Strategically Targeting Burnout with an Operational Wellness Initiative

Mitigating physician burnout is crucial to the broader goal of improving care delivery for patients throughout our healthcare systems. We must borrow from other industry leaders such as business magnate Richard Branson, who famously said, “Clients do not come first. Employees come first. If you take care of your employees, they will take care of the clients.”

In medicine, the value of this statement is exponentially important considering that physicians are more than diagnosticians; they are healers who must also delve into their humanity to deliver compassion and warmth.

Physicians are also the patient’s direct interface and the highest frontline representative of “the healthcare system.” In this role, the physician bears the burden of all the fractures in the system while conveying confidence to the patients that they are in safe hands. Unfortunately, for many physicians, conveying confidence through the appearance of a well-orchestrated system comes at the cost of moral injury, as they must repeatedly navigate complex systems, leaving themselves exposed to a toxic mélange of chronic workplace stressors.

Burnout is defined by the World Health Organization ICD-11 as an occupational phenomenon characterized by feelings of energy depletion or exhaustion, increased depersonalization, mental distance from one’s job, feelings of negativism or cynicism related to one’s job, and reduced professional efficacy.(1) For physicians, the implications are broad and can impact their lives through relationship trauma, substance abuse, depression, and loss of earnings.

A significant impact on patient care is demonstrated through decreased quality of care, negative patient satisfaction, and medical errors.(2,3) Consequently, there also are attributable financial costs to departments and institutions(4-6) due to increased physician attrition, decreased productivity, and malpractice. Societal implications are also profound as the relative risk for suicide for men (1.41) and women (2.27) are greater for physicians than for the general population.(7)

The causes of burnout are many and well-documented in the literature, but all stem from chronic workplace stress and moral injury, leading to depersonalization, emotional exhaustion, and low personal accomplishment. In academic settings, non-clinical work essential for career development is often relegated to personal time, further compromising work-life balance. Initial strategies to combat burnout focused on individual resilience, but concerns and skepticism developed about the core efforts of the wellness movement since they weren’t seen as addressing the underlying causes. Fundamentally, the efforts were perceived as victim-shaming, suggesting that physicians were not strong enough to endure the work conditions.

In 2014, the Quadruple Aim was introduced.(9) It expanded upon the Triple Aim goals: improving the health of populations, enhancing the patient experience of care, and reducing costs.(10) It cleanly branded a self-evident truth that was not previously formally recognized in medicine: improving the clinical experience for healthcare workers as a prerequisite for the first three goals. The Quadruple Aim has done more to bind healthcare worker experience to patient outcomes than has been previously experienced.

To better address the factors leading to burnout, leaders are now turning to operational wellness initiatives. These initiatives are designed to bridge operations and wellness by fitting neatly into the structure of organizations and departments and are little-to-no cost in comparison to the cost of burnout. Democratizing the decision-making process for some of these initiatives can also reveal the willingness of departments and colleagues to support one another.

In response to our specialty regularly ranking among the highest burnout levels, in 2017 our clinical emergency medicine department created the Committee for Physician Wellness & Satisfaction.(8) As an offshoot, in 2019, we developed the Emergency Medicine Professional Development Program (EMPDP). This program is akin to traditional sabbatical programs; however, it targets mid-career physicians. The premise of the program is to encourage and support faculty in academic pursuits to facilitate mid-career development. The EMPDP allows eligible physicians to schedule a three-month discretionary leave of absence every five years.

In our program, physicians who have accumulated the equivalent of five years of full-time service in the department, have a minimum rank of assistant professor, and are in good standing within the department with respect to compliance requirements are eligible to apply. Applicants are required to submit their professional development plan to the chair for approval. Plans must include details of how they plan to use their time and expected deliverables (see Figure 1).

Figure 1. Prerequisites for EMPDP participation

Contracts for the EMPDP participants are amended for the year in which they are participating in the program. Salaries for physicians are prorated to 75 percent and structured to be paid over the course of the year. Fringe benefits and medical malpractice coverage are untouched. From the department standpoint, this program is designed to be budget- and staffing-neutral through staggered time-off periods (see Figure 2).

Figure 2. Program details for benefits, malpractice, budgeting, and staffing

Through a structured academic leave for personal and academic development, our faculty has the opportunity to recharge their batteries and rekindle or ignite their intellectual curiosity. Departments also stand to benefit from this program with an expected reduction in burnout, increased academic productivity, and increased loyalty of its physicians who will feel invested in what we expect to translate into decreased attrition (see Figure 3). We also expect this program to be an effective marketing tool to recruit and retain top talent looking for organizations that are willing to take new approaches to encourage professional growth and physician well-being.

Figure 3. Departmental and staff benefits

It is incumbent on leaders to demonstrate the willingness to try novel strategies (see Figure 4) to improve clinician well-being, especially in the midst of generational change and staggeringly high rates of burnout, to make a career in medicine more attractive and livable. Though we have yet to matriculate a faculty member through the program, the structure is in place, and we intend to assess burnout through our annual Well-Being Index surveys and by tracking academic engagement. As our department grows, we are proud to offer this opportunity as it highlights our mission to lead emergency care through innovation, scholarship and compassion.

Figure 4. Take-home points on combating burnout

References

1. World Health Organization. Burn-out an “Occupational Phenomenon”: International Classification of Diseases. WHO website. Available at: https://www.who.int/mental_health/evidence/burn-out/en . Accessed March 1, 2020

2. Panagioti M, Geraghty K, Johnson J, et al. Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction: A Systematic Review and Meta-analysis. JAMA Intern Med. 2018;178(10):1317–31. doi:10.1001/jamainternmed.2018.3713

3. Tawfik, D, Profit J, Morgenthaler T, et al. Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors. Mayo Clin Proc. 2018;93(11):1571–80.

4. Ellison EM. Beyond the Economics of Burnout. Ann Intern Med. 2019;170:807–8. [Epub ahead of print 28 May 2019]

5. Swensen SJ, Dilling JA, Mccarthy PM, Bolton JW, Harper CM Jr. The Business Case for Health-care Quality Improvement. J Patient Saf. 2013 Mar;9(1):44–52.

6. Shanafelt T, Goh J, Sinsky C. The Business Case for Investing in Physician Well-being. JAMA Intern Med. 2017;177(12):1826–32.

7. Schernhammer ES, Colditz GA. Suicide Rates Among Physicians: A Quantitative and Gender Assessment (Meta-analysis). Am J Psychiatry. 2004;161(12):2295–2302.

8. Willis L, Mital R, Steel P, Sharma R. Discussion: Physician-Led Wellness Plan Beating Burnout. Physician Leadership Journal. 2017;4(5):38–42.

9. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med. 2014;12(6):573–76. doi:10.1370/afm.1713

10. Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health, and Cost. Health Aff (Millwood). 2008;27(3):759–69.