Most surgeons today are familiar with professional burnout – in their colleagues, in surgical trainees, and perhaps, in themselves. But the understanding of burnout is evolving. The discussion is moving away from blaming physicians for their poor coping skills toward identifying the structural and organizational roots of burnout.
Burnout is a syndrome cause by work-related stress that features emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment. A recent study of nearly 7,000 physicians using the Maslach Burnout Inventory found that 54.4% of those surveyed reported at least one symptom of burnout (Mayo Clin Proc. 2015 Dec;90[12]:1600-19). Other studies have found similar rates of burnout in the surgical specialties such as orthopedic, oncologic, cardiothoracic, and plastic surgery (JAMA Surg. 2014 Sep;149:948-53; Ann Surg Oncol 2011 May;18:1229-35; Internat J Cardiol. 2015 Jan 20;179:7-72; Aesthet Surg J. 2016 Sep 27. E-pub ahead of print).
Courtesy Mayo Clinic
Dr. Tait D. Shanafelt
A new paradigm of burnout
The paradigm of burnout as a personal issue that can be managed by individual coping strategies is giving way to an understanding that the structural roots of burnout require the shared responsibility of individuals and their work organizations to solve the problem. A revised approach has emerged: Physician burnout as a symptom not of personal failure to cope, but of institutional failure to adapt to new circumstances in the health care milieu. The growing number of physicians employed in large group practices and medical centers has come with a whole array of management problems that are only beginning to be recognized, and burnout may be one of the most challenging.
Tait D. Shanafelt, MD, of the Mayo Foundation for Medical Education and Research, and John H. Noseworthy, MD, president and CEO of the Mayo Clinic, both in Rochester, Minn., have partnered to distill years of study and practice on the issue of burnout to a set of organizational strategies to tackle the problem and describe the Mayo Clinic experience. The study, “Executive Leadership and Physician Well-Being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout” (Mayo Clin Proc. 2016 Nov 18. doi. org/10.1016/j.mayocp.2016.10.004) reverses the conventional “blame the victim” approach and identifies instead institutional responsibility to address burnout.
“Increasing evidence over the last 10 years demonstrating links to quality of care, productivity, and turnover have raised appreciation … by organizations that they have a substantial stake in this issue and that they control many of the factors that contribute to this problem,” said Dr. Shanafelt in an interview.
Unintended consequences of the individual solution
The focus on individual responsibility can have unintended consequences. A physician suffering from burnout can take action by leaving his or her job or cutting back. Staff turnover, a phenomenon closely tied to burnout, is costly and damaging to productivity and patient care (Physician Leadersh J. 2015 May-Jun;2[3]:22-5); Health Care Manage Rev. 2004;29[1]2-7). These personal strategies may help individuals cope but can end up harming the institution and the work life of other staff members. Physicians experiencing burnout in their own lives can trigger the same condition in their colleagues.
The Mayo paper by Dr. Shanafelt and Dr. Noseworthy states, “Mistakenly, most hospitals, medical centers, and practice groups operate under the framework that burnout and professional satisfaction are solely the responsibility of the individual physician. This frequently results in organizations pursuing a narrow list of ‘solutions’ that are unlikely to result in meaningful progress (e.g., stress management workshops and individual training in mindfulness/resilience). Such strategies neglect the organizational factors that are the primary drivers of physician burnout and are correctly viewed with skepticism by physicians as an insincere effort by the organization to address the problem.”
Organizational strategies to reduce burnout
Dr. Shanafelt and Dr. Noseworthy developed a list of nine organizational strategies that have been shown to reduce burnout among doctors. A critical piece of this approach is the accumulated evidence of the financial burden of burnout among physicians in health care institutions. The approach is based on an informed leadership that recognizes the costs of inaction, without which a systemic solution is unlikely to be achieved.
1. Naming the issue and assessing the problem
Acknowledgment of burnout as an institutional problem and meaningful measurement of physician well-being are the initial steps in tackling the problem. This requires a sincere commitment at the highest level of management to listen and to recognize what staff physicians are saying. “At Mayo Clinic, we have incorporated town halls, radio broadcasts, letters, and video interviews along with face-to-face meetings involving clinical divisions, work units, and small groups as formats or [by using] the CEO to reach the staff.” Assessing physician well-being and quality of work life using one or more of the many available tools has to be an ongoing “a barometer of organization health,” and not just a one-off, crisis management activity.
2. Harnessing the power of leadership
Studies have found that management behaviors and strategies of supervisors are key components of physician well-being. The bottom line is that physician supervisors must accept a share of responsibility for burnout in those they manage. Leaders can be chosen on the basis of their ability to listen, engage, develop, and lead, and but they can also be trained to improve. In addition, leaders should be regularly assessed by those whom they lead. Dr. Shanafelt and Dr. Noseworthy argue that a crucial element of successful leadership involves recognizing unique interests and talents of individual physicians whom they manage and facilitating professional development so that each staff member spends about 20% of work time engaged in activities that he or she finds most meaningful.
