Sabbaticals: Antidote to Physician Burnout?

The topic of “physician burnout” has permeated the blogosphere,(1) trade publications,(2) scientific journals,(3) and popular media.(4) Fingers point in many directions as to causes of physician burnout and ways to ameliorate them. There are calls for longitudinal studies of these interventions and even calls for regular (potentially mandatory) assessments of lurking burnout among providers lest it rear its head and negatively affect patient care.

These are draconian measures it may seem, but as illustrated by both anecdotal and accrued data, the problem is alarming in terms of its potential devastating impact on our healthcare system. The upsurge in prevalence of “burnout” signs is also remarkably rapid, increasing from 45.4 percent to 54.4 percent between 2011 and 2014.(5)

The effects of physician burnout range from increased physician suicide rates and other personal health issues to increased medical errors, decreased quality of care, and potential shortages of caregivers because of early departures from the profession.(6)

Hopefully, this outcry means that funding will materialize for potential solutions and study of their effectiveness to prevent worsening of, if not full amelioration of, the crisis.

Frequently mentioned in the milieu of symptoms and stresses that contribute to this ongoing critical issue is the altered work-life balance that results from intensive and demanding training programs and the practice settings into which physicians then enter. When these are coupled with the various productivity and technological demands placed upon physicians (onerous EHR documentation, among others), the resultant psychosocial tensions seem to eclipse the stresses rampant in the prior generation of pre-work-hour-restrictions-trained physicians.

According to a Mayo Clinic study, burnout rates for physicians experiencing one or more burnout markers as measured by the Maslach Burnout Inventory jumped significantly among all specialties during the first portion of this decade, to the point that today more than 50 percent of physicians express one or more of these markers.(5)

Integral to this study was the assessment of work-life balance, which, coupled with results of the Maslach data, illustrates a majority of specialties tipping precariously toward the “danger zone” of high burnout scores and low work-life balance. Other investigation has shown similar trends.(7) Projected forward, the doctor shortage many have been predicting may show up much sooner than expected.

While admirable efforts are underway to reduce the day-to-day stressors — including documentation via cumbersome EHRs and regulatory and payment barriers that must be navigated to allow patients to get care and doctors to get payment — some organizations are re-considering the value of sabbatical leave time as a partial solution to this complex problem.

The concept of the sabbath, meaning abstinence from work, over time has been implemented in many workplaces with beneficial results. While there are many potential benefits to both the worker and the workplace, the employee and the employer, subject perhaps to the particulars of duration, circumstances, and setting, the concept has yet to find truly broad application across medicine.

Perhaps it is time to reconsider this state by exploring several questions.

What defines a sabbatical?

The traditional academic approach to sabbatical leave was a one- or two-semester (half or full year) break from the rigors of teaching and related campus-based activities with the intent to pursue academic purposes that could not be accomplished while tethered to the regular routines in one’s home institution. Usually sabbatical leave entailed some kind of approval process, often contingent upon a certain number of years of past service (most often seven), and efforts to procure living and funding arrangements to make the experience beneficial to the individual’s career and to the granting institution.

In the corporate world, the duration of a sabbatical leave has been more variable, from as little as four to six weeks, to well over a year. The use of the time has not always been of direct benefit to the operation of the business, current or future, but most often still requires some sort of vetting process. In the medical practices that use the strategy, the duration has also been variable, usually measured in weeks or months, though the formality of application and approval has not been used as frequently. Often, but not always, some sort of accountability is required in the form of a report on the experience.

Therefore, a sabbatical leave might be defined as a continuous period of leave from usual work duties to pursue diverse activities, closely related to one’s field or not, often with a defined purpose and some form of accountability upon completion.

What are the emotional and psychosocial benefits to the employee?

One oft-cited case-control study of 258 people demonstrated that individuals who took a sabbatical leave experienced a decline in stress and returned to work with increased psychological resources to continue work when compared to peers who remained behind.(8) Evidence suggests these benefits continue to carry over into the post-sabbatical period.

For those serving in leadership roles, studies have suggested that leadership is enhanced by a sabbatical of several months duration(9) and that the problem of executive burnout may be avoided or diminished, as sabbatical awardees often end up extending their careers rather than departing early. Both of these benefits seem particularly germane to the discussion around physician burnout.

