The BETER Tool: A Mentorship Intervention for Addressing Burnout in Medicine Department Physicians

Burnout among physicians has been on the rise and is now a serious issue within the healthcare profession.(2) As this issue has garnered more attention, so too has the research that has advanced our knowledge of burnout prevalence, causes, and interventions. The many causes of burnout cluster around an imbalance between demands on physicians and the control and support they have with respect to their practices.(3)

To learn about burnout and potential interventions, the common practice has been to measure burnout and possible causes within groups of physicians (practices, medical departments, hospitals, or healthcare systems). In turn, conclusions are made about these large groups, and interventions are considered that best match the identified leading causes of burnout for that specific group, although they may not be applicable to a particular individual.

This approach has garnered scattered success for group practices in terms of lowering burnout rates, but perhaps not to the degree that most would like.(4) The method is a practical approach to efficiently addressing burnout to benefit large groups of physicians at once, but it isn’t designed to measure and intervene on burnout at the individual level where tailored approaches might lead to a wider impact on burnout reduction.

This issue led to the study of implementing individual mentorship in burnout identification and reduction using the newly developed BETER (Burnout Elimination Through Education and Reflection) tool.

Methods

The BETER tool is a cooperative assessment and planning framework developed to address burnout by implementing individual mentorship in burnout identification and reduction. Physician mentees first fill out a form assessing the degree of their burnout (from no burnout to high) and potential causes, after which they review the assessment with their mentors. Each mentor then uses this information to guide the mentee on how to reduce burnout, if present, considering the identified individual triggers and associated potential interventions from an evidence-based list.(4)

The process for developing the BETER tool began with reviewing what has been shown to cause physician burnout. Specifically, (1) EHR (electronic health record) burden, (2) chaotic work environments, (3) lack of time spent on clinical work one feels passionate about, (4) lack of control over one’s work, (5) insufficient teamwork, and (6) lack of values alignment with leadership.(1,5-10) With these six areas targeted, the BETER tool was developed with a survey instrument to identify possible specific causes for an individual physician’s burnout and provide a definitive course to address the identified causes.

Before initiating the intervention, this project was reviewed by the Human Subjects Research Committee and was determined to fall outside of the Intuitional Review Board (IRB) jurisdiction because of its low risk; thus, the study was deemed by the IRB to not require IRB approval. The Department of Medicine is the largest in the system, so it was decided that 13 divisions within the Department of Medicine would be randomized into intervention (training and use of the BETER tool for individuals within the division) and control groups based on results from the previous year’s annual provider wellness survey. Three divisions were excluded because they did not participate in the survey, leaving 13 to be randomized.

The included divisions were stratified on the burnout variable, with division-wide scores ranging from 1.0 to 3.0 on a five-point scale, then assigned to intervention vs. control using a random number generator to ensure a full range of burnout levels were represented in each arm of the study. There were 66 physicians in the intervention group and 69 physicians in the control group (see Figure 1).

Figure 1: Intervention and control group divisions with n values

Division leaders from each intervention group were invited to serve as burnout reduction mentors. These leaders had formal and informal power within the division to implement interventions and address possible challenges identified by the mentees. It was thought this authority would be helpful to advocate for changes in the whole division that would be beneficial to other providers as well (such as physician assistants and nurse practitioners). Larger divisions had multiple mentors to limit the mentor:mentee ratio to a maximum of 1:7. There was a median number of three mentees for each mentor.

The intervention arm of the BETER tool was implemented in seven divisions, with 12 mentors and 54 mentees. Mentors underwent in-person training by the principal investigators, who have extensive experience with burnout measurement, interpretation, and intervention. This training included a review of study background, in-depth review of the BETER tool and its implementation, and a short baseline survey to measure their understanding of and comfort with individually addressing burnout. Subsequent in-person trainings highlighted ways to address the various burnout categories (e.g., EMR work, chaos). These presentations were shared electronically with those mentors unable to attend.

Those randomized to the intervention group first completed the BETER Baseline Index, which included the 10-item Mini Z, a validated assessment of satisfaction, burnout, and their predictors, along with one additional question that assessed time spent on clinically meaningful work tasks.(1,5) Mentors and mentees reviewed the Index results together and identified one or two burnout themes. The burnout themes pointed to known workplace stressors that the pair addressed during the intervention period.

Mentors were given step-by-step instructions on how to use the Index in a mentorship setting, as well as a mentorship discussion guide, which facilitated ongoing conversation around workplace stressors.

