Framework to Gauge Physician Burnout

Physician burnout is not only the topic of much discussion regarding symptomatology and etiology, but it it generates multiple theories regarding syndrome management.<sup>1</sup> Many, if not most, therapeutic tips can be useful. However, even successful attempts at mitigating the effects of the symptoms can leave the underlying etiological framework unexplained.

This article intends to provide a well-researched and -documented
social psychological framework for what is often labeled as “burnout”
within the medical professions — a theoretical framework that can have
practical relevance for the both the “patient” and attending
professionals, including physician leaders charged with managing the
effects of burnout within the physician workforce in an organization.

First, framing the problem: Dictionary definitions of “burnout”
provide for applications to both the physical sciences and the
psychology of the human condition. For the physical sciences, “burnout”
can be defined as the reduction of a fuel or substance to nothing
through use or combustion. For the psychology of the human condition,
burnout can be defined as “a physical or mental collapse by overwork or
stress.” With both conditions, the endpoint is beset by finality. The
point to be made is under both sets of conditions, the outcome can be
relatively the same if left uninterrupted.

But a coherent and tested theoretical framework can be applied to
give physician leaders a foundation from which the problem of burnout
can be understood and addressed within organizations.

ROTTER’S SOCIAL LEARNING THEORY

A Dialog on Change Versus Pain

Rotter’s social learning theory, developed by American psychologist
Julian B. Rotter (1916-2014), is predicated on the assumption that an
individual’s personality does not exist independent of that individual’s
environment. The principle on which his theory is constructed is the
empirical law of effect, which holds that people are motivated to see
positive stimulation. Behavior is a function of a person’s expectation
for a reward. A person’s behavior and personality are shaped by that
person’s experiences and interactions with their social environment.

articleInclude Rotters Theory

Rotter postulated that behavior (and potential behavior) is a
function of an individual’s expectation for a reward that is valued (see Figure 1),
with interest, reward value and expectations, operating separately and
together to affect behavior. With this model, “attitude” is considered
to be a behavior. Rotter goes deeper to describe the “expectations
variables” as being related to one’s sense of personal control over life
in general (an individual’s general locus of control orientation)
and/or one’s specific locus of control orientation (an individual’s
situationally specific locus of control orientation; the practice of a
profession, for example).

An individual’s general and specific locus of control can operate
independently and together as an individual interacts with the
environment presented, including one’s work environment. Those who are
more internally oriented generally feel they can and need to exert more
control over their environment. Those more externally oriented feel less
personal control over their environment. Extremes on the “scale” can be
problematic.

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Reward structures and incentives are important within the model as
well. Simply stated, as long as an individual’s perceptions of rewards
acquired for efforts expended are equal to or greater than a minimal
expectation, individuals feel they are ahead. Falling below the expected
minimum reward value creates dissonance and worse. A negative reward
imbalance occurs when individuals believe external and intrinsic rewards
gained are insufficient when stacked up against all efforts required to
attain them.

The last variable of importance in the model is the unforeseen or
uncontrollable external factors in the environmental mix — the
uncontrollable disruptive events, often described in clinical psychology
as “situational disorder.” These are the external events that occur as a
result of the nature of health care delivery in the United States
interacting with the nature of the human condition — for example, the
unforeseen changes in health policy and economics; the vicissitudes of
political environments, mergers and acquisitions; and changes in the
financial fortunes of organizations that employ physicians and other
professionals.

In Rotter’s social learning theory, behaviors (including attitude)
are a function of an individual’s expectation for a reward that is
valued, plus any environmental dynamics that may interact with the
individual in their environment. One or all relevant factors might
influence behavior over time. Pernicious imbalances of the relevant
factors are proposed here as a legitimate explanatory framework for what
is described as “physician burnout.”

APPLYING THE MODEL TO PHYSICIAN BURNOUT

Before discussing application of the model to physician burnout, consider this:

A five-physician internal medicine group is acquired by a community
health system. Concern for the future of small, independent practices
drove the decision. The going-in expectation was the trading of some
autonomy (personal control) for future financial security. Some of the
concerns related to “selling out to the hospital” were allayed by the
promise from health system leadership that, “Nothing has to change. You
keep practicing medicine as you have, and we will take care of
everything else.” Six months following the closing of the practice
purchase, the guaranteed compensation payments convert to a risk-based,
work-relative value production model. Three months after that, the
groups are presented with the need to change referral patterns from
specialists they have used and trusted for years to specialists employed
by the health system.

