Avoid Burnout by Finding Your “Fit” in the Organization

Physicians are leaving independent practice in droves, or at least considering leaving practice for employment in healthcare organizations, according to a 2018 survey conducted by Merritt-Hawkins,(1) which revealed that 78 percent of physicians said they sometimes, often, or always experience feelings of burnout.

Employed physicians reported higher rates of burnout than did those who owned their practice, suggesting that working for healthcare organizations may not be an antidote for private practice-related stress. According to the Merritt-Hawkins survey, “The independent practice model is under pressure in a healthcare system increasingly dominated by large, integrated organizations, whether hospital systems, large medical groups, corporations, or insurance companies.”

As physicians transition to employment, they should consider the “goodness of fit” between themselves and the organization. In the field of statistics, goodness of fit describes how well a model correlates with actual observations or values. Organizational psychologists borrowed the term to describe the compatibility of a person’s temperament and skills with workplace requirements and environment.

The interaction between workplace variables and physician characteristics profoundly influences the effects of work. The ultimate consequence of a poor fit is disillusionment, pessimism, burnout, and depression. Although major depressive disorder and burnout are clinically distinct entities, there is significant overlap in symptoms.(2)

Goodness of fit should not be confused with fitness for duty. Fitness for duty evaluations are conducted to determine whether an individual can safely perform a defined job. Fitness for duty has come into sharp focus recently considering the epidemic of physician burnout. The manifestations of burnout syndrome — exhaustion, cynicism, and reduced personal accomplishment — threaten the health and well-being of physicians and, by extension, their patients. It is important for physicians to examine the goodness of fit prior to accepting a job offer in an organization lest they become victims of overwhelming work demands, prolonged stress, and other causes of burnout.(3)

Psychological Health

The impact work has on an individual’s mental health and well-being is undeniable. The definition of psychological health has long been considered the capacity to work and love (incorrectly attributed to Freud) and also the capacity to “play.” Mental health benefits accrue when work is characterized by certain features common to good-fitting jobs.

Research(4) has shown that individuals who fit in well with their organizations report higher levels of job commitment and satisfaction and less anxiety, depression, and substance use. In addition, working for a good-fitting organization leads to high individual productivity, low absenteeism, and few disability claims.

Although no single set of job characteristics is good or bad for everyone, and although job requirements may change over time, research(4) indicates 10 conditions are important, perhaps prerequisite, for a good fit between physicians and organizations, and may diminish professional burnout:

1. Type of Organization. A survey conducted by the American College of Physician Executives (now the American Association for Physician Leadership) and reported by Howard Kirz(5) shed significant light on goodness of fit by examining physician executive terminations. Among 15 types of healthcare organizations examined, two-thirds of the terminations occurred in the following kinds of organizations: hospitals or health systems with more than 250 beds (25 percent), health plans with more than 100,000 members (18 percent), plans with fewer than 100,000 members (8 percent), hospitals with fewer than 250 beds (8 percent), and integrated delivery systems (7 percent).

Organizations involved in mergers, acquisitions, downsizing, outsourcing, and other economic forces beyond their control put physicians’ job security at risk. Continued exposure to market dynamics over which they have no control threatens physicians’ job security and may lead to physician burnout.

2. Reporting Relationships. The survey also demonstrated that a disproportionate number of physician executives lose their jobs when they are the first physician in a new or loosely defined job or work for an organization that has sustained two or more years of heavy financial losses. Moreover, persistent conflict with a supervisor, a board member, or a key stakeholder can shorten the tenure of employed physicians. New bosses who may be intent on replacing their direct reports with friends and former colleagues in a proverbial housecleaning may be difficult supervisors. Frontline leaders with poor leadership qualities have negative effects on the personal well-being and job satisfaction of the physicians they lead and burn them out over time.(6)

3. C-Suite Climate. Physicians seeking employment as executives should gauge the temperament of non-physician executives with whom they will be working. Dissimilarities between physician executives and other leaders in the C-suite are the result of distinctive and different processes of training and professional socialization, as well as differences in psychological makeup.

Physicians tend to be more introverted, feeling, and perceiving than non-clinical administrators. Divergent views often contribute to conflict and discord, which is distressing and creates barriers to effective integrated leadership. Toxic workplaces can stem from dysfunctional leadership or management and may induce burnout if the work environment includes bullying, discrimination, and harassment.

Awareness of essential psychological differences between physician leaders and non-physician executives equips physicians with meaningful insight into how their counterparts think and act, which makes it easier to form new relationships, to strengthen existing ones, and to work in harmony to counteract burnout.

4. Communication. Communication is at the center of all relationships. Good communication is the primary vehicle for generating the level of trust, respect, and understanding necessary to cultivate effective relationships in healthcare organizations. Poor communication is harmful at best and deadly at worst. For example, many physicians are reluctant to participate in programs to report medical errors, and as a result, the underreporting of adverse events may be as high as 96 percent.(7)

Joseph Grenny, author of Crucial Conversations and the article “Speak Up or Burn Out,”(8) observes that physicians who engage more consistently and effectively in conversations that strengthen their social support systems and give them a greater sense of efficacy are less likely to burn out. Crucial conversations also breed powerful organizations toward which physicians gravitate.

5. Career Development. Physicians often cite stalled careers and lack of opportunity for advancement as reasons for burnout. Although many physicians are content to practice continuously in the same specialty, a significant number seek career alternatives or plan to alter their practice patterns, creating a fundamental disconnect between what provides physicians with the most professional satisfaction and what others expect them to do.