The mentors were tasked with meeting with their mentees two to three times throughout the nine-month intervention period to develop and follow through on the individual burnout reduction interventions. Details about exactly how often each mentor met with each mentee were unavailable, in part because some pairs incorporated mentoring into standing meetings.

The Mentor Tracking Chart, completed by each mentor for each mentee, served three purposes: (1) to guide creation and ongoing progress on goals, (2) to regularly report progress back to the study team, and (3) to help the primary investigators guide mentor-mentee interventions if the pair was struggling. Together, these materials comprise the BETER tool. This approach allowed for every mentee’s burnout triggers to be addressed individually instead of at the more commonly used aggregate level.

In addition to data collected from the use of the BETER tool, baseline data were collected in a Mentor Pre-Survey and from the annual Mini Z survey. Post-intervention data were collected from the following year’s Mini Z survey, in addition to a Mentor Post-Survey and Mentee Post-Survey. The control group physicians did not participate in the mentoring nor the pre- and post-surveys, but their data from the annual Mini Z surveys were used to compare their data with the intervention groups’ Mini Z data.

The Mentor Survey assessed knowledge, comfort, and ability to mentor about burnout reduction, the results of which were compared pre- and post-intervention. The Mentee Survey assessed mentees’ perceived benefit of the BETER tool and associated mentoring program at the completion of the study. Additionally, informal feedback received from the mentors and mentees via email, phone, or in person was documented separately for the purpose of informing future research on this subject.

Results

Both qualitative and quantitative data were collected pre- and post-study in the intervention group. All positive results described are based on qualitative feedback from both mentors and mentees. Survey data indicated that within the intervention group, 56 percent of mentors thought this experience was valuable (n=5/9), 22 percent thought it was neutral (n=2/9), and 22 percent thought it was negative (n=2/9).

Before being trained with and using the BETER tool, 42 percent of mentors considered themselves knowledgeable of physician burnout (n=5/12), 42 percent considered themselves neutral (n=5/12), and 17 percent considered themselves not knowledgeable (n=2/12). They reported increased knowledge about the topic of physician burnout and its contributing factors after using the BETER tool, with 67 percent considering themselves knowledgeable (n=6/9), 33 percent considering themselves neutral (n=3/9), and 0 percent considering themselves not knowledgeable (See Table 1).

The tool also increased the number of mentors who felt comfortable mentoring to reduce burnout (50 percent to 78 percent absolute response). Mentors indicated the tool afforded them the opportunity to discuss aspects of their mentees’ work lives that would not have otherwise arisen (78 percent), and most mentees (96 percent [n=23]) found the experience of being mentored around burnout neutral (65 percent [n=15]) or positive (30 percent [n=7]). Mentees reported that perceived benefit from the BETER tool increased the longer they used the tool. The individual components of the BETER tool performed well in both increasing knowledge about burnout and its predictors as well as guiding mentors in the individualized discussions about burnout.

Because each mentor tailored the interventions to the individuals in their department, it was challenging to track the various interventions. Each was modified based on the division and the individual; however, multiple divisions reported implementing specific burnout-reduction interventions as a result of this study.

One division with strong mentor involvement made a significant change to the leadership of their fellowship program after receiving mentee feedback. A high-burnout division, in which multiple physicians identified electronic medical record (EMR) stress as a major contributor to burnout, worked with EMR resources within the hospital to create a custom template that was subsequently rolled out to all division providers. Several divisions also reported reorganizing their appointment scheduling to address multiple mentee concerns and bringing real-time elbow-to-elbow EMR training to their division providers to reduce burnout.

When an individual mentor-mentee pair identified system-based contributors affecting burnout, many mentors felt they were not able to effectively make changes along with their mentees because of the complexity of the organizational system, lack of empowerment to affect change, or institutional barriers. This was reflected not only in that only 56 percent of mentors felt empowered to affect change to reduce burnout, but also in the qualitative results. Those with identified burnout triggers that fell within divisional or personal control were able to more readily implement changes to reduce burnout.

The intervention and control groups were compared using the annual Mini Z results of all divisions from both several months before and immediately after the intervention. There were no statistically significant differences in aggregate division-level burnout scores, which may have been reflective of large internal health system changes during the same time period, as well as the small number of faculty in many divisions.

All surveys were collected anonymously and thus did not track individual change comparisons from year to year; therefore, division burnout scores were compared on an aggregate level, making it impossible to analyze how burnout mentorship affected the scores of individual physicians.