Shortly thereafter, the conversion to the new electronic health
record and office staff cuts are implemented to reduce practice
operating expenses and a new patient experience evaluation system is
implemented. The results of the first round of responses demonstrate
some negative results for the practice. The physicians dispute the
interpretation of the results. Physicians are becoming disquieted by
their decision and know that noncompete agreements restrict their
personal and professional freedoms of opportunities unless they want to
disrupt their personal lives and those of their families to leve their
communities. Attitudes of many of the physicians turn negative. A
general malaise overtakes the group. Patients ask staff members, “Why
doesn’t my doctor like working here anymore?” There is little energy for
sitting down to talk about the group and its future, and the principal
focus of a two of the “partners” has become generating as many WRVU’s
(financial reward value) as possible until they can leave without
violating their noncompetes.

How would the application of Rotter’s theory create a framework for a diagnosis of the social psychological state of the group?

The physicians here were expecting that by selling their practice
they could escape an unfriendly environment (a changing health care
marketplace); that the sale to the health system would insulate them
from current and future financial risk. In return, all they needed to do
was practice medicine as before and somehow the economics would work
out for the acquirer, although the specific and necessary questions
about this never were addressed directly by the acquired or the
acquirer. Limitations on professional freedoms began to mount and the
realities of the contractual obligations attendant to the sale of the
practice became evident to the physicians. Personal control over
trusted, reliable and comfortable professional referral relationships
was disrupted. The realities of the evolving compensation design (the
physicians’ most tangible reward system) began to be perceived as
lacking the security (the reward value) they believed they were
promised.

Physicians suffering from progressive “burnout” from perceived loss
of personal and professional freedoms interacting with a perceived
insufficiency of tangible and intrinsic rewards coupled with
expectations of future diminishing control over their professional
practice, professional relationships and work environment.

WHAT PHYSICIAN LEADERS CAN DO

In the above vignette, let’s presume we can restart the transaction,
including the involvement of the physician leader within the health
system that acquired the practice.

The goals of this process are defined within the framework of our Rotter’s model:

• Establish the expectations for personal and system control within the relationship.

• Demonstrate how those who join matter (and “belong”) in the context of the whole and its mission and plan.

• Explain how physicians will have a voice in the framework of the whole to exercise on behalf of colleagues and self.

• Define how changes in the system will involve affiliated physicians in organizational change.

Setting the expectations of “joining the system” from the beginning,
what could have been done by a physician leader within the acquiring
health system?

• The mission, vision, value and strategy of the health system are made clear.

• The collective “belief system” of the health system’s plan to
  succeed is made clear. Clarity of belief systems is rare in health
  systems, yet they are essential to their success. The collective beliefs
  of leaders direct and guide those behaviors that are the health system
  in action.

  2

• The purpose, role and goals of the physician group within the health
  system are made clear. That is, its reason to exist within the context
  of the whole of the integrated health system.

• The longer-term strategic plan for the physician network is made
  clear, including each subsequent group addition to the network. Each
  physician and group know how they “matter” to the team and the game
  plan.

• Descriptions of expectations of behavior as a member of the team are
  made clear. That includes how being a member of the team differs from
  being in “private practice.”

• The benefits of being a member of the team are made clear from the
  perspective of the physician leader (the reward system available to
  participating physicians).

• Expectations of professional freedoms and exercisable personal
  controls over patient care and physicians’ control over their
  professional practice are made clear.

• Physicians’ abilities and obligations to participate in decision-making at the practice and network level are made clear.

• How the network “keeps score” is presented, as are the practice performance “scorecards” used.

• How the opportunity presented differs from private practice because
  to join means change is required, and change does present challenges;
  more for some, less for others.

• The expected attributes of the operating culture of the network.

  3

The process required to do a sufficient job with the bullet points
above is essential, but it’s not time-consuming. It should be done
physician to physician with a nonphysician leader present, so all are
aware of what is being said and what it means.

Application of Rotter's Theory

The approach above prevents problems experienced by practices joining
the health system by way of acquisition. There’s more — physician
burnout within established physician communities.

Given the growth curve of the physician organizations within health
systems, physician leaders will not be available to attend to individual
physicians at-risk for burnout. As such, they may wish to consider a
“public health” approach to addressing the problem.

