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CASE
Dr. Peter D is a mid-career family physician in a group practice that recently adopted an electronic health record system. Although he realizes he is now competent at computerized medicine, he has far less of the one-on-one patient contact that he once found so gratifying about the field of medicine.
Others in the practice have similar concerns, but they suggest that everyone ought to “go along to get along.” To manage the increasing demands of his case load and the required documentation, Dr. D has begun staying late to finish charting, which is negatively impacting his family life.
Dr. D finds himself burdened by record keeping that is increasingly complicated and insurance company demands that are onerous. Pharmaceutical prior authorizations that previously had been mildly bothersome are now a full-on burden. More often than not, he finds himself becoming irritable over extra requests and administrative demands, impatient with some patients and staff, and extremely fatigued at the end of workdays. Simply put, he finds that practicing medicine is far less enjoyable than it once was. He takes the Maslach Burnout Inventory, and his score indicates that he has moderate burnout.
Physician burnout has been a growing concern in recent decades.1 Characterized by varying degrees of job dissatisfaction, cynicism, emotional exhaustion, clinical inefficiency, and depression, physician burnout can impede effective patient care, cause significant health issues among physicians, diminish professional gratification and feelings of accomplishment, and financially burden society as a whole. Here we present the information you need to recognize burnout in yourself and colleagues and address the problem on personal, organizational, and legislative levels.
A problem that affects physicians of all ages
Physician burnout has been recognized to present anywhere on a spectrum, manifesting as ineffectiveness, overextension, disengagement, and/or an inability to practice.2 Such features may lead to feelings of professional inadequacy among even the highest functioning physicians.
Burnout occurs in all stages of medical life—as students, residents, and practicing physicians.3-6 Due to pressures in excess of coping capacity, some physicians will suffer from alcohol or other drug abuse, depression, and/or suicidal thinking.7 Stress and burnout can also result in musculoskeletal disorders, immune system dysfunction, cardiac pathology, and a shorter lifespan.8
Not only do individual practitioners suffer consequences from burnout, but it also compromises health care delivery. In 2018, the Medscape National Physician Burnout and Depression Report surveyed 15,000 physicians from 29 specialties; 33% of the respondents said that they were more easily frustrated by patients, and 32% reported less personal engagement.9 Burnout adversely impacts care, patient satisfaction, productivity, physician retention, retirement, and income, as well.6 Safety during clinical practice deteriorates because of an increase in medical error rates.10 Resultant emotional distress for physicians creates a vicious cycle.10
[polldaddy:10427848]
Continue to: These issues negatively impact...
These issues negatively impact practice enthusiasm and may engender self-doubt.11 They may lead to absenteeism or, worse, to abandoning the profession, further contributing to physician shortages.12 The financial impact of physician burnout in lost revenue in 2018 was about $17 billion, according to the National Taskforce for Humanity in Medicine.13
How prevalent is physician burnout?
Between October 2012 and March 2013, the American Society of Clinical Oncology surveyed US oncologists and found that 45% had evidence of burnout.14 In another survey of US physicians from all specialties conducted in 2011, at least 1 symptom of burnout was documented in nearly 46% of respondents.15 By 2014, this percentage increased to 54%.16
In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.9 About 48% of female practitioners reported burnout vs 38% of male peers.9 Work-related distress varies between specialties, with internists, family physicians, intensivists, neurologists, and gynecologists more affected than those from other specialties.9
Causes and contributing factors
Job stress generally increases with changes in the workplace. This can be heightened in the health care workplace, which demands perfection and leaves little room for emotional issues. Loss of autonomy, time constraints associated with clinical care, electronic health record (EHR) documentation, and disorganized workflow tend to contribute to provider dissatisfaction and stress, as do ethical disagreements about patient care between physicians and leadership.10,17 Fear of reprisal for speaking up about such issues can further exacerbate the problem. Some older physicians may have difficulty with technology and computerized record keeping. Reduced patient contact due to increasing reliance on computers can diminish physicians’ job satisfaction. And managing recurrent or difficult-to-treat ailments can result in compassion fatigue, diminished empathy, and emotional disengagement.
Burnout in the health care workplace is inconsistently addressed, despite negative professional and personal ramifications. The reasons include denial, uncertainty about monetary implications, and lack of corrective programs by decision-making organizations and/or employers.6 American medicine has lacked the political and financial will to implement strategies to mitigate burnout. Improvement requires changes on the part of government, physician groups, and the population at large.
The answer?
A multipronged approach
Identifying burnout is the first step in management. The 22-item Maslach Burnout Inventory (MBI) is a self-reporting questionnaire, reliable at detecting and assessing burnout severity.18 It screens 3 main domains: emotional exhaustion, depersonalization, and diminished feelings of accomplishment. The American Medical Association recommends the 10-item Zero Burnout Program—the “Mini Z Survey”—as being quicker and more convenient.19
Once the problem is recognized, experts suggest adopting a multipronged approach to prevention and intervention by using personal, organizational, and legislative strategies.20
Continue to: On a personal level...
On a personal level, it’s important to identify stressors and employ stress-reduction and coping skills, such as mindfulness and/or reflection.21 Mindfulness programs may help to minimize exhaustion, increase compassion, and improve understanding of other people’s feelings.22 Such programs are widely available and may be accessed through the Internet, mental health centers, or by contacting psychiatric or psychological services.
Other self-care methods include ensuring adequate sleep, nutrition, exercise, and enjoyable activities. If a physician who is suffering from burnout is taking any prescription or over-the-counter drugs or supplements, it is important to be self-aware of the potential for misuse of medications. Of course, one should never self-prescribe controlled drugs, such as opiates and sedatives. Consumption of alcohol must be well-controlled, without excesses, and drinking near bedtime is ill-advised. The use of illegal substances should be avoided.