Discussion

This randomized controlled trial of an educational mentorship-based intervention to reduce burnout in a Department of Medicine indicated that use of the BETER tool increased mentors’ knowledge of burnout, as well as comfort and perceived skill in burnout mentoring. Furthermore, qualitative and quasi-quantitative data from the BETER study show promising results that could prompt wider use and testing of the tool; however, the impact of the quantitative data was limited by the small number of participants randomized in this exploratory study. Future studies should include a larger cohort of participants to determine what changes to the interventions could lead to increased efficacy. It is predicted that longitudinal measurement and a larger sample size could lead to more relevant quantitative results.

One hypothesis worth testing is whether the intervention would be more effective if the mentors were all physicians in division or department leadership positions since they would potentially have more power to implement changes to reduce burnout in their mentees. Future studies could investigate if this predicted benefit would outweigh the potential negative consequences, which might include discomfort of some leaders in discussing burnout, their having a conflict of interest with potential mentee interventions and institutional priorities, or being assigned mentees who feel inhibited in their responses due to the power dynamic of the mentor-mentee working relationship.

Additionally, timelines for mentor-mentee communication should be individualized. For example, initial meetings could be incorporated into annual review meetings or other standing meetings. Based on our pilot results, giving mentors a menu of actions available to approach a typical problem may be useful; for example, using EHR support personnel at-the-elbow to evaluate opportunities for improvement in individual EHR workflow, customizing visit templates to increase control, or intentionally pairing physicians with support staff to improve teamwork.

Future studies could incorporate these interventions and be evaluated for efficacy to expand understanding and impact of the tool. Whether formally or informally studied in the future, use of the BETER tool, combined with regular burnout surveys, can help to proactively prevent and remedy burnout at the individual level with a goal of maintaining a high-functioning team of physicians.

Conclusion

The BETER tool is an intervention tool to guide physicians dedicated to addressing burnout through diagnosis, treatment, and prevention on the individual level. There are many potential uses of this tool, such as incorporating it as a standardized part of annual faculty reviews, offering it to leaders as a method to reduce burnout in their teams, and adding it to institutional wellness programs. Based on information collected in this pilot study, physicians should be encouraged to adapt and further evaluate this tool as one method to reduce burnout in their organizations.

References

1. Olson K, Sinsky C, Rinne ST, et al. Cross-Sectional Survey of Workplace Stressors Associated with Physician Burnout Measured by the Mini-Z and the Maslach Burnout Inventory. Stress and Health. 2019;35(2):157-75. doi:10.1002/smi.2849

2. Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Burnout Among Health Care Professionals: A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care. NAM Perspective. 2017. doi: 10.31478/201707b

3. Linzer M, Visser MR, Oort FJ, et al. Predicting and Preventing Physician Burnout: Results from the United States and the Netherlands. Am J Med. 2001;111(2):170-75. doi:10.1016/s0002-9343(01)00814-2

4. Linzer M, Poplau S, Grossman E, et al. A Cluster Randomized Trial of Interventions to Improve Work Conditions and Clinician Burnout in Primary Care: Results from the Healthywork Place (HWP) Study. J Gen Intern Med. 2015;30 (8):1105-11. doi:10.1007/s11606-015-3235-4

5. Linzer M, Manwell LB, Williams ES, et al.; MEMO (Minimizing Error, Maximizing Outcome) Investigators. Working Conditions in Primary Care: Physician Reactions and Care Quality. Ann Intern Med. 2009;151(1):28-36. doi:10.7326/0003-4819-151-1-200907070-00006

6. Shanafelt TD, West CP, Sloan JA, et al. Career Fit and Burnout Among Academic Faculty. Arch Intern Med. 2009;169(10):990-5. doi:10.1001/archinternmed.2009.70

7. West CP, Dyrbye LN, Shanafelt TD. Physician Burnout: Contributors, Consequences, and Solutions (Review). J Intern Med. 2018;283:516-29.
   doi: 10.1111/joim.12752.

8. 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;12(2):1600-13. doi: 10.1016/j.mayocp.2015.08.023.

9. Shanafelt T, Goh J, Sinsky C. The Business Case for Investing in Physician Well-being. JAMA Intern Med. 2017;177(12):1826-32. doi:10.1001/jamainternmed.2017.4340

10. Linzer M, Sinsky C, Poplau S, et al. Joy in Medical Practice: Clinician Satisfaction in The Healthy Work Place Trial. Health Aff. 2017;36(10):
    1808-14. doi: 10.1377/hlthaff.2017.0790.

