “Recent Changes in Physician Practice Characteristics.” AMA. June 5, 2021. Available from: bit.ly/3929bgA.