Pursuing aspects of health care that are meaningful and that increase patient contact time can boost enthusiasm, as can focusing on the positives aspects of one’s career.23 Continuing medical education can enhance self-esteem and promote a sense of purpose.24
Peer support. Practice partners may assist their colleagues by alerting them to signs of burnout, offering timely intervention suggestions, and monitoring the effectiveness of strategies. Physicians should discuss stress and burnout with their peers; camaraderie within a practice group is helpful.
Professional coaches or counselors may be engaged to mitigate workplace distress. Coaching is best instituted collegially with pre-identified goals in order to minimize stigmatization.
Continue to: Professional societies and medical boards
Professional societies and medical boards. Reporting requirements by medical boards tend to stigmatize those seeking professional assistance. But that could change if all of us—through our participation in these organizations—pursue change.
Specifically, organizations and related societies could assist with better guidance and policy adjustment (see “Resources”). State medical boards could, for example, increase education of, and outreach to, physicians about mental health issues, while maintaining confidentiality.25 Medical organizations could regularly survey their membership to identify burnout early and identify personal, social, and institutional shortcomings that contribute to physician burnout. In addition, hospital quality improvement committees that monitor health care delivery appropriateness could take steps toward change as well.
SIDEBAR
Resources to help combat burnout
- National Academy of Medicine Action Collaborative on Clinician Well- Being and Resilience: https://nam.edu/initiatives/clinician-resilience-and-well-being/
- The Schwartz Center for Compassionate Healthcare: http://www.theschwartzcenter.org
- NEJM Catalyst: http://catalyst.nejm.org/posts?q=burnout
- The American Medical Association, Joy in Medicine: https://www.ama-assn.org/search?search=joy+in+medicine
- Agency for Healthcare Research and Quality: https://www.ahrq.gov/prevention/clinician/ahrq-works/burnout/index.html
- Accreditation Council for Graduate Medical Education Tools and Resources for Resident and Faculty Member Well-Being: https://www.acgme.org/What-We-Do/Initiatives/Physician-Well-Being/Resources
The American Medical Association (AMA) just recently announced that they are launching a new effort to fight the causes of physician burnout. The AMA’s Practice Transformation Inititative26 seeks to fill the knowledge gaps regarding effective interventions to reduce burnout. AMA’s leadership indicates that the initiative will focus on “improving joy in medicine by using validated assessment tools to measure burnout; field-testing interventions that are designed to improve workflows, applying practice science research methodology to evaluate impact, and sharing best practices within an AMA-facilitated learning community.”26
Stanford’s example. Stanford University instituted a ‘time bank’ program, to help their academic medical faculty balance work and life and reduce stress. They essentially offer services, such as home food delivery and house cleaning, in return for hours spent in the clinic.27
Reorganizing and reprioritizing. Prioritizing physician wellness as a quality indicator and instituting a committee to advocate for wellness can help attenuate burnout.28,29 Specific measures include minimizing rushed, overloaded scheduling and allowing more clinical contact time with patients. Using nursing and office staff to streamline workflow is also helpful.29 The University of Colorado’s “Ambulatory Process Excellence Model” strives to assist doctors by increasing the medical assistant-to-clinician ratio, yielding better productivity.23 Medical assistants are increasingly handling tasks such as data entry, medication reconciliation, and preventive care, to allow physicians more time to focus on medical decision-making.23
Continue to: The role of the EHR
The role of the EHR. One important way to boost professional morale is to simplify and shorten the EHR. The complexity of and reduced patient contact caused by today’s record-keeping systems is the source of great frustration among many physicians. In addition, many patients dislike the disproportionate attention paid by physicians to the computer during office visits, further compromising physician-patient relationships. Improving documentation methodology and/or employing medical assistant scribes can be helpful.30,31 (See “Advanced team-based care: How we made it work” at http://bit.ly/2lNaB5Q.)
Legislation with physician input can mandate policies for more appropriate work environments. A good way to initiate improvement and reform strategies is to contact local medical societies and political representatives. Federal and state collaboration to reduce physician shortages in selected specialties or geographic regions can improve work-related stress. This might be attained by expanding residency programs, using telemedicine in underserved regions, and employing more physician assistants.32
Health insurance. Enhancing universal access to affordable medical care, including pharmaceutical coverage, would alleviate stress for physicians and patients alike.33 Health insurance regulation to decrease paperwork and simplify coverage would decrease physician workload. Standardized policy requirements, fewer exclusionary rules, and simplified prescribing guidelines (including having less cumbersome prescription pre-authorizations and greater standardization of drug formularies by different payer sources or insurance plans) would facilitate better clinical management.
CASE
Dr. D begins by discussing his concerns with his colleagues in the group practice and finds he is not alone. Many of the concerns of the group center around brief, rushed appointments that diminish relationships with patients, a lack of autonomy, and the fear of medical malpractice. Several older physicians acknowledge that they just want to retire.
To address the patient contact and documentation issues, the group decides to hire scribes. They also decide to bring their concerns to the next county medical society meeting. The end result: They petitioned their state medical association to host presentations about mitigating burnout, to hold roundtable discussions, and to establish panels focused on remedying the situation.
Continue to: With this accomplished...
With this accomplished, Dr. D’s anxieties lessened. He surveyed relevant literature and shared tips for improving professional time management with his partners. In a hopeful mood, he volunteered to address burnout prevention at the next statewide medical meeting. He felt it was a good start.
CORRESPONDENCE
Steven Lippmann, MD, 401 E. Chestnut Street, Suite 610, Louisville, KY 40202; steven.lippmann@louisville.edu.
1. Ramirez AJ, Graham J, Richards MA, et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer. 1995;71:1263-1269.
2. Leiter MP, Maslach C. Latent burnout profiles: a new approach to understanding the burnout experience. Burnout Research. 2016;3:89-100.
3. Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Int Med. 2008;149:334-341.
4. West CP, Shanafelt TD, Kolars JC. Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents. JAMA. 2011;306:952-960.
5. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250:463-471.
