Mountains of Modules: Assessment and Redesign of Online Mandatory Training to Promote Physician Wellness and Reduce Burnout

Expert Perspective: Making Molehills out of Mountains by Ryan D. Kindle, MD, and Thomas L. Higgins, MD, MBA, FAAPL, can be found following the references for this article.

Physician leaders strive to have physicians work at the top of their licenses while maintaining high productivity in a work environment with minimal occupational distress. Relative to the general U.S. population, however, U.S. physicians reported increased rates of burnout and dissatisfaction with work-life balance.(1,2)

There are many well-recognized contributors to health workforce occupational distress and physician burnout, well-recognized problems that have been exacerbated by the COVID-19 pandemic. One reason commonly cited for physician burnout is time spent on required administrative tasks, including medical paperwork and mandatory training.(3-5)

Mandatory training, often imposed by regulatory bodies or institutions, is intended to help document presentation of information thought to ensure that physicians maintain expertise and competence. In the current technological environment, this training is often accomplished through online modules, which facilitate documentation of institutional compliance with regulatory requirements.

Mandatory online training modules for physicians meet the need for ongoing education in an evolving post-pandemic work environment, which involves more remote activities. Research on educating physicians to deliver high-value, cost-conscious care suggests that learning by practicing physicians, resident physicians, and medical students is promoted by combining specific knowledge transmission, reflective practice, and a supportive environment.(6)

Despite limited evidence, well-intentioned institutions use required training modules to improve patient safety and quality of care, with unintended deleterious impacts on physician wellness. There is a growing concern that the volume, lack of relevance, and redundancy of mandatory training requirements may be a contributor to occupational distress and physician burnout.(4,5) The time and effort required to complete these modules can detract from more meaningful clinical activities, professional development, and personal life, further exacerbating the occupational distress.(7)

Although online training modules have the theoretical benefits of convenience,(8,9) rarely is there allocated, compensated time for this activity during physicians’ normal working hours. In addition, physicians have described limited relevance and transferability of mandatory training to their workplace.(10)

In 2022, the National Academy of Medicine published their National Plan for Health Workforce Wellbeing,(3) which describes the significant administrative burden on healthcare workers and identifies seven priorities for action. Priority No. 4 includes a call to “re-evaluate mandatory learning and trainings to shorten or eliminate those that add to [this] burden” to achieve the goal of streamlining requirements for healthcare workers while still complying with regulations and policies. Another related action described is to “provide training for healthcare workers and learners that offers interactive, engaging formats that build communication and collaboration and goes beyond mandatory e-learning.”

This analysis quantifies the burden of mandatory online training modules for physicians using data from an online training system at a large quaternary care and public academic medical center. We also identify opportunities for burden reduction and module redesign that maintain regulatory compliance, and report efforts to streamline physician mandatory training at our institution.

METHODS

This quality improvement project was approved by the University of California San Diego Health (UCSDH) Aligning and Coordinating Quality Improvement, Research and Evaluation (ACQUIRE) Committee and was excused from institutional review board oversight.(11)

Module Completion Analysis

In this analysis, the authors conducted a comprehensive retrospective examination of records from the institutional learning management system to investigate the impact of mandatory online training modules on physicians’ workload and personal time.

The project population was comprised of physicians holding an MD degree or equivalent who provide direct or indirect patient care at University of California San Diego Health. The analysis included records for physicians from 18 clinical departments in the UCSDH system who completed at least one of the six mandatory online training modules—chosen for analysis given highest completion counts—between January 1, 2022, and February 14, 2023. Physician demographics included self-reported gender, departmental affiliations, trainee/faculty status, and the number of years they had spent at the institution.

The institutional system relies on self-reporting and currently reports the categories of female/male. These demographic variables were used to examine potential differences in module completion patterns across various departments and experience levels.

Module completion variables included the number of completed modules, time expended per module, and time of day for module initiation. Initiation time of day was further divided into three categories: traditional healthcare weekday business hours (6 a.m. to 6 p.m.), weekend hours (all hours of Saturday and Sunday of a given week), “off hours” (6 p.m. to 6 a.m., including weekdays and weekends).