3. Developing targeted interventions
Just as all politics is local, the study suggests that many sources of burnout are local as well. For example, although a high clerical burden on physicians may be a universal driver of burnout, it manifests differently in each institutional setting. The key here is to dig into the specific structural driver at the unit or ward level, engage physicians in analysis and problem-solving, and implement a plan to address the problem.
Dr. Shanafelt noted, “We organize the drivers of engagement and burnout around seven dimensions: workload, efficiency, flexibility/control, community at work, organizational culture and values, work-life integration, and meaning in work. Each of these dimensions has organizational and individual components. Work units should begin by identifying which one or two dimensions are the biggest challenges for the group and then begin a stepwise process to address them.”
4. Cultivating community at work
Peer support, a long-standing source of strength among surgeons and other physicians, unintentionally has been eroded in many modern medical institutions. There is ample evidence that this loss of collegiality is tied to burnout. “These interactions have been an unintended casualty of increasing productivity expectations, documentation requirements, and clerical burden. [Many organizations have eliminated] formal spaces for physicians to interact (e.g., physicians’ lounge or dining room) without recognizing the important role that this dedicated space played in fostering interpersonal connections among physicians.” The Mayo Clinic and other institutions are reversing this trend by creating dedicated physician rooms for breaks, snacks, and a venue for peer interaction and camaraderie.
5. Rethinking rewards and incentives
Compensation is now commonly linked to productivity in many health care organizations, but this approach has some profound drawbacks: It can lead to physician burnout. Incentive structures based on patient satisfaction and quality metrics can have similar unintended consequences. All these incentive structures can combine to drive physicians to overwork. “Physicians may be particularly vulnerable to overwork due to high levels of education debt, their desire to ‘do everything for their patients,’ unhealthy role modeling by colleagues, and normalization of extreme work hours during the training process.” The investigators do not claim to have the ultimate answer to the problem of incentives that create unhealthy work patterns, but they argue that it is critical for leaders to recognize the potential unintended consequences of the productivity reward/incentive model and consider strategies to prevent overwork leading to burnout.
6. Aligning values and strengthening culture
The investigators also describe Mayo’s efforts to pursue self-appraisal of alignment of mission, values, and culture. They also describe the regular use of an all-staff survey, which has on occasion yielded candid feedback that, while not always flattering, has been the basis of a profound institutional rethink. The willingness of leadership to be receptive to hard truths from physicians is the foundation of institutional learning about burnout prevention and encourages engagement of the staff.
7. Promoting flexibility and work-life integration
Allowing employees greater flexibility in how and when they work is a management strategy that is gaining ground in many industries. Increasing part-time positions and expanding options for the work day have both been found to help prevent burnout and also help physicians recover from burnout. In addition, “institutions should also comprehensively examine the structure of their vacation benefits, coverage for life events (e.g., birth of a child, illness/death in family), approach to scheduling, and strategy for coverage of nights and weekends. Compensation practices that disincentivize using vacation time are shortsighted and should be eliminated.”
8. Providing resources to promote resilience and self-care
The solutions to burnout have been aimed at the individual and involve stress-reduction training and other personal management strategies. A metastudy of the interventions mentions psychoeducation, counseling, wellness management, interpersonal communication, and mindfulness meditation (J Nerv Ment Dis. 2014 May;202:353-9). But without concomitant structural reform, these individual solutions can backfire. “When individually focused offerings are not coupled with sincere efforts to address the system-based issues contributing to burnout, this approach is typically met with skepticism and resistance by physicians (‘They are implying I am the problem’). In this context, the response to well-intentioned ‘resilience training’ is frequently a cynical one (‘You only want to make me more resilient so you can further increase my workload’).”
9. Funding organizational research
Organizational science is a well-developed field of study. But cutting-edge management models such as the learning organization, participatory management, and collaborative action planning have been slow in coming to health care institutions. Dr. Shanafelt and Dr. Noseworthy argue that “vanguard institutions” such as the Mayo Clinic (which began its Program on Physician Well-Being in 2008), Stanford (Calif.) University, and other innovative institutions have the responsibility of developing evidence-based strategies to combat burnout that smaller institutions can implement.
Burnout among physicians is now on the radar of leadership in many health care institutions. Evidence on the cost and consequences is accumulating, and it becoming increasingly difficult to ignore what is happening to many physicians. Dr. Shanafelt projected an increasing need for operational solutions at the organizational level to address the problem. He said, “We need evidence to guide organizations to implement changes that truly make a difference, not well-intentioned but ineffective programs. Now that organizations recognize the strong business case, they are ready to invest resources to address this issue but they need to know it is money well spent and that there is an evidence-base to justify the investment.”