6. Shanafelt TD, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177:1826-1832.
7. Cottler LB, Ajinkya S, Merlo LJ, et al. Lifetime psychiatric and substance use disorders among impaired physicians in a physicians health program. J Addict Med. 2013;7:108-112.
8. Consiglio C. Interpersonal strain at work: a new burnout facet relevant for the health of hospital staff. Burnout Res. 2014;1:69-75.
9. Peckham C. Medscape National Physician Burnout and Depression Report 2018. January 12, 2018. https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235. Accessed October 4, 2019.
10. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251:995-1000.
11. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174:527-533.
12. Suñer-Soler R, Grau-Martin A, Flichtentrei D, et al. The consequences of burnout syndrome among healthcare professionals in Spain and Spanish speaking Latin American countries. Burnout Research. 2014;1:82-89.
13. National Taskforce for Humanity in Healthcare. Position paper: The business case for humanity in healthcare. April 2018. https://www.vocera.com/public/pdf/NTHBusinessCase_final003.pdf. Accessed October 4, 2019.
14. Shanafelt TD, Gradishar WJ, Kosty M, et al. Burnout and career satisfaction among US oncologists. J Clin Oncol. 2014;32:678-686.
15. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Int Med. 2012;172:1377-1385.
16. Shanafelt TD, Hasan O, Dyrbye LN, et al. 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;1600-1613.
17. Linzer M, Manwell LB, Williams ES, et al. Working conditions in primary care: physician reactions and care quality. Ann Intern Med. 2009;151:28-36.
18. Maslach C, Jackson SE. The measurement of experienced burnout. J Occcup Behav. 1981;2:99-113.
19. Linzer M, Guzman-Corrales L, Poplau S. Physician Burnout: improve physician satisfaction and patient outcomes. June 5, 2015. https://www.stepsforward.org/modules/physician-burnout. Accessed October 4, 2019.
20. West CP, Dyrbye LN, Erwin PJ, et al. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388:2272-2281.
21. Nedrow A, Steckler NA, Hardman J. Physician resilience and burnout: can you make the switch? Fam Prac Manag. 2013;20:25-30.
22. Verweij H, van Ravesteijn H, van Hooff MLM, et al. Mindfulness-based stress reduction for residents: a randomized controlled trial. J Gen Intern Med. 2018;33:429-436.
23. Wright AA, Katz IT. Beyond burnout – redesigning care to restore meaning and sanity for physicians. N Eng J Med. 2018;378:309-311.
24. Shanafelt TD, Gorringe G, Menaker R, et. al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90:432-440.
25. Hengerer A, Kishore S. 2017. Breaking a culture of silence: the role of state medical boards. National Academy of Medicine, Washington DC. https://nam.edu/breaking-a-culture-of-silence-the-role-of-state-medical-boards/. Accessed October 4, 2019.
26. American Medical Association. AMA fights burnout with new practice transformation initiative. September 5, 2019. https://www.ama-assn.org/press-center/press-releases/ama-fights-burnout-new-practice-transformation-initiative. Accessed September 5, 2019.
27. Schulte B. Time in the bank: a Stanford plan to save doctors from burnout. The Washington Post. https://www.washingtonpost.com/news/inspired-life/wp/2015/08/20/the-innovative-stanford-program-thats-saving-emergency-room-doctors-from-burnout/?utm_term=.838c930e8de7. Accessed October 4, 2019.
28. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374:1714-1721.
29. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12:573-576.
30. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Info Assoc. 2014;21:E100-E106.
31. Bodenheimer T, Willard-Grace R, Ghorob A. Expanding the roles of medical assistants: who does what in primary care? JAMA Intern Med. 2014;174:1025-1026.
32. Mangiofico G. Physician shortage requires multi-prong solution. January 26, 2018. Am J Manag Care. https://www.ajmc.com/contributor/dr-gary-mangiofico/2018/01/physician-shortage-requires-multiprong-solution. Accessed October 4, 2019.
33. Reuben DB, Knudsen J, Senelick W, et al. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174:1190-1193.
CASE
Dr. Peter D is a mid-career family physician in a group practice that recently adopted an electronic health record system. Although he realizes he is now competent at computerized medicine, he has far less of the one-on-one patient contact that he once found so gratifying about the field of medicine.
Others in the practice have similar concerns, but they suggest that everyone ought to “go along to get along.” To manage the increasing demands of his case load and the required documentation, Dr. D has begun staying late to finish charting, which is negatively impacting his family life.
Dr. D finds himself burdened by record keeping that is increasingly complicated and insurance company demands that are onerous. Pharmaceutical prior authorizations that previously had been mildly bothersome are now a full-on burden. More often than not, he finds himself becoming irritable over extra requests and administrative demands, impatient with some patients and staff, and extremely fatigued at the end of workdays. Simply put, he finds that practicing medicine is far less enjoyable than it once was. He takes the Maslach Burnout Inventory, and his score indicates that he has moderate burnout.
Physician burnout has been a growing concern in recent decades.1 Characterized by varying degrees of job dissatisfaction, cynicism, emotional exhaustion, clinical inefficiency, and depression, physician burnout can impede effective patient care, cause significant health issues among physicians, diminish professional gratification and feelings of accomplishment, and financially burden society as a whole. Here we present the information you need to recognize burnout in yourself and colleagues and address the problem on personal, organizational, and legislative levels.
A problem that affects physicians of all ages
Physician burnout has been recognized to present anywhere on a spectrum, manifesting as ineffectiveness, overextension, disengagement, and/or an inability to practice.2 Such features may lead to feelings of professional inadequacy among even the highest functioning physicians.