This analysis uses the traditional healthcare weekday business hours as imperfect proxies for personal time. California state law requires a two-hour minimum duration to meet completion criteria for the Preventing Harassment & Discrimination module, which must be completed every two years.

Descriptive analysis, including count, median, and interquartile range (IQR), was completed within Microsoft Excel (Version 1808).

Burden Reduction and Streamlining Efforts

A multidisciplinary group that included physicians, module owners, and quality improvement employees was assembled to identify and describe the impetus for the initiative, physician burden concerns, and potential areas for improvement using a timeline of important planned intervention checkpoints (Figure 1). The group identified several opportunities to reduce the burden of annual mandatory training while adhering to regulatory and compliance requirements. It was quickly apparent that the oversight process to assess and curate content lacked clarity, and additional content had accumulated over time.

Figure 1. Timeline of Planned Intervention

A set of questions was developed to evaluate each module (Figure 2) with the goal of identifying the regulatory requirements and limiting content to that which would meet those requirements in a streamlined manner. Initial inquiries clarified that additional content had been added to required content and provided clear evidence supporting the need for development of an ongoing content assessment process.

Figure 2. Questions for Module Owners

Module owners’ answers to these questions allowed us to gauge the level of requirement of various content areas and identify potential opportunities for changes in content or structure related to the overall initiative. Answers to module assessment questions were use to gauge how initiative leaders align content with actual regulatory requirements, avoiding “add-on” content which, while desirable, was not required.

Other educational content was moved to a newly established list of “recommended” training modules. The regulatory language was reviewed to ensure that compliance was achievable with the streamlined content. Module owners were asked to use strategies that optimized physician wellness and minimized physician time and effort while preserving the educational intent.

RESULTS

Demographics

The final analytic cohort included 1,367 academic physicians (43% female, 50% male, 7% not specified, median age 46 years [range 28–90 years], median time at the academic institution 8 years [range <1–51 years]).

Module Completion Analysis

Table 1 displays physician completion variables for the six mandatory modules at the time of data collection. Despite the “mandatory” nature of the assignment, not all physicians completed all assigned modules: 539 (39%) completed all six modules, 725 (53%) completed two to five, and 103 (7%) completed only one.

Using an estimated median time (calculated by adding the times for each mandatory module), it was determined that physicians who completed all six required online modules would have spent an estimated median time of 296 minutes (4.9 hours). Excluding the biannual state-required module that has a required duration of 120-minutes, the inter-quartile range (IQR) for completion of one annual module (calculated by taking the median and IQR of the five remaining mandatory modules) was 20–74 minutes (median=35 minutes).

“Off hours” starts occurred for 32% (range/module: 28%–34%) of completed modules, either over the weekend (21%, range/module: 17%–22%) or otherwise “off hours” (16%, range/module: 15%–17%). Table 2 displays the significant differences detected by specialty for “off-hours start” and the significant variation in median completion time of a single module by department. The median completion time did not differ substantially by years of experience at the project institution (Supplementary Table 1), or by gender (Supplementary Table 2).

The total physician time for this single training module group was 9,185 hours. Using a conservative average physician compensation rate of $167/hour, the estimated cost of physician time for module completion was $1,533,895. Currently, mandatory training is an uncompensated and unscheduled activity for physicians.

Burden Reduction and Streamlining Initiative

Streamlining resulted in removal of an entire module, which remains available to those interested or may be required on a case-by-case basis. The remaining modules were streamlined to highlight crucial information quickly with optional links embedded for more detailed information. After input from physicians, the module completion time window was increased to 60 days and shifted to start each May (graduating GME physicians will not need to complete the modules; new GME physicians will receive the module assignments as part of their onboarding). A mobile application was also introduced to facilitate completion of the training module.

DISCUSSION

Our findings quantify the significant physician time, effort, and cost required to maintain compliance with a single set of core mandatory training requirements. Moreover, the burden of this requirement frequently affected “off hours” and “weekends” with potential impact on physicians’ personal lives. The time and effort required to complete these modules is costly and can detract from more meaningful clinical activities, professional development, and personal life, further exacerbating the problem.(7)

The absolute number of hours measured in this cohort completing one cycle of mandatory module training is unlikely to equate with the perceived burden or impact on physician wellness. Time and effort for an uncompensated activity that is generally perceived to be of low clinical relevance add to the cumulative administrative burden experienced by physicians who do not have much, if any, free time in their professional lives. Physicians have notoriously tightly scheduled days with little room for “non-core tasks,”(12,13) including administrative work such as training modules. Time calculations should be considered to be only a starting point to measure the burden of this administrative requirement.