Other benefits may be as diverse as the different kinds of experiences sought, whether humanitarian or in community service settings, developing skills in a new area of endeavor tangential to one’s core competencies, or simply flying kites with one’s kids on a foreign shore. New networks, new experiences, new knowledge, new skills, shifted perspectives, and other life-changing experiences are the fruits, if not the primary motives, for pursuing a sabbatical.

One physician used a portion of a sabbatical leave to craft children’s stories pertinent to some of the science in his life. Another used the time to provide regular consultation to colleagues in a developing country and to give lectures to the trainees there. In both circumstances the physicians returned with an enriched emotional and intellectual trove of experiences that made a difference in the next phase of their careers.

What are the benefits to the employer and fellow workers?

The change of pace to unwind and relax, the new skills developed, the new colleagues or networks cultivated, and other benefits of a sabbatical might seem disproportionately skewed toward the individual, leaving the organization and other team members with more work in order to accomplish the work of their absent colleague. But the opposite may be true: The benefits to the organization may be greater than those of any single individual.

A seminal study by Debra Linnell and Tim Wolfred uncovered several significant organizational benefits when a leader stepped out for a sabbatical.(9) Among these were revitalized leadership, improved governance (largely due to more engaged boards and other leaders stepping up to compensate for the planned absence), enhanced capacity and depth of leadership, improved delegation and task sharing among both staff and leaders, and improved succession options.

From a fiscal standpoint, several potential cost savings point to additional benefits and some potential sources for the funding needed to support a sabbatical program. First among these are recruitment and retention improvements that reduce the expenses of finding and training new personnel.(10) Since search and on-boarding costs can approach a half- or a full-year’s salary in some settings, depending on the position, reducing those costs by half or more, which is not unrealistic for a sabbatical program, could readily recoup all or part of the cost of funding a two- or three-month sabbatical at full salary.

One way these recruiting costs decrease is by the enhanced loyalty those on sabbatical feel toward their organization, but equally important, improved mental health status actually results in leaders continuing to work longer than they may have originally anticipated, a sign of having allayed burnout.

Similarly, ensuring a better mental health status among key employees should reduce risk of costly errors, patient catastrophes of the type cited to call physician burnout a healthcare crisis, and other kinds of problems, such as employee discontent, stifled or mis-directed anger, etc.(6) Another fiscal benefit may be recouped from the enhanced engagement and effectiveness of sabbatical recipients in the workplace, as uncovered in the Davidson, et al., study noted above.(8)

The organization also benefits when the recipient uses a sabbatical to learn new skills or master new technology pertinent to the organization’s business. Such “straight-line” concurrence of goals and objectives may not be the case with every sabbatical, but when it is, the results can be dynamic. Likewise, the onsite presence of an interested devotee who then returns to their former institution helps to build a relationship between institutions that remains long after the sabbatical has ended.

Finally, in an era when employers are quick to tout their employee-friendly, environmentally conscious, socially responsible workplace, a sabbatical-leave policy that validates these values by offering leave for humanitarian, social, or other noble causes will provide meaningful substance to the claims.

Are there significant negatives to be considered for the individual or the organization?

One can easily imagine coming back to work following a period of sabbatical only to find that the locks on the doors have been changed, an immensely talented and handsome individual is sitting in one’s chair and carrying on quite well, and that one’s co-workers (or patients) regard one with an inquisitive, “Do I know you?” kind of look.

It is entirely possible that any sense of “indispensability” to an organization will have been rudely crushed by a prolonged absence and capable substitutes. Likewise, one can imagine the flip side of that in which the sabbatical experience so enriches the sabbattee that the new relationships and talents discovered or developed lead to new opportunities for employment. These are both real possibilities, but tend to be mitigated by economic, contractual, and other obligations.

Another potential negative might appear when a critical organizational decision arises while a key individual is absent. Of course, this situation also can arise under routine leave circumstances as well as in the setting of a sabbatical, and appropriate contact provisions can be made beforehand if a key leader is planning a sabbatical. And as some have noted, this organizational opportunity for leadership development is in fact a benefit of the process, even when painful.

What kinds of barriers might need to be overcome to allow wider application of the sabbatical principle — i.e., to make it sustainable?