Burnout occurs in all stages of medical life—as students, residents, and practicing physicians.3-6 Due to pressures in excess of coping capacity, some physicians will suffer from alcohol or other drug abuse, depression, and/or suicidal thinking.7 Stress and burnout can also result in musculoskeletal disorders, immune system dysfunction, cardiac pathology, and a shorter lifespan.8
Not only do individual practitioners suffer consequences from burnout, but it also compromises health care delivery. In 2018, the Medscape National Physician Burnout and Depression Report surveyed 15,000 physicians from 29 specialties; 33% of the respondents said that they were more easily frustrated by patients, and 32% reported less personal engagement.9 Burnout adversely impacts care, patient satisfaction, productivity, physician retention, retirement, and income, as well.6 Safety during clinical practice deteriorates because of an increase in medical error rates.10 Resultant emotional distress for physicians creates a vicious cycle.10
[polldaddy:10427848]
Continue to: These issues negatively impact...
These issues negatively impact practice enthusiasm and may engender self-doubt.11 They may lead to absenteeism or, worse, to abandoning the profession, further contributing to physician shortages.12 The financial impact of physician burnout in lost revenue in 2018 was about $17 billion, according to the National Taskforce for Humanity in Medicine.13
How prevalent is physician burnout?
Between October 2012 and March 2013, the American Society of Clinical Oncology surveyed US oncologists and found that 45% had evidence of burnout.14 In another survey of US physicians from all specialties conducted in 2011, at least 1 symptom of burnout was documented in nearly 46% of respondents.15 By 2014, this percentage increased to 54%.16
In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.9 About 48% of female practitioners reported burnout vs 38% of male peers.9 Work-related distress varies between specialties, with internists, family physicians, intensivists, neurologists, and gynecologists more affected than those from other specialties.9
Causes and contributing factors
Job stress generally increases with changes in the workplace. This can be heightened in the health care workplace, which demands perfection and leaves little room for emotional issues. Loss of autonomy, time constraints associated with clinical care, electronic health record (EHR) documentation, and disorganized workflow tend to contribute to provider dissatisfaction and stress, as do ethical disagreements about patient care between physicians and leadership.10,17 Fear of reprisal for speaking up about such issues can further exacerbate the problem. Some older physicians may have difficulty with technology and computerized record keeping. Reduced patient contact due to increasing reliance on computers can diminish physicians’ job satisfaction. And managing recurrent or difficult-to-treat ailments can result in compassion fatigue, diminished empathy, and emotional disengagement.
Burnout in the health care workplace is inconsistently addressed, despite negative professional and personal ramifications. The reasons include denial, uncertainty about monetary implications, and lack of corrective programs by decision-making organizations and/or employers.6 American medicine has lacked the political and financial will to implement strategies to mitigate burnout. Improvement requires changes on the part of government, physician groups, and the population at large.
The answer?
A multipronged approach
Identifying burnout is the first step in management. The 22-item Maslach Burnout Inventory (MBI) is a self-reporting questionnaire, reliable at detecting and assessing burnout severity.18 It screens 3 main domains: emotional exhaustion, depersonalization, and diminished feelings of accomplishment. The American Medical Association recommends the 10-item Zero Burnout Program—the “Mini Z Survey”—as being quicker and more convenient.19
Once the problem is recognized, experts suggest adopting a multipronged approach to prevention and intervention by using personal, organizational, and legislative strategies.20
Continue to: On a personal level...
On a personal level, it’s important to identify stressors and employ stress-reduction and coping skills, such as mindfulness and/or reflection.21 Mindfulness programs may help to minimize exhaustion, increase compassion, and improve understanding of other people’s feelings.22 Such programs are widely available and may be accessed through the Internet, mental health centers, or by contacting psychiatric or psychological services.
Other self-care methods include ensuring adequate sleep, nutrition, exercise, and enjoyable activities. If a physician who is suffering from burnout is taking any prescription or over-the-counter drugs or supplements, it is important to be self-aware of the potential for misuse of medications. Of course, one should never self-prescribe controlled drugs, such as opiates and sedatives. Consumption of alcohol must be well-controlled, without excesses, and drinking near bedtime is ill-advised. The use of illegal substances should be avoided.
Pursuing aspects of health care that are meaningful and that increase patient contact time can boost enthusiasm, as can focusing on the positives aspects of one’s career.23 Continuing medical education can enhance self-esteem and promote a sense of purpose.24
Peer support. Practice partners may assist their colleagues by alerting them to signs of burnout, offering timely intervention suggestions, and monitoring the effectiveness of strategies. Physicians should discuss stress and burnout with their peers; camaraderie within a practice group is helpful.
Professional coaches or counselors may be engaged to mitigate workplace distress. Coaching is best instituted collegially with pre-identified goals in order to minimize stigmatization.
Continue to: Professional societies and medical boards
Professional societies and medical boards. Reporting requirements by medical boards tend to stigmatize those seeking professional assistance. But that could change if all of us—through our participation in these organizations—pursue change.
Specifically, organizations and related societies could assist with better guidance and policy adjustment (see “Resources”). State medical boards could, for example, increase education of, and outreach to, physicians about mental health issues, while maintaining confidentiality.25 Medical organizations could regularly survey their membership to identify burnout early and identify personal, social, and institutional shortcomings that contribute to physician burnout. In addition, hospital quality improvement committees that monitor health care delivery appropriateness could take steps toward change as well.