This analysis focused on six core modules assigned to physicians at the project institution. However, many other mandatory modules may be assigned by the institution based on role, supervisory/teaching responsibilities, clinical unit, or clinical equipment use, etc. These additional modules understandably further burden physicians, adding to their occupational distress.

Although these were not measured in the present analysis, future studies may deepen our understanding of the administrative burden on individual physicians, and/or individual clinical departments or specialties, based on their personal mandatory training requirements.

Although the 24-7 responsibilities of clinicians make it difficult to precisely measure “off hours,” the high proportion of “off-hours” completions in this analysis suggest that required online training is intruding into physicians’ personal time. While there may be differences in training burdens and work-life balance among various clinical departments, the variability in module completion times and variation across specialties has not been explored in prior research.

These variations warrant further exploration as the encroachment of training on personal time may be much more pronounced for certain clinical groups. Variability in time spent on administrative duties has been reported previously.(12) This variability is unlikely to be explained by differences in cognitive or learning ability, as physicians are well-educated individuals accustomed to participating in activities such as mandatory training.

More likely, we suspect that this variability is caused by differences in multi-tasking that occurs during module completion, as physicians may be attending to patient needs, research tasks, or administrative responsibilities while or in between when they have the mandatory training module running simultaneously.

Physician wellness is essential to sustain a healthcare system’s workforce. Despite increased recognition, burnout rates among physicians remain high compared to workers in other fields,(14,15) leading to significant reduction in professional work effort.(16) Lower professional fulfillment by physicians has been associated with higher burnout scores at an academic institution, citing organizational culture as a main contributor.(17)

Characteristics of the work environment have also been reported to be a significant driver of physician burnout.(18) The rise of electronic technology has inspired many changes in a physician’s practice environment, including the shift of medical documentation as well as administrative training modules to the electronic screen.(19) This has inspired at least a handful of initiatives(3,7,20-22) aimed toward reducing these and other contributors to physician burnout and cultivating physician well-being and professional fulfillment.(21)

In 2017, the Centers for Medicare & Medicaid Services (CMS) launched the Patients Over Paperwork (POP) program to target burdensome medical documentation regulations.(20,23) An analysis of the initiative’s early performance demonstrated a decline in medical documentation burden (measured by word count) over time.(23) This analysis also found differences in word counts between notes for various payer types, visit types, clinician gender, and patient comorbidity burden.

CMS reports eliminating 42 million hours of documentation burden through 2021 and saving the healthcare system more than $6 billion.(20) While these results are encouraging, the initiative described is aimed at reducing primarily compensated patient-related administrative burden as opposed to uncompensated training administrative burden, which remains substantial. The American College of Physicians (ACP) also initiated a similarly titled initiative (Patients Before Paperwork) that expanded the scope of physician administrative burden targeted.(7)

The strengths of the present analysis include a quantitative approach to a large sample of more than 1,300 academic physicians in a large public university setting, analysis of commonly assigned mandatory modules, and description of the process and results of an initial streamlining effort. In addition, data on timing of module completion was included. Limitations include the lack of longitudinal data for individual physicians over time or following streamlining efforts.

There are opportunities for physician leaders to foster physician education and compliance with regulatory requirements while reducing the time and uncompensated effort for mandatory online training. Streamlined content that focuses on high-impact, relevant topics can be offered in more flexible, self-paced learning opportunities.

Breaking down the training content into smaller modules may allow physicians to complete the training in short, manageable sessions without overwhelming overloads of information at once. While this may lead to a more daunting appearing list of modules, it may promote flexibility of scheduling to complete the modules during compensated time such as between patients or other downtime. Starting modules with a “pre-assessment” that can earn an ability to “test out” of a particular topic may decrease time burden on seemingly unnecessary items.

Involving physicians in the training module design and evaluation can help ensure that they are relevant, engaging, and efficient. With physician leaders as partners, our institution continues its work on administrative burden reduction for physicians, with further streamlined training and plans to provide Continuing Medical Education (CME) credit for training modules, whenever possible.

