Combating Physician Burnout: Do We Need More Chiefs in the C-Suite?

The number of healthcare administrators has proliferated over the past 35 years. The number of physicians in the United States increased by 150% between 1975 and 2010, whereas the number of healthcare administrators increased by 3200% during the same time.(1) The growing number of administrators is alleged to be in response to regulatory and technology changes that have complicated the way healthcare is delivered.

It is quite possible, however, that the number of “chiefs” in the C-Suite has swelled in response to the epidemic of physician burnout.(2) For example, the Chief Wellness Officer (CWO), Chief Clinical Effectiveness Officer (CCEO), and Chief Experience Officer (CXO) are new roles that have been created in part or in whole to improve physician wellness. This article examines the responsibilities of those positions and potential benefits to burned-out physicians.

Chief Wellness Officer

Following Stanford School of Medicine’s landmark 2017 hiring of Tait Shanafelt, MD, as CWO, several other notable academic medical centers followed suit, including Johns Hopkins, Mount Sinai (New York), the University of California—Davis, and the University of Alabama. The CWO role is designed specifically to combat staff burnout—estimated to be nearly 50% in Medscape’s 2019 National Physicians Burnout & Depression Report,(3) which surveyed more than 15,000 physicians in over 29 specialties.

Physician burnout has been linked to a range of adverse consequences.

Improving physicians’ sense of fulfillment and well-being is a high priority. Physician burnout has been linked to a range of adverse consequences, including increased medical errors, reduced quality of care, poor outcomes, increased malpractice litigation, decreased productivity, absenteeism, and staff turnover. Findings from a recent study(4) estimate the annual cost of physician burnout is, conservatively, $4.6 billion in costs related to physician turnover and reduced clinical hours. The authors concluded that “these findings suggest substantial economic value for policy and organizational expenditures for burnout reduction programs for physicians.”

The essential responsibilities of the CWO vary by scope and type of organization. Based on my review of CWO positions described in academic healthcare systems, here is a representative list of job responsibilities:

• Establish a “wellness” or “work–life” center and manage the ongoing, day-to-day operations—clinical, business, and budgetary—and oversee growth and expansion of the center.

• Hire center staff to include, at minimum, an administrator, psychiatrist, and Master’s-level clinical counselor to support all employees through peer groups, on-site counseling and coaching, and the development of an intervention plan accessing internal and external resources (e.g., employee assistance program/behavioral health benefits or other campus and community resources).

• Provide faculty and trainees with a customized on-campus confidential behavioral health program, including 24/7 crisis services.

• Assist program directors, department chairs, and hospital leadership with personnel behavioral health issues upon request.

• Provide leadership and training to center staff, and implement educational outreach and preventive programs to promote wellness, employee engagement, mindfulness, resilience, and coping skills among employees.

• Evaluate the center’s impact on employee wellness, professional fulfillment, and patient satisfaction and safety, and lead programmatic changes based on outcomes data.

• Develop and administer research projects supported through grant and foundation opportunities, securing and maintaining extramural funding to grow the program and provide additional support for the center.

• Create and maintain a system-wide culture of wellness by promoting and supporting staff well-being.

• Work with mental health leaders and department heads to decrease stigma and improve awareness and diagnosis of mental health disorders.

The minimum qualifications for the position of CWO typically include the following:

• Licensed board-certified physician or other appropriate clinician with a special interest in health psychology and at least 10 years of experience providing services in a healthcare setting, with demonstrated results developing and leading projects to reduce staff burnout;

• Experience with a culturally diverse patient population and medical faculty, house staff, and health system employees;

• Experience in personnel management, including hiring, evaluation, human resource requirements; and documentation;

• Ability to coordinate wellness undertakings with other executive leaders to ensure an agenda of ongoing activities that prioritize well-being; and

• Ability to work closely with marketing and communication teams to promote community wellness.

Chief Clinical Effectiveness Officer

The CCEO—not to be confused with the chief executive officer—is tasked with overseeing the planning and execution of quality initiatives in several areas, including clinical performance, regulatory compliance, and patient safety. The CCEO is the champion of policies, procedures, and practices related to error prevention and high reliability—removing the noise, reducing variation, ensuring consistency, and hitting prespecified quality and utilization targets.