SIDEBAR
Resources to help combat burnout
- National Academy of Medicine Action Collaborative on Clinician Well- Being and Resilience: https://nam.edu/initiatives/clinician-resilience-and-well-being/
- The Schwartz Center for Compassionate Healthcare: http://www.theschwartzcenter.org
- NEJM Catalyst: http://catalyst.nejm.org/posts?q=burnout
- The American Medical Association, Joy in Medicine: https://www.ama-assn.org/search?search=joy+in+medicine
- Agency for Healthcare Research and Quality: https://www.ahrq.gov/prevention/clinician/ahrq-works/burnout/index.html
- Accreditation Council for Graduate Medical Education Tools and Resources for Resident and Faculty Member Well-Being: https://www.acgme.org/What-We-Do/Initiatives/Physician-Well-Being/Resources
The American Medical Association (AMA) just recently announced that they are launching a new effort to fight the causes of physician burnout. The AMA’s Practice Transformation Inititative26 seeks to fill the knowledge gaps regarding effective interventions to reduce burnout. AMA’s leadership indicates that the initiative will focus on “improving joy in medicine by using validated assessment tools to measure burnout; field-testing interventions that are designed to improve workflows, applying practice science research methodology to evaluate impact, and sharing best practices within an AMA-facilitated learning community.”26
Stanford’s example. Stanford University instituted a ‘time bank’ program, to help their academic medical faculty balance work and life and reduce stress. They essentially offer services, such as home food delivery and house cleaning, in return for hours spent in the clinic.27
Reorganizing and reprioritizing. Prioritizing physician wellness as a quality indicator and instituting a committee to advocate for wellness can help attenuate burnout.28,29 Specific measures include minimizing rushed, overloaded scheduling and allowing more clinical contact time with patients. Using nursing and office staff to streamline workflow is also helpful.29 The University of Colorado’s “Ambulatory Process Excellence Model” strives to assist doctors by increasing the medical assistant-to-clinician ratio, yielding better productivity.23 Medical assistants are increasingly handling tasks such as data entry, medication reconciliation, and preventive care, to allow physicians more time to focus on medical decision-making.23
Continue to: The role of the EHR
The role of the EHR. One important way to boost professional morale is to simplify and shorten the EHR. The complexity of and reduced patient contact caused by today’s record-keeping systems is the source of great frustration among many physicians. In addition, many patients dislike the disproportionate attention paid by physicians to the computer during office visits, further compromising physician-patient relationships. Improving documentation methodology and/or employing medical assistant scribes can be helpful.30,31 (See “Advanced team-based care: How we made it work” at http://bit.ly/2lNaB5Q.)
Legislation with physician input can mandate policies for more appropriate work environments. A good way to initiate improvement and reform strategies is to contact local medical societies and political representatives. Federal and state collaboration to reduce physician shortages in selected specialties or geographic regions can improve work-related stress. This might be attained by expanding residency programs, using telemedicine in underserved regions, and employing more physician assistants.32
Health insurance. Enhancing universal access to affordable medical care, including pharmaceutical coverage, would alleviate stress for physicians and patients alike.33 Health insurance regulation to decrease paperwork and simplify coverage would decrease physician workload. Standardized policy requirements, fewer exclusionary rules, and simplified prescribing guidelines (including having less cumbersome prescription pre-authorizations and greater standardization of drug formularies by different payer sources or insurance plans) would facilitate better clinical management.
CASE
Dr. D begins by discussing his concerns with his colleagues in the group practice and finds he is not alone. Many of the concerns of the group center around brief, rushed appointments that diminish relationships with patients, a lack of autonomy, and the fear of medical malpractice. Several older physicians acknowledge that they just want to retire.
To address the patient contact and documentation issues, the group decides to hire scribes. They also decide to bring their concerns to the next county medical society meeting. The end result: They petitioned their state medical association to host presentations about mitigating burnout, to hold roundtable discussions, and to establish panels focused on remedying the situation.
Continue to: With this accomplished...
With this accomplished, Dr. D’s anxieties lessened. He surveyed relevant literature and shared tips for improving professional time management with his partners. In a hopeful mood, he volunteered to address burnout prevention at the next statewide medical meeting. He felt it was a good start.
CORRESPONDENCE
Steven Lippmann, MD, 401 E. Chestnut Street, Suite 610, Louisville, KY 40202; steven.lippmann@louisville.edu.
CASE
Dr. Peter D is a mid-career family physician in a group practice that recently adopted an electronic health record system. Although he realizes he is now competent at computerized medicine, he has far less of the one-on-one patient contact that he once found so gratifying about the field of medicine.
Others in the practice have similar concerns, but they suggest that everyone ought to “go along to get along.” To manage the increasing demands of his case load and the required documentation, Dr. D has begun staying late to finish charting, which is negatively impacting his family life.
Dr. D finds himself burdened by record keeping that is increasingly complicated and insurance company demands that are onerous. Pharmaceutical prior authorizations that previously had been mildly bothersome are now a full-on burden. More often than not, he finds himself becoming irritable over extra requests and administrative demands, impatient with some patients and staff, and extremely fatigued at the end of workdays. Simply put, he finds that practicing medicine is far less enjoyable than it once was. He takes the Maslach Burnout Inventory, and his score indicates that he has moderate burnout.
Physician burnout has been a growing concern in recent decades.1 Characterized by varying degrees of job dissatisfaction, cynicism, emotional exhaustion, clinical inefficiency, and depression, physician burnout can impede effective patient care, cause significant health issues among physicians, diminish professional gratification and feelings of accomplishment, and financially burden society as a whole. Here we present the information you need to recognize burnout in yourself and colleagues and address the problem on personal, organizational, and legislative levels.
A problem that affects physicians of all ages
Physician burnout has been recognized to present anywhere on a spectrum, manifesting as ineffectiveness, overextension, disengagement, and/or an inability to practice.2 Such features may lead to feelings of professional inadequacy among even the highest functioning physicians.
Burnout occurs in all stages of medical life—as students, residents, and practicing physicians.3-6 Due to pressures in excess of coping capacity, some physicians will suffer from alcohol or other drug abuse, depression, and/or suicidal thinking.7 Stress and burnout can also result in musculoskeletal disorders, immune system dysfunction, cardiac pathology, and a shorter lifespan.8
Not only do individual practitioners suffer consequences from burnout, but it also compromises health care delivery. In 2018, the Medscape National Physician Burnout and Depression Report surveyed 15,000 physicians from 29 specialties; 33% of the respondents said that they were more easily frustrated by patients, and 32% reported less personal engagement.9 Burnout adversely impacts care, patient satisfaction, productivity, physician retention, retirement, and income, as well.6 Safety during clinical practice deteriorates because of an increase in medical error rates.10 Resultant emotional distress for physicians creates a vicious cycle.10
[polldaddy:10427848]
Continue to: These issues negatively impact...