Low morale and burnout often set in when physicians are not allowed to explore alternatives to traditional medical practice or are denied capital and other resources to remain competitive and cutting edge in their specialty.

6. Clear and Unambiguous Roles. Studies have shown that role conflict and role ambiguity are significant factors in work stress among employees. Dealing with ambiguity in the workplace is frustrating because ambiguity entails uncertainty, which causes leadership teams to become indecisive and unable to plan or make firm commitments. An entire organization suffering from inaction is counterproductive to physicians’ work ethic.

When a clear path is not in sight, it is only natural for organizations to flounder and eventually fail for lack of focus and direction. Practicing under these conditions deflates physicians’ morale and contributes to burnout.

7. Goal Alignment. Organizations and physicians need alignment of goals to create safe and high-quality care at lower cost. Mutually rewarding goals lead not only to business success, but also personal satisfaction. Goals that resonate with one’s sense of purpose and meaning are likely to appeal to physicians, as are personal challenges and projects that lead to highly valued outcomes.

By incorporating shared goals in daily work and interactions with patients and colleagues, physicians help their organizations succeed. Only by leveraging the talents of physicians can healthcare organizations continue to thrive and be innovative in a competitive environment.

8. Rewards and Retention. Formalized physician retention programs are growing in popularity. Retention programs have been shown to be particularly effective in reducing separation among early career physicians, considered a proxy for burnout.

Common incentives are relocation assistance, income guarantee, signing and/or retention bonus, educational loan forgiveness, and malpractice insurance, including “tail” coverage. Other “perks” may include an expense account, professional dues, journal subscriptions, CME expense reimbursement, research stipends and honoraria, and paid time off beyond vacation.

If structured appropriately, rewards provide a competitive advantage in recruitment and retention and help create an esprit de corps among the medical staff that is essential to preventing burnout.

9. Social Engagement. Collegial relationships are a major source of satisfaction for physicians. Although physicians relish clinical autonomy, they also appreciate a workplace where they can interact and network with peers, be recognized for good performance, and be included in management decisions.

Physicians who find it difficult to disentangle their professional and family lives are likely to burn out and leave organizations that do not prioritize social events and family matters. Safe and pleasant working conditions coupled with family-friendly policies help create job flexibility and work-life balance important to job satisfaction.

10. Culture. Organizational culture encompasses values and behaviors that contribute to the unique social and psychological environment of a business. The culture of organizations may be evident through both written and unwritten “rules of engagement” such as vision and mission statements, profit status, and spiritual affiliation (written), or a set of shared assumptions that guide behaviors (unwritten).

When physicians do not identify with the corporate culture, the result is a lack of trust, involvement, communication, and responsiveness to problem solving. The inability to comply with cultural norms is a significant driver of physician turnover, more so than inadequate compensation and other sources of job dissatisfaction such as regulatory and insurance requirements and electronic health record design and interoperability.

Burnout, an outgrowth of a culture clash, causes high levels of job dissatisfaction; however, physicians who recognize the importance of cultural fit and attain it are more likely to be happy and productive.

Conclusion

Few individuals are able to treat work solely as an impersonal activity. Physicians, more than most professionals, find it difficult to disengage from work, to the point that many succumb to burnout rather than walking away from a toxic workplace. A careful assessment of the goodness of fit before accepting a job may result in job longevity and reduce the risk of burnout.

References

1. The Physicians Foundation. 2018 Survey of America’s Physicians: Practice Patterns & Perspective. Survey conducted on behalf of The Physicians Foundation by Merritt-Hawkins. September 2018. https://physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf . Accessed May 30, 2019.

2. Messias E, Flynn V. The Tired, Retired, and Recovered Physician: Professional Burnout Versus Major Depressive Disorder. Am J Psychiatry. 2018;175(8):716-19.

3. Drummond D. Physician Burnout: Its Origin, Symptoms, and Five Main Causes. Fam Pract Manag. 2015 September/October22(5):42-7. https://www.aafp.org/fpm/2015/0900/p42.pdf . Accessed May 30, 2019.

4. Gold LH, Shuman DW. Evaluating Mental Health Disability in the Workplace: Model, Process, and Analysis. New York: Springer, 2009; 49-53.

5. Kirz HL. Congratulations...You’re Fired! Physician Exec. 2000;26(4):
   19-22, 25.

6. Shanafelt TD, Gorringe G, Menaker R, Storz KA, et al. Impact of Organizational Leadership on Physician Burnout and Satisfaction. Mayo Clin Proc. 2015 Apr;90(4):432-40. https://www.viewfindercoaching.com/uploads/4/3/6/6/436688/mayo_impact_leaders_on_physicianburnout-08apr2015.pdf . Accessed May 30, 2019.

7. Harper ML, Helmreich RL. Identifying Barriers to the Success of a Reporting System. In: Henriksen K, Battles JB, Marks ES, et al., editors. Advances in Patient Safety: From Research to Implementation (Volume 3: Implementation Issues). Rockville, MD: Agency for Healthcare Research and Quality, 2005. https://www.ncbi.nlm.nih.gov/books/NBK20544 . Accessed May 30, 2019

8. Grenny J. Speak up or Burn Out. Physician Exec. 2006;32(6):24-6.