FIGURE 2: STAKEHOLDER ALIGNMENT SURVEY

This is a composite profile of “beliefs alignment” of key
stakeholders of two community health systems. “Stakeholders” are defined
as members of the governing board, the senior leadership team, select
formal and informal leaders of the employed physician group and select
formal and informal leaders of independent members of the hospital
medical staff. It tests stakeholder alignment on a grouping of 10
beliefs relating to the performance of the organization. This grouping
of 10 is a strong predictor of respondents’ perspectives on whether the
culture of the organization is as good as it should be.

Average Score by Respondent Category

Rotter’s social learning theory provides the “blueprint” for this
approach. Rotter’s social learning theory would direct physician leaders
to:

• “Vaccinate” as many people as possible with education — especially,
  other existing and emerging physician leaders. This validates reality
  within the organization, removes any stigma attached and ensures the
  pathway to care for those afflicted and those responsible for the
  environment and culture of the organization.

• Assess and evaluate the physician environment and climate.
  Physicians will tell leaders how they feel about the organization, their
  place in it and stressors they face

  (see Figure 2). Physician leaders should be attentive to physicians employed by the
  organization as well as independents. An initial focus of this work is
  physicians’ perspectives on the culture of the organization.

• Communicate frequently and liberally regarding where the physician
  organization “is” within the whole of the health system (its goals,
  objectives, forward progress, achievements and plans). Leaders can
  import and enhance the sense of “control” with clarity regarding where
  the organization is on its mission path and where physicians and their
  contributions fit.

• Include physicians in the discussion about how the organization is
  performing, including its contributions to the totality of the vision
  and mission of the organization, as well as quality of care, the patient
  experience and growth and development of the organization, financial
  performance and future investments. With this approach, there is a
  higher likelihood of physicians appreciating the intrinsic rewards
  derived from being part of the team.

Physician leaders need to remain ahead of the dynamics and potential
“situational disorders” that can shock the culture of organizations. No
reasonable individual physician can expect an environment free of
organizational stressors. They can expect that leaders effectively
represent their interests when they occur, and bring them into the
conversation when it is time for problem-solving.

Figure 2 is a composite profile of “beliefs alignment” of key stakeholders of two community health systems. Stakeholders are defined as members of the
governing board, the senior leadership team, select formal and informal
leaders of the employed physician group and select formal and informal
leaders of independent members of the hospital medical staff. A
“stakeholder alignment survey” is constructed to test stakeholder
alignment on a grouping of 10 beliefs related to the performance of the
organization. This grouping is a strong predictor of respondents’
perspectives on the 11th response item: “The culture of the organization
is as good as it should be.”

When the statistical power of the model, as a predictor of the state
of the culture of the organization, is isolated to physician respondents
only, it increases (adjusted R-squared equals 0.84 for physician
respondents only; an adjusted R-squared equals 0.76 for all
respondents). The construct of the alignment survey, as presented in the
figure, is based largely on Rotter’s social learning theory as the
basis for the design of the items applied.

CONCLUSION

While Rotter didn’t develop his social learning theory to address
physician burnout specifically, his framework does provide physician
leaders a basis for an explanation of etiology, as well as a blueprint
for addressing the problem on an organizational scale. Physician leaders
hold accountability to address the risk in their organizations at the
levels of prevention, evaluation and pathways to intervention.

Daniel K. Zismer, PhD, is managing director and co-founder of
Minnesota-based Castling Partners, which works with health care leaders
on strategy. He holds the same roles with Minnesota’s Keystone Culture
Group, which helps organization develop high-performance cultures.

REFERENCES

1. Dzau VJ, Kirch DG and Nasca TJ. “To Care is Human — Collectively Confronting the Clinician-Burnout Crisis,”

   N Engl J Med 378:4, nejm.org Jan. 25, 2018.

2. Zismer DK. “Why a ‘Belief System’ is Essential to the Success of
   Culture in Organizations; and Application to Healthcare.” Keystone
   Culture Group, https://www.keystoneculturegroup.com/2018/07/03/why-a-belief-system-is-essential-to-the-success-of-culture-in-organizations-an-application-to-healthcare .

3. Utecht B, Zismer DK. “Culture Alignment, High-Performing Healthcare
   Organizations, and the Role of the Governing Board, Part One: Culture
   and Culture Alignment — The Foundation of a Board’s Culture Game Plan.”
   The Governance Institute E-Briefings. 2018;15(2). keystoneculturegroup.com/2018/03/01/culture-alignment-high-performing-healthcare-organizations-and-the-role-of-the-governing-board-part-one .