These issues negatively impact practice enthusiasm and may engender self-doubt.11 They may lead to absenteeism or, worse, to abandoning the profession, further contributing to physician shortages.12 The financial impact of physician burnout in lost revenue in 2018 was about $17 billion, according to the National Taskforce for Humanity in Medicine.13
How prevalent is physician burnout?
Between October 2012 and March 2013, the American Society of Clinical Oncology surveyed US oncologists and found that 45% had evidence of burnout.14 In another survey of US physicians from all specialties conducted in 2011, at least 1 symptom of burnout was documented in nearly 46% of respondents.15 By 2014, this percentage increased to 54%.16
In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.9 About 48% of female practitioners reported burnout vs 38% of male peers.9 Work-related distress varies between specialties, with internists, family physicians, intensivists, neurologists, and gynecologists more affected than those from other specialties.9
Causes and contributing factors
Job stress generally increases with changes in the workplace. This can be heightened in the health care workplace, which demands perfection and leaves little room for emotional issues. Loss of autonomy, time constraints associated with clinical care, electronic health record (EHR) documentation, and disorganized workflow tend to contribute to provider dissatisfaction and stress, as do ethical disagreements about patient care between physicians and leadership.10,17 Fear of reprisal for speaking up about such issues can further exacerbate the problem. Some older physicians may have difficulty with technology and computerized record keeping. Reduced patient contact due to increasing reliance on computers can diminish physicians’ job satisfaction. And managing recurrent or difficult-to-treat ailments can result in compassion fatigue, diminished empathy, and emotional disengagement.
Burnout in the health care workplace is inconsistently addressed, despite negative professional and personal ramifications. The reasons include denial, uncertainty about monetary implications, and lack of corrective programs by decision-making organizations and/or employers.6 American medicine has lacked the political and financial will to implement strategies to mitigate burnout. Improvement requires changes on the part of government, physician groups, and the population at large.
The answer?
A multipronged approach
Identifying burnout is the first step in management. The 22-item Maslach Burnout Inventory (MBI) is a self-reporting questionnaire, reliable at detecting and assessing burnout severity.18 It screens 3 main domains: emotional exhaustion, depersonalization, and diminished feelings of accomplishment. The American Medical Association recommends the 10-item Zero Burnout Program—the “Mini Z Survey”—as being quicker and more convenient.19
Once the problem is recognized, experts suggest adopting a multipronged approach to prevention and intervention by using personal, organizational, and legislative strategies.20
Continue to: On a personal level...
On a personal level, it’s important to identify stressors and employ stress-reduction and coping skills, such as mindfulness and/or reflection.21 Mindfulness programs may help to minimize exhaustion, increase compassion, and improve understanding of other people’s feelings.22 Such programs are widely available and may be accessed through the Internet, mental health centers, or by contacting psychiatric or psychological services.
Other self-care methods include ensuring adequate sleep, nutrition, exercise, and enjoyable activities. If a physician who is suffering from burnout is taking any prescription or over-the-counter drugs or supplements, it is important to be self-aware of the potential for misuse of medications. Of course, one should never self-prescribe controlled drugs, such as opiates and sedatives. Consumption of alcohol must be well-controlled, without excesses, and drinking near bedtime is ill-advised. The use of illegal substances should be avoided.
Pursuing aspects of health care that are meaningful and that increase patient contact time can boost enthusiasm, as can focusing on the positives aspects of one’s career.23 Continuing medical education can enhance self-esteem and promote a sense of purpose.24
Peer support. Practice partners may assist their colleagues by alerting them to signs of burnout, offering timely intervention suggestions, and monitoring the effectiveness of strategies. Physicians should discuss stress and burnout with their peers; camaraderie within a practice group is helpful.
Professional coaches or counselors may be engaged to mitigate workplace distress. Coaching is best instituted collegially with pre-identified goals in order to minimize stigmatization.
Continue to: Professional societies and medical boards
Professional societies and medical boards. Reporting requirements by medical boards tend to stigmatize those seeking professional assistance. But that could change if all of us—through our participation in these organizations—pursue change.
Specifically, organizations and related societies could assist with better guidance and policy adjustment (see “Resources”). State medical boards could, for example, increase education of, and outreach to, physicians about mental health issues, while maintaining confidentiality.25 Medical organizations could regularly survey their membership to identify burnout early and identify personal, social, and institutional shortcomings that contribute to physician burnout. In addition, hospital quality improvement committees that monitor health care delivery appropriateness could take steps toward change as well.
SIDEBAR
Resources to help combat burnout
- National Academy of Medicine Action Collaborative on Clinician Well- Being and Resilience: https://nam.edu/initiatives/clinician-resilience-and-well-being/
- The Schwartz Center for Compassionate Healthcare: http://www.theschwartzcenter.org
- NEJM Catalyst: http://catalyst.nejm.org/posts?q=burnout
- The American Medical Association, Joy in Medicine: https://www.ama-assn.org/search?search=joy+in+medicine
- Agency for Healthcare Research and Quality: https://www.ahrq.gov/prevention/clinician/ahrq-works/burnout/index.html
- Accreditation Council for Graduate Medical Education Tools and Resources for Resident and Faculty Member Well-Being: https://www.acgme.org/What-We-Do/Initiatives/Physician-Well-Being/Resources
The American Medical Association (AMA) just recently announced that they are launching a new effort to fight the causes of physician burnout. The AMA’s Practice Transformation Inititative26 seeks to fill the knowledge gaps regarding effective interventions to reduce burnout. AMA’s leadership indicates that the initiative will focus on “improving joy in medicine by using validated assessment tools to measure burnout; field-testing interventions that are designed to improve workflows, applying practice science research methodology to evaluate impact, and sharing best practices within an AMA-facilitated learning community.”26
Stanford’s example. Stanford University instituted a ‘time bank’ program, to help their academic medical faculty balance work and life and reduce stress. They essentially offer services, such as home food delivery and house cleaning, in return for hours spent in the clinic.27
Reorganizing and reprioritizing. Prioritizing physician wellness as a quality indicator and instituting a committee to advocate for wellness can help attenuate burnout.28,29 Specific measures include minimizing rushed, overloaded scheduling and allowing more clinical contact time with patients. Using nursing and office staff to streamline workflow is also helpful.29 The University of Colorado’s “Ambulatory Process Excellence Model” strives to assist doctors by increasing the medical assistant-to-clinician ratio, yielding better productivity.23 Medical assistants are increasingly handling tasks such as data entry, medication reconciliation, and preventive care, to allow physicians more time to focus on medical decision-making.23
Continue to: The role of the EHR
The role of the EHR. One important way to boost professional morale is to simplify and shorten the EHR. The complexity of and reduced patient contact caused by today’s record-keeping systems is the source of great frustration among many physicians. In addition, many patients dislike the disproportionate attention paid by physicians to the computer during office visits, further compromising physician-patient relationships. Improving documentation methodology and/or employing medical assistant scribes can be helpful.30,31 (See “Advanced team-based care: How we made it work” at http://bit.ly/2lNaB5Q.)