CONCLUSIONS

Our findings support prioritized action involving physician leaders to reduce the mandatory administrative training module burden on physicians, consistent with priorities proposed by the National Academy of Medicine Plan for the Healthcare Workforce. In response to these findings, healthcare organizations should consider scrutinizing efforts to add unnecessary training content and enhancing streamlined redesign of their mandatory online training modules with attention to physician wellness.

Acknowledgment: The authors wish to acknowledge the outstanding project management skills of Amy Kosifas.

Conflict of Interest and Source of Funding: Linda Brubaker, MD, discloses editorial stipends from JAMA and Up to Date. For the remaining authors none are declared.

References

1. Hodkinson A, Zhou A, Johnson J, et al. Associations of Physician Burnout with Career Engagement and Quality of Patient Care: Systematic Review and Meta-analysis. BMJ. 2022;378: p. e070442. https://doi.org/10.1136/bmj-2022-070442

2. West CP, Dyrbye LN, Sinsky C, et al. Resilience and Burnout Among Physicians and the General US Working Population. JAMA Netw Open. 2020;3(7):1–11. https://doi.org/10.1001/jamanetworkopen.2020.9385

3. National Academy of Medicine. National Plan for Health Workforce Well-being. Washington, DC: The National Academies Press; 2022.

4. Barrett E, Hingle ST, Smith CD, Moyer DV. Getting Through COVID-19: Keeping Clinicians in the Workforce. Ann Intern Med. 2021;174(11):1614–1615. https://doi.org/10.7326/M21-3381

5. West CP, Dyrbye LN, Shanafelt TD. Physician Burnout: Contributors, Consequences and Solutions. J Intern Med. 2018;283(6):516–529. https://doi.org/10.1111/joim.12752

6. Stammen LA, Stalmeljer RE, Paternotte E, et al. Training Physicians to Provide High-Value, Cost-Conscious Care: A Systematic Review. JAMA. 2015;314(22):2384-2400. https://doi.org/10.1001/jama.2015.16353

7. Erickson SM, Rockwern B., Koltov M, et al. Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians. Ann Intern Med. 2017;166(9):659–661. https://doi.org/10.7326/M16-2697

8. Ruiz JG, M.M., Leipzing RM. The Impact of E-learning in Medical Education. Acad Med. 2006; 81(3):207–212. https://doi.org/10.1097/00001888-200603000-00002

9. Regmi K, Jones L. A Systematic Review of the Factors — Enablers and Barriers — Affecting e-Learning in Health Sciences Education. BMC Med Educ. 2020;20(91):91. https://doi.org/10.1186/s12909-020-02007-6

10. Humphrey-Murto S, Makus D, Moore S, et al. Training Physicians and Residents for the Use of Electronic Health Records—A Comparative Case Study Between Two Hospitals. Med Educ. 2023; 57(4):337–348. https://doi.org/10.1111/medu.14944

11. El-Kareh R, Brenner DA, Longhurst CA, Developing a Highly-reliable Learning Health System. Learn Health Syst. 2022;7(3):e10351. https://doi.org/10.1002/lrh2.10351

12. Rao SK, Kimball AB, Lehrhoff SR, et al. The Impact of Administrative Burden on Academic Physicians: Results of a Hospital-Wide Physician Survey. Acad Med. 2017;92(2):237–243. https://doi.org/10.1097/ACM.0000000000001461

13. Thun S, Halsteinli V, Lovseth L. A Study of Unreasonable Illegitimate Tasks, Administrative Tasks, and Sickness Presenteeism Amongst Norwegian Physicians: An Everyday Struggle? BMC Health Serv Res. 2018;18(1):407. https://doi.org/10.1186/s12913-018-3229-0

14. Shanafelt TD, Boone S, Litjen T, et al. Burnout and Satisfaction with Work-Life Balance Among US Physicians Relative to the General US Population. Arch Intern Med. 2012;172(18):1377–1385. https://doi.org/10.1001/archinternmed.2012.3199

15. Shanafelt TD, West, CP, Sinsky C, et al. Changes in Burnout and Satisfaction with Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2017. Mayo Clin Proc. 2019;94(9):1681–1694. https://doi.org/10.1016/j.mayocp.2018.10.023