Clinical effectiveness is a core competency all healthcare organizations strive to imbue in physicians as they work to satisfy Healthcare Effectiveness Data and Information Set and other clinical improvement initiatives. Unwell or burned-out physicians, however, provide suboptimal care and negatively affect patients’ satisfaction with treatment and services.(5) Patient dissatisfaction is among the most serious sequelae of physician burnout, because the patient–physician relationship is the center of medicine, and keeping the doctor–patient connection from further eroding is a significant challenge in the age of the electronic medical record.(6)

Early-career physicians, in particular, are highly susceptible to burnout, according to a 2018 meta-analysis.(7) Burnout in this study was associated with low professionalism and patient discontent. In related research,(8) it was shown that empathy begins to decline as early as the third year of medical school, precisely when students start their clinical rotations and empathy is most needed. Empathy can be measured using the Jefferson Scale of Empathy. High scores should become part of the criteria for acceptance into medical school, because physician empathy has a direct impact on patient outcomes and experiences.(9)

A representative job description for the CCEO might read as follows:

• Serve as a role model and contribute to the development of evidence-based care pathways and programs to support effective use of clinical resources and create clinical value;

• Review utilization trends and identify opportunities to reduce clinical variation, length of stay, and overutilization of resources, including inpatient and intensive care, imaging studies, laboratory services, blood products, pharmaceutical agents, medical devices, and post-acute care;

• Provide direction on policies and procedures based on practice guidelines and emerging scientific data;

• Review medical literature and seek input of peers to determine best practices;

• Prepare and present clinical effectiveness educational programs for health system personnel and medical staff relative to specific needs or quality data;

• Oversee the development of clinical metrics and make periodic reports to the Board and executive leadership on clinical effectiveness;

• Partner with supply chain/value analysis teams, service line leaders, medical staff leaders, and clinically integrated network leaders to determine best value products that promote clinical effectiveness; and

• Develop an appropriate continuing medical education agenda on critical topics relevant to clinical effectiveness, utilization, and medical coding and documentation.

Minimum requirements for the position of CCEO typically include:

• Licensed board-certified physician or other appropriate clinician with a special interest in clinical effectiveness and quality improvement;

• At least 10 years clinical practice experience with demonstrated results leading improvement efforts, multidisciplinary rounds, and projects to reduce clinical variation; and

• Ability to work closely with regulatory/accreditation /certification agencies and peer review organizations.

Chief Experience Officer

In 2007, the Cleveland Clinic became the first academic medical center to hire a CXO to address deficiencies in overall patient satisfaction. The CXO also is responsible for transforming the healthcare delivery experience for physicians, helping them avoid burnout by streamlining initiatives and allowing physicians to perform their jobs more efficiently. This includes not only the clinical aspects of practicing medicine, but also practice logistics—for example, relations with staff, scheduling snafus, wait times, and communication issues.

Ensuring that both clinical and business interactions meet or exceed patients’ expectations increases loyalty and strengthens the bottom line of healthcare organizations.

Under the Affordable Care Act, patient experience is tied to reimbursements, which gives the CXO role extra significance. In addition, patients have developed higher expectations about their experiences at hospitals due to the growth of high-deductible health plans and online reviews. Ensuring that both clinical and business interactions meet or exceed patients’ expectations increases loyalty and strengthens the bottom line of healthcare organizations.

Specific duties in a typical CXO officer job description include the following:

• Assume oversight and responsibility for enhancing and continually improving the overall experience of patients and families throughout the health system;

• Work in conjunction with vendors and process management teams regarding the patient satisfaction measurement process and achieve performance in the upper tier (75th percentile or higher);

• Clearly define the optimal patient experience, including the behavioral changes necessary to achieve cultural transformation throughout the entire organization;

• Instill a culture of service excellence and hospitality through alignment of people, processes, systems and rewards utilizing coaching, best practices, and collaboration;

• Identify and present key issues impacting the patient/family experience for Board and executive leadership discussion and decision making—issues that include findings, barriers to success, and progress toward results; and

• Serve as the subject matter expert for service excellence, maintaining an active understanding of current thinking and innovative interventions and programs regarding the patient experience—locally, nationally, and internationally.

Essential qualifications for the position of CXO include the following:

• A licensed board-certified physician or individual with an advanced degree in nursing, organizational development, public health, health administration, business, or related field (Becker’s Hospital Review(10) included only four physicians among the “30 CXOs to know in 2018.”);

• At least 10 years of related experience, with progressive levels of responsibility and a documented track record of implementing and accomplishing customer service improvements in a large healthcare organization;

• Advanced data analysis and interpretation skills to lead the service improvement effort and create the credibility needed for interaction with health system leaders and faculty; and

• Advanced knowledge of Consumer Assessment of Health Providers and Systems and other surveys and tools to advance patient-centered care.

Skepticism

It is not uncommon for the newly appointed CWO, CCEO, or CXO to face skepticism from rank-and-file staff physicians, who often become frustrated at seeing new layers of administration without understanding how it benefits them. It is legitimate to ask: “Are these positions really necessary?” “How do they add value?” “Can the new chiefs connect with physicians in the trenches?” and “Can they ultimately improve physician morale and decrease burnout?”

