Fighting Physician Burnout at the Organizational Level

Most doctors want to be working in a setting where they feel valued and have some say in the process, one expert says.

Hospitals have two broad realms in which to combat physician burnout, a problem of pandemic proportion that afflicts about half in the profession nationwide and contributes to an estimated 300 to 400 physician suicides annually.

First, there’s installing interventions just for individual physicians — things such as providing them with training in communication skills, self-care, stress management and overall strategies for coping with the hardships of the job.

Then there’s reworking standards at an organizational level — things such as reducing hours worked daily and weekly, providing more scheduling flexibility, and other systemwide changes.

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Two recent studies dug into both options by analyzing past research. The first — from Mayo Clinic and published online in The Lancet in September 2016— found that “structural or organizational interventions were more effective” but did conclude that both methods can reduce physician burnout and both are “probably necessary.”

The second — from researchers in England and Greece and published in JAMA Internal Medicine in February 2017 — found that “organization-directed interventions were more likely to lead to reductions in burnout” as compared with physician-directed ones.

Tait Shanafelt

Despite effectiveness leaning more toward organization-level initiatives, such efforts are far rarer, says Tait Shanafelt, MD, a professor of medicine and director of Mayo Clinic’s Program on Physician Well-Being, a leading institution in physician-burnout research.

“There are a number of places who have really started to embrace this like a system problem,” says Shanafelt, who co-authored the September 2016 study. “But most places have recognized the problem and have responded with individual-focused maneuvers: telling physicians to get more sleep, eat granola and do yoga.”

Michael Myers, MD, a professor of clinical psychiatry at SUNY Downstate Medical Center in Brooklyn, New York, and author of Why Physicians Die by Suicide, agrees, noting that individual methods can never overcome nagging institutional problems.

“Some of them will say, ‘I’ve been trying to do things in my personal life. I’ve been doing yoga. I’ve been going out more with my friends,’ ” Myers says. “But yet there’s still so many things at the workplace that are really continuing.”

Examples of institutions that have taken the rare, larger steps include Mayo Clinic in Minnesota, Stanford Health Care in California, Atrius Health in Massachusetts and Indigo Health Partners in Michigan, Shanafelt says.

“More than five years ago, few places would even recognize that there was an issue,” he says. “I think we’ve now come to a place where the overwhelming majority recognize that there is a problem. But so far, it’s only the vanguard places who … have made an effective response.”

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One strategy implemented at Indigo: scheduling software that quickly generates physicians’ schedules based on which days and times they prefer to work and on their requests for time off.

The software alleviates physician schedulers of the many hours it takes to manually put together shifts for Indigo’s six hospitals in rural North Michigan. And with it, all physicians now have their on-the-clock preferences instantly taken into consideration, making for easier scheduling flexibility depending on individual preferences.

At Mayo — according to an article by Shanafelt and Mayo CEO John Noseworthy, MD — physicians:

• Have an ongoing “open and candid dialogue” with the CEO through town halls, remote video chats and face-to-face meetings.

• Have their professional satisfaction and burnout measured anonymously.

• Complete annual reviews of their supervisors.

• Complete an annual survey, along with all other Mayo staff members, on how well the clinic is carrying out its core values.

• Are provided with a designated meeting area with free fruit, drinks, computers and lunch tables.

• Participate in the Program on Physician Well-Being, which researches changes to alleviate burnout, for implementation at Mayo and, through published findings, other institutions.

The designated meeting area is in place at a time when many hospitals have already done away with such spaces — something that reduces the organic collegiality often formed in them, Shanafelt says.

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“People are more isolated, and they’re interacting with each other less,” he says, noting that screen-to-face is becoming more common than face-to-face.

Michael Myers

“Organizations that strategically think about, ‘How are we going to find new ways to create connection, community, colleagues able to support each other and interact to counteract that?’ is a helpful strategy.”

Another strategy is the creation of Balint groups, Myers says. These, named after psychoanalyst Michael Balint, give physicians a platform in which to discuss their more difficult and stressful cases.

“There’s a level of trust and mutual respect — that this is a group in which I can let my hair down, and it feels safe to do that,” Myers says.

Another one is giving physicians more flexibility in their scheduling, Shanafelt says, especially as grueling as the on-the-clock hours often shape up to be. (Research co-authored by Shanafelt found that, as of 2014, about 42 percent of U.S. physicians were working more than 60 hours a week.)

An example of scheduling flexibility he gives: allowing a physician to schedule more patients on Mondays, Tuesdays and Wednesdays in order to attend his or her child’s soccer matches on Thursdays.

“Traditionally, they had a lot more control” with things like scheduling, Shanafelt says, but “it has changed a lot as more and more physicians are working in an employed-practice model.”

Myers says one of the most pressing problems in all this is the stigma attached to seeking professional help. Physicians — who likely wouldn’t have a problem with leaving work early for, say, cancer treatment — traditionally avoid mental-health appointments for fear of losing their job, license or malpractice insurance, he says.

Ten to 15 percent of the families he interviewed for his book on physician suicide said the person didn’t seek any help. Instead, they might have let problems with their marriage, kids, depression or post-traumatic stress disorder build up — and then compensated with drugs and alcohol — until it was too much.

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“I think it took a while for [physicians] to realize, ‘Hey, this isn’t just me. Fifty percent of doctors in this country are suffering from this,’ ” he says, referencing Shanafelt and others’ 2014 research that showed 54.4 percent of physicians have at least one symptom of burnout.

“Too often, those were just seen as the outliers when they’re not. This affects a huge percentage of the workforce.”

But Myers and Shanafelt say that with the issue now in full view, shifts nationwide — in health systems, accreditation entities and legislative bodies — are in the works or will be soon.

“At the end of the day,” Myers says, “most doctors will say, ‘Look, I don’t mind working hard. I’m used to hard work. But I need to be working in a setting where I feel valued, where I feel that the bulk of my work is efficient, and where I feel I’ve got some say in this process.’ ”

Michael Stone is a freelance health care writer based in Tennessee.