16. Shanafelt TD, Mungo M, Schmitgen J, et al. Longitudinal Study Evaluating the Association Between Physician Burnout and Changes in Professional Work Effort. Mayo Clin Proc. 2016;91(4):422–431. https://doi.org/10.1016/j.mayocp.2016.02.001

17. Burns KEA, Pattani R, Lorens E, Straus SE, Hawker GA. The Impact of Organizational Culture on Professional Fulfillment and Burnout in an Academic Department of Medicine. PLoS One. 2021; 16(6):e0252778. https://doi.org/10.1371/journal.pone.0252778

18. Trockel MT, Corcoran D, Minor LB, et al. Advancing Physician Well-Being: A Population Health Framework. Mayo Clin Proc. 2020;95(11):2350–2355. https://doi.org/10.1016/j.mayocp.2020.02.014

19. Tai-Seale M, Baster S, Millen M, et al. Association of Physician Burnout with Perceived EHR Work Stress and Potentially Actionable Factors. J Am Med Inform Assoc. 2023;30(10):1665–1672. https://doi.org/10.1093/jamia/ocad136

20. Centers for Medicare and Medicaid Services. Patients Over Paperwork. U.S. Department of Health & Human Services website. March 3, 2020.

21. Shanafelt TD, Trockel M, Rodriguez A, Logan D. Wellness-Centered Leadership: Equipping Health Care Leaders to Cultivate Physician Well-Being and Professional Fulfillment. Acad Med. 2021;96(5):641–651. https://doi.org/10.1097/ACM.0000000000003907

22. DeChant PF, Acs A, Rhee KB, Boulanger TS, Snowdon JL, Tutty MA, et al. Effect of Organization-Directed Workplace Interventions on Physician Burnout: A Systematic Review. Mayo Clinic Proceedings Innov Qual Outcomes. 2019;3(4):384–408. https://doi.org/10.1016/j.mayocpiqo.2019.07.006

23. Nguyen OT, Hannah K, Merlo LJ, Parek A, Tabriz AA, Hong YR, Feldman SS, Turner K. Early Performance of the Patients Over Paperwork Initiative Among Family Medicine Physicians. South Med J. 2023;116(3):255–263. https://doi.org/10.14423/SMJ.0000000000001526

EXPERT PERSPECTIVE: Making Molehills out of Mountains

By Ryan D. Kindle, MD, and Thomas L. Higgins, MD, MBA, FAAPL

The history of educational mandates for physicians in the United States can be traced back over a century to the Flexner Report, for good or ill. In the era of modern healthcare delivery, however, these dictates have expanded beyond the laudable goal of improving medical knowledge to encompass a far broader and arguably less relevant corpus of information, with little study of the impacts on patient care, physician wellbeing, and economics. As the healthcare system recovers from a viral pandemic with increasing physician burnout, a critical re-evaluation of rote educational mandates is long overdue.

New physicians are rewarded with abundant paperwork and training modules required to enter practice, and often on a recurring basis thereafter. The Federal Drug Enforcement Agency has an eight-hour educational requirement before registering to prescribe controlled substances,(1) which is necessary for employment at many hospital systems. State governments impose other continuing medical education requirements, frequently with mandated recurring activities.(2)

Healthcare systems, hospitals, medical staffs, and research organizations heap further educational requirements on physicians, whether by legal mandate or institutional priorities. Topics range from proper posture to infection control to disaster management; the authors’ institution required 21 online training modules in 2023. Understanding the impact of these requirements on physicians, much less patients, is lacking despite an ever-expanding volume.

Goldhaber, Gudea, Skillens, Perez-Hall, Francisco, Brubaker, and El-Kareh have analyzed the time burden and completion rates for mandatory online training modules at an academic medical center. This single-center study encompassed 1,367 academic physicians in 18 clinical departments with institutional experience ranging from 1 to 51 years.

Most physicians (61%) did not complete all six modules analyzed, and those who did required an estimated median time of 296 minutes. Nearly a third of the modules were completed on nights and weekends, likely intruding into physicians’ personal time. Despite being recurring requirements, the median completion time did not significantly decrease with additional years of practice at the institution.