The answers to these questions require a return-on-investment analysis of newly created roles, preferably at more than one organization. Although there are anecdotal accounts about the effectiveness of the CWO, CCEO, and CXO in countering burnout, and there is certainly a business case(11) for investing in physician wellness, published research studies using rigorous methodology have not determined whether these new roles, alone or in combination, significantly reduce the incidence of physician burnout in the long run.

In fact, a large randomized study(12) of a workplace wellness program involving nearly 33,000 employees showed no significant differences in clinical measures of health, healthcare spending and utilization, and employment outcomes after 18 months. It should be noted, however, that physicians were not specifically the focus of the study.

Leadership

There is an alternative approach to tackling burnout that does not require hiring additional personnel—just the opposite, it requires eliminating or replacing bad leaders. A study involving hospitality industry employees(13) found that the degree of perceived burnout was related to the degree of perceived stress, and the degree of perceived stress was related to the type of leadership employed by managers. A transformational leadership style, where individuals use non-threatening, consensus-building methods to empower employees and encourage them to accept change, keeps stress to a minimum.

In terms of reducing physician burnout, hiring leaders with the “right stuff” may prove more cost-beneficial than simply expanding the C-suite into unchartered waters.

On the other hand, toxic leaders—those who demonstrate abusive behaviors and terrorize or alienate their teams—are more likely to cause stress and burnout than reduce it. Replacing toxic leaders, or converting them into less volatile and more predictable leaders, if possible, creates a favorable workplace and also benefits the organization financially—it is more profitable to remove toxic leaders than to hire top-performing ones.(14) In terms of reducing physician burnout, hiring leaders with the “right stuff”—the right expertise, curiosity, emotional intelligence, and empathy and integrity—may prove more cost-beneficial than simply expanding the C-suite into unchartered waters.

Conclusion

Healthcare organizations have been encouraged to invest in efforts to improve physician wellness, because burned-out physicians imperil the recruitment and retention of physicians, workplace productivity and efficiency, and quality of patient care and patient safety. However, the answer to the question “Do we need more chiefs in the C-suite?” to combat burnout cannot be answered in the affirmative until published studies demonstrate value in creating additional roles as opposed to the alternative course of action of identifying and eliminating bad leaders.

In addition, because these new positions have a broad range of responsibilities, with most focusing on quality, safety, and performance improvement, their roles overlap with traditional C-suite executives, such as the chief safety, quality, information, and human resource officers. C-suite bloat may satisfy an organizational checklist and appear to address the problem of physician burnout, but it may prove to be an ill-conceived way to effectively deal with it. If organizations want to improve physicians’ work experience, they should start by improving their current leadership.

References

1. Cantlupe J. The rise (and rise) of the healthcare administrator. AthenaHealth, Inc. November 7, 2017. www.athenahealth.com/insight/expert-forum-rise-and-rise-healthcare-administrator .

2. American Medical Association. What should be done about the physician burnout epidemic? www.ama-assn.org/practice-management/physician-health/what-should-be-done-about-physician-burnout-epidemic .

3. Kane L. Medscape National Physician Burnout, Depression & Suicide Report 2019. January 16, 2019. www.medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056 .

4. Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. 2019;170:784-790.

5. Wallace JE, Lemaire, JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374:1714-1721.

6. Ofri D. Empathy in the age of the electronic medical record. Lancet. 2019;394(10201):822-823.

7. Panagioti M, Geraghty K, Johnson J. Association between burnout and patient safety, professionalism and patient satisfaction: a systematic review and meta-analysis. JAMA Intern Med. 2018;178:1317-1331.

8. Hojat M, Vergare MJ, Maxwell K, et al. . The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84:1182-1191.

9. Hojat M, Shannon SC, DeSantis J, Speicher MR, Bragan L, Calabrese LH. National norms for the Jefferson Scale of Empathy: a nationwide project in osteopathic medical education and empathy (POMEE). J Am Osteopath Assoc. 2019;119:520-532.

10. Murphy B. 30 CXOs to know in 2018. Becker’s Hospital Review. March 29, 2018. www.beckershospitalreview.com/lists/30-hospital-and-health-system-cxos-to-know-2018.html .

11. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. September 25, 2017. https://medschool.ucsd.edu/som/hear/resources/Documents/jamainternal_Shanafelt_2017_sc_170009.pdf .

12. Song Z, Baicker K. Effect of a workplace wellness program on employee health and economic outcomes: a randomized clinical trial. JAMA. 2019;321:1491-1501.

13. Gill AS, Flaschner AB, Shachar M. Mitigating stress and burnout by implementing transformational_leadership. International Journal of Contemporary Hospitality Management. 2006;18:469-481.

14. Housman M, Minor D. Toxic workers. Harvard Business School Working Paper 16-057. November 2015. www.hbs.edu/faculty/Publication Files/16-057_d45c0b4f-fa19-49de-8f1b-4b12fe054fea.pdf .