Acknowledgments

The study team received funding from The Physicians Foundation to develop the BETER tool and conduct this pilot study. The funder had no role in study design, data interpretation nor writing of the manuscript.

This research was supported by the National Institutes of Health’s National Center for Advancing Translational Sciences, grant UL1TR002494. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health’s National Center for Advancing Translational Sciences.

More information about the CTSA can be found at https://www.ctsi.umn.edu/about/what-we-do/about-ctsa-award

Beter Baseline Index

• This should be reviewed side-by-side to determine which two themes the mentor/mentee pair will work on this year.

  • This should be primarily mentee-driven with some guidance from mentors.

  • The themes include control over workload, EHR stress, chaos in the workplace, values alignment with team leaders, teamwork, and time spent on enjoyable work activities.

• You may consider saying, “It appears to me that _____ and _____ are the two most troublesome areas. Does that sound right to you?”

• Some mentees will know their distress areas right away. Others may need some guiding questions to begin the conversation such as:

  • “How important does working on feel to you?”

  • “Which of these themes feel like they are most negatively affecting your worklife?”

• Once the top two items have been identified and agreed upon, it’s time to discuss which elements of each item are causing distress. (See Mentor Discussion Guide)

My control over my workload is:

1 – Poor 2 – Marginal 3 – Satisfactory 4 – Good 5 – Optimal

Sufficiency of time for documentation is:

1 – Poor 2 – Marginal 3 – Satisfactory 4 – Good 5 – Optimal

The amount of time I spend on the electronic health record (EHR) at home is:

1 – Excessive 2 – High 3 – Satisfactory 4 – Modest 5 – Minimal/ None

My proficiency with EHR use is:

1 – Poor 2 – Marginal 3 – Satisfactory 4 – Good 5 – Optimal

Which number best describes the atmosphere in your primary work area?

1 – Hectic/Chaotic 2 3 – Busy, but reasonable 4 5 – Calm

My professional values are well aligned with those of my department leaders:

1 – Strongly disagree 2 – Disagree 3 – Neither disagree nor agree 4 – Agree 5 – Strongly agree

The degree to which my team works efficiently together is:

1 – Poor 2 – Marginal 3 – Satisfactory 4 – Good 5 – Optimal

I spend at least 10% of my overall work time on something I enjoy/something I’m passionate about:

1 – False 2 – True

Intervention Chart

Mentor Tracking Chart

BETER Mentor Pre-Intervention Survey

1. How knowledgeable are you about the topic of physician burnout?

2. How important to you is mentoring within your division to reduce burnout?

3. How comfortable are you mentoring those within your division to reduce burnout?

4. How would you rate your ability to mentor those within your division to reduce burnout?

5. Do you feel empowered to affect change in your division to reduce burnout?

6. Do you feel like you have adequate time to mentor those within your division about burnout?

7. Do you have any other thoughts for us regarding your knowledge, comfort, and/or ability to mentor others about burnout reduction?

BETER Mentor Post-Intervention Survey

1. How valuable was this mentoring experience for you?

2. How knowledgeable are you about the topic of physician burnout?

3. How important to you is mentoring within your division to reduce burnout?

4. How comfortable are you mentoring those within your division to reduce burnout?

5. How would you rate your ability to mentor those within your division to reduce burnout?

6. Do you feel empowered to affect change in your division to reduce burnout?

7. Do you feel like you have adequate time to mentor those within your division about burnout?

8. Did this study afford you the opportunity to discuss aspects of your mentees’ work lives that would not have otherwise arisen?

9. Do you feel like the outcomes of the mentoring outweighed the addition to your workload?

10. Was the BETER tool helpful for you in mentoring about burnout?

11. What was this mentoring experience like for you?

12. Do you have any other thoughts for us regarding your knowledge, comfort, and/or ability to mentor others about burnout reduction and prevention?

BETER Mentee Survey

1. How valuable was this experience to you?

2. How positive or negative of an experience was this for you?

3. If it was negative, can you identify a specific reason why?

4. Are these one-on-one conversations about burnout and potential interventions something you would like to continue?

5. Did this study afford you the opportunity to discuss aspects of your work life that would not have otherwise arisen?

6. Did any positive changes come out of meeting with a BETER study mentor from your division?

7. What would you change about this experience?

8. Do you have any other thoughts for us?