The study authors argue for balancing physician wellness while achieving regulatory compliance and educational needs, noting that dedicated time for mandatory activities is rarely allocated or separately compensated. While traditionally, physicians were considered “exempt” employees and thus ineligible for overtime payments, the line has blurred. Physicians often clock in and out for shifts like non-exempt employees who must be compensated for time attending meetings and programs for employers’ benefit under the Fair Labor Standards Act. Employers that improperly categorize non-exempt employees as exempt risk significant penalties.(3)

Although it is difficult to argue against education, the modern medical system in the United States still prioritizes patient-facing time in determining physician compensation. The estimated institutional cost associated just with the subset of required modules analyzed in this study exceeded $1.5 million using a conservative physician compensation rate of $167/hour. The indirect costs to the institution related to physician dissatisfaction, burnout, and turnover are unmeasured but may well be significantly higher.

Based on these results, the institution eliminated one module, streamlined the others, adjusted the completion window to align with graduate medical education, and created a mobile application. These are reasonable initial steps, and organizations are encouraged to evaluate mandatory training programs using the following criteria:

1. Required? Federal and state laws must be obeyed and implemented in accordance with regulations. Training beyond those requirements, whether exceeding a government mandate or separate topics chosen by the institution, should be subject to cost-benefit analysis like any other business decision. Education alone is a weak intervention for quality improvement with limited impact on systemic factors affecting patient outcomes.

2. Relevant? Training mandates must address topics affecting a significant majority of the physicians expected to comply. Fire safety regulations requiring automatic sprinklers to have 18 inches of clearance below the ceiling(4) are important but their applicability to physicians is questionable.

3. Recurrent? Medical knowledge is constantly evolving and warrants lifelong learning consistent with the ethical obligations assumed by physicians in caring for patients. The frequency of the educational requirements is open for debate, but critical basic practices such as practicing hand hygiene and not harassing staff are unlikely to be forgotten in the absence of biannual reinforcement.

4. Re-evaluation? An educational activity that meets these criteria should be re-evaluated intermittently to determine if it achieves its desired goals in an efficient manner. The Health Insurance Portability and Accountability Act (HIPAA)(5) does not require biannual training, but the institution studied by Goldhaber, Gudea, Skillens, Perez-Hall, Francisco, Brubaker, and El-Kareh and many others do. Unfortunately, HIPAA violations continue to increase nationwide despite these institutional efforts.(6)

The requirements placed on physicians for initial and recurrent training by federal, state, and institutional authorities are extensive. Analyzing their necessity, cost, frequency, and effectiveness are no less important than clinical trials, as physician time is often a limiting factor in patient care and a valuable resource not to be squandered.

Seneca wrote that “It is not that we have a short space of time, but that we waste much of it.” Goldhaber and colleagues have shown the impact of mountains of modules, and it is past time to reduce them to minimally necessary molehills.

References

1. Prevoznik, TW. Requirements for Training for Medication Assisted Treatment as Part of the MATE Act. U.S. Department of Justice Drug Enforcement Agency. March 27, 2023. https://deadiversion.usdoj.gov/pubs/docs/MATE_Training_Letter_Final.pdf

2. Federation of State Medical Boards. Continuing Medical Education Board-by-Board Overview. May 2023. https://www.fsmb.org/siteassets/advocacy/key-issues/continuing-medical-education-by-state.pdf

3. Fair Labor Standards Act of 1938, 29 USC §201–219 (2022).

4. Occupational Safety and Health Standards — Fire Protection — Automatic Sprinkler Systems. 29 CFR §1910.159(c)(10). May 1, 1981. https://www.ecfr.gov/current/title-29/part-1910/subject-group-ECFR7a02737a205fd22#p-1910.159(c)(10)

5. Privacy of Individually Identifiable Health Information — Administrative Requirements. 45 CFR §164.530(b). February 26, 2001. https://www.ecfr.gov/current/title-45/part-164/subpart-E#p-164.530(b)

6. U.S. Department of Health and Human Services Office for Civil Rights. Annual Report to Congress on HIPAA Privacy, Security, and Breach Notification Rule Compliance For Calendar Year 2021. February 16, 2023. https://www.hhs.gov/sites/default/files/compliance-report-to-congress-2021.pdf