Legislation with physician input can mandate policies for more appropriate work environments. A good way to initiate improvement and reform strategies is to contact local medical societies and political representatives. Federal and state collaboration to reduce physician shortages in selected specialties or geographic regions can improve work-related stress. This might be attained by expanding residency programs, using telemedicine in underserved regions, and employing more physician assistants.32
Health insurance. Enhancing universal access to affordable medical care, including pharmaceutical coverage, would alleviate stress for physicians and patients alike.33 Health insurance regulation to decrease paperwork and simplify coverage would decrease physician workload. Standardized policy requirements, fewer exclusionary rules, and simplified prescribing guidelines (including having less cumbersome prescription pre-authorizations and greater standardization of drug formularies by different payer sources or insurance plans) would facilitate better clinical management.
CASE
Dr. D begins by discussing his concerns with his colleagues in the group practice and finds he is not alone. Many of the concerns of the group center around brief, rushed appointments that diminish relationships with patients, a lack of autonomy, and the fear of medical malpractice. Several older physicians acknowledge that they just want to retire.
To address the patient contact and documentation issues, the group decides to hire scribes. They also decide to bring their concerns to the next county medical society meeting. The end result: They petitioned their state medical association to host presentations about mitigating burnout, to hold roundtable discussions, and to establish panels focused on remedying the situation.
Continue to: With this accomplished...
With this accomplished, Dr. D’s anxieties lessened. He surveyed relevant literature and shared tips for improving professional time management with his partners. In a hopeful mood, he volunteered to address burnout prevention at the next statewide medical meeting. He felt it was a good start.
CORRESPONDENCE
Steven Lippmann, MD, 401 E. Chestnut Street, Suite 610, Louisville, KY 40202; steven.lippmann@louisville.edu.
1. Ramirez AJ, Graham J, Richards MA, et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer. 1995;71:1263-1269.
2. Leiter MP, Maslach C. Latent burnout profiles: a new approach to understanding the burnout experience. Burnout Research. 2016;3:89-100.
3. Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Int Med. 2008;149:334-341.
4. West CP, Shanafelt TD, Kolars JC. Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents. JAMA. 2011;306:952-960.
5. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250:463-471.
6. Shanafelt TD, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177:1826-1832.
7. Cottler LB, Ajinkya S, Merlo LJ, et al. Lifetime psychiatric and substance use disorders among impaired physicians in a physicians health program. J Addict Med. 2013;7:108-112.
8. Consiglio C. Interpersonal strain at work: a new burnout facet relevant for the health of hospital staff. Burnout Res. 2014;1:69-75.
9. Peckham C. Medscape National Physician Burnout and Depression Report 2018. January 12, 2018. https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235. Accessed October 4, 2019.
10. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251:995-1000.
11. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174:527-533.
12. Suñer-Soler R, Grau-Martin A, Flichtentrei D, et al. The consequences of burnout syndrome among healthcare professionals in Spain and Spanish speaking Latin American countries. Burnout Research. 2014;1:82-89.
13. National Taskforce for Humanity in Healthcare. Position paper: The business case for humanity in healthcare. April 2018. https://www.vocera.com/public/pdf/NTHBusinessCase_final003.pdf. Accessed October 4, 2019.
14. Shanafelt TD, Gradishar WJ, Kosty M, et al. Burnout and career satisfaction among US oncologists. J Clin Oncol. 2014;32:678-686.
15. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Int Med. 2012;172:1377-1385.
16. Shanafelt TD, Hasan O, Dyrbye LN, et al. 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;1600-1613.
17. Linzer M, Manwell LB, Williams ES, et al. Working conditions in primary care: physician reactions and care quality. Ann Intern Med. 2009;151:28-36.
18. Maslach C, Jackson SE. The measurement of experienced burnout. J Occcup Behav. 1981;2:99-113.
19. Linzer M, Guzman-Corrales L, Poplau S. Physician Burnout: improve physician satisfaction and patient outcomes. June 5, 2015. https://www.stepsforward.org/modules/physician-burnout. Accessed October 4, 2019.
20. West CP, Dyrbye LN, Erwin PJ, et al. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388:2272-2281.
21. Nedrow A, Steckler NA, Hardman J. Physician resilience and burnout: can you make the switch? Fam Prac Manag. 2013;20:25-30.
22. Verweij H, van Ravesteijn H, van Hooff MLM, et al. Mindfulness-based stress reduction for residents: a randomized controlled trial. J Gen Intern Med. 2018;33:429-436.
23. Wright AA, Katz IT. Beyond burnout – redesigning care to restore meaning and sanity for physicians. N Eng J Med. 2018;378:309-311.
24. Shanafelt TD, Gorringe G, Menaker R, et. al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90:432-440.
25. Hengerer A, Kishore S. 2017. Breaking a culture of silence: the role of state medical boards. National Academy of Medicine, Washington DC. https://nam.edu/breaking-a-culture-of-silence-the-role-of-state-medical-boards/. Accessed October 4, 2019.
26. American Medical Association. AMA fights burnout with new practice transformation initiative. September 5, 2019. https://www.ama-assn.org/press-center/press-releases/ama-fights-burnout-new-practice-transformation-initiative. Accessed September 5, 2019.
27. Schulte B. Time in the bank: a Stanford plan to save doctors from burnout. The Washington Post. https://www.washingtonpost.com/news/inspired-life/wp/2015/08/20/the-innovative-stanford-program-thats-saving-emergency-room-doctors-from-burnout/?utm_term=.838c930e8de7. Accessed October 4, 2019.
28. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374:1714-1721.
29. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12:573-576.
30. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Info Assoc. 2014;21:E100-E106.
31. Bodenheimer T, Willard-Grace R, Ghorob A. Expanding the roles of medical assistants: who does what in primary care? JAMA Intern Med. 2014;174:1025-1026.
32. Mangiofico G. Physician shortage requires multi-prong solution. January 26, 2018. Am J Manag Care. https://www.ajmc.com/contributor/dr-gary-mangiofico/2018/01/physician-shortage-requires-multiprong-solution. Accessed October 4, 2019.
33. Reuben DB, Knudsen J, Senelick W, et al. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174:1190-1193.
1. Ramirez AJ, Graham J, Richards MA, et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer. 1995;71:1263-1269.
2. Leiter MP, Maslach C. Latent burnout profiles: a new approach to understanding the burnout experience. Burnout Research. 2016;3:89-100.
3. Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Int Med. 2008;149:334-341.
4. West CP, Shanafelt TD, Kolars JC. Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents. JAMA. 2011;306:952-960.
5. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250:463-471.
6. Shanafelt TD, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177:1826-1832.
7. Cottler LB, Ajinkya S, Merlo LJ, et al. Lifetime psychiatric and substance use disorders among impaired physicians in a physicians health program. J Addict Med. 2013;7:108-112.
8. Consiglio C. Interpersonal strain at work: a new burnout facet relevant for the health of hospital staff. Burnout Res. 2014;1:69-75.
9. Peckham C. Medscape National Physician Burnout and Depression Report 2018. January 12, 2018. https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235. Accessed October 4, 2019.
10. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251:995-1000.
11. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174:527-533.
12. Suñer-Soler R, Grau-Martin A, Flichtentrei D, et al. The consequences of burnout syndrome among healthcare professionals in Spain and Spanish speaking Latin American countries. Burnout Research. 2014;1:82-89.
13. National Taskforce for Humanity in Healthcare. Position paper: The business case for humanity in healthcare. April 2018. https://www.vocera.com/public/pdf/NTHBusinessCase_final003.pdf. Accessed October 4, 2019.
14. Shanafelt TD, Gradishar WJ, Kosty M, et al. Burnout and career satisfaction among US oncologists. J Clin Oncol. 2014;32:678-686.
15. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Int Med. 2012;172:1377-1385.
16. Shanafelt TD, Hasan O, Dyrbye LN, et al. 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;1600-1613.
17. Linzer M, Manwell LB, Williams ES, et al. Working conditions in primary care: physician reactions and care quality. Ann Intern Med. 2009;151:28-36.
18. Maslach C, Jackson SE. The measurement of experienced burnout. J Occcup Behav. 1981;2:99-113.
19. Linzer M, Guzman-Corrales L, Poplau S. Physician Burnout: improve physician satisfaction and patient outcomes. June 5, 2015. https://www.stepsforward.org/modules/physician-burnout. Accessed October 4, 2019.
20. West CP, Dyrbye LN, Erwin PJ, et al. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388:2272-2281.
21. Nedrow A, Steckler NA, Hardman J. Physician resilience and burnout: can you make the switch? Fam Prac Manag. 2013;20:25-30.
22. Verweij H, van Ravesteijn H, van Hooff MLM, et al. Mindfulness-based stress reduction for residents: a randomized controlled trial. J Gen Intern Med. 2018;33:429-436.
23. Wright AA, Katz IT. Beyond burnout – redesigning care to restore meaning and sanity for physicians. N Eng J Med. 2018;378:309-311.
24. Shanafelt TD, Gorringe G, Menaker R, et. al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90:432-440.
25. Hengerer A, Kishore S. 2017. Breaking a culture of silence: the role of state medical boards. National Academy of Medicine, Washington DC. https://nam.edu/breaking-a-culture-of-silence-the-role-of-state-medical-boards/. Accessed October 4, 2019.
26. American Medical Association. AMA fights burnout with new practice transformation initiative. September 5, 2019. https://www.ama-assn.org/press-center/press-releases/ama-fights-burnout-new-practice-transformation-initiative. Accessed September 5, 2019.
27. Schulte B. Time in the bank: a Stanford plan to save doctors from burnout. The Washington Post. https://www.washingtonpost.com/news/inspired-life/wp/2015/08/20/the-innovative-stanford-program-thats-saving-emergency-room-doctors-from-burnout/?utm_term=.838c930e8de7. Accessed October 4, 2019.
28. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374:1714-1721.
29. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12:573-576.
30. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Info Assoc. 2014;21:E100-E106.
31. Bodenheimer T, Willard-Grace R, Ghorob A. Expanding the roles of medical assistants: who does what in primary care? JAMA Intern Med. 2014;174:1025-1026.
32. Mangiofico G. Physician shortage requires multi-prong solution. January 26, 2018. Am J Manag Care. https://www.ajmc.com/contributor/dr-gary-mangiofico/2018/01/physician-shortage-requires-multiprong-solution. Accessed October 4, 2019.
33. Reuben DB, Knudsen J, Senelick W, et al. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174:1190-1193.