If the assertions of the TH Chan School of Public Health and their collaborators are correct and we truly are reaching a physician burnout crisis point,(4) then it is time to ask whether this solution is worthy of trial on a broader scale within medicine. While nearly a quarter of public corporations have some sort of sabbatical policy and a much larger number of academic institutions do, managing the logistics can be difficult in medical practices, because of the longitudinal nature of medical care, with its associated patient loyalties, the difficulty in arranging coverage for many services, particularly in lower volume settings or highly specialized services, and the economic costs involved for a physician, whose overhead may not be diminished while away.

These two issues, continuity of patient care coverage and individual economic constraints, loom largest. Beyond that, other logistical issues such as maintaining licensure and privileging, and family issues such as spousal employment, schooling concerns, and housing may impose constraints to make uptake fall short of universal.

Economic Obstacles

There are potential cost savings to justify some portion of the expenses of a sabbatical leave for a key employee such as a physician. But recognizing the difference between potential savings and real expenditures to pay a locum tenens physician or another person to cover the duties of the absent individual, the organization — both leadership and other stakeholders — need to discuss how to manage this challenge.

Offering sabbatical leave without pay or with limited pay/benefits is one option of course; there are others, including seeking external grant funding or tapping development or education funds. Offering support for educational loan repayment, malpractice insurance (if needed) during the short-term leave, or other potentially deterrent expenses might also enhance interest by those in need of the therapeutic benefits of a sabbatical.

Instituting a sabbatical program with clear guidelines and transparent processes also would encourage specific economic planning and saving by physicians to be able to take advantage, even if that imposed some economic constraints for a season. Adding a term of service before one could qualify for such a benefit, as well as obligatory continuance following, could provide more real savings in retention/recruitment costs to cover part or all of the program costs.

Table 1 illustrates a hypothetical cost comparison of two 10-physician practices, one with a sabbatical program and one without. The estimates for recruitment, turnover rates, coverage costs, etc., are conservative overall, but these assumptions and the specifics merit closer analysis given the relatively small differences in net costs.

Another example of a way to internally fund the granting of added leave in a quasi-sabbatical form is that used by a group practice of 12 single-specialty physicians we know. At a minimum, the group needed eight physicians to “cover the bases” at all times, so 416 worked weeks was the minimum required to keep the practice afloat.

The practice required associates to take a minimum of eight weeks of vacation and educational leave. That left 112 potential leave weeks for discretionary use as regular vacation or as continuous stretches of sabbatical leave. The practice chose to allow some individual preference in using this time, apportioning end-of-year profits according to “worked weeks,” but that allowed the physician associates to choose between time or monetary benefits. In their setting it would have been fairly simple to allocate six to eight weeks or even more for a mini-sabbatical if needed or desired, without incurring additional expenses or curtailing benefits. Coverage issues for particular services were the primary constraint.

Medical Coverage-Patient Care Obstacles

Two options are commonly available for medical coverage and patient care. In a larger organization, internal personnel re-arrangement and cross coverage for an absent physician may be feasible. Practices as small as four and five physicians have been able to successfully employ this method, albeit with some temporary stresses depending on the specific skill distribution among the group.

Hiring a short-term substitute is another option, subject to availability and cost constraints. But unlike emergent health-related absences, a sabbatical program allows sufficient advance planning to make this feasible. In some settings, outsourcing components of the workflow may also be possible without the need to bring in and credential substitute labor with those associated costs.

Summary

Launching a process to allow physicians in your organization to take a sabbatical, or perhaps even requiring them to take a sabbatical, is a bold and brave step, but one that has known benefits to the individuals and the organization. Human resources, the skills and talents that people bring to their task, are crucial to the success of any healthcare enterprise and deserve careful management.

Providing means for physicians and other leaders in high-stress positions to have periods of rest, rejuvenation, and diversion can allow for a meaningful reset of the mind and emotional stressors, as well as the work-life balance parameters that can result in safer, higher-quality work; enhanced skills and networks; and greater engagement in the important work we do. The benefits to patients, to the healthcare organizations in which they serve, and to the communities in which they live and work are immense.

References

1. Hockman D. A Relatively Simple Solution to Physician Burnout. KevinMD.com , May 15, 2018. https://www.kevinmd.com/blog/2018/05/a-relatively-simple-solution-to-physician-burnout.html .

2. Cohen JK. Physician Burnout Is a ‘Public Health Crisis’: 3 Strategies to Address It. Becker’s Hospital Review, January 18, 2019; https://www.beckershospitalreview.com/hospital-physician-relationships/physician-burnout-is-a-public-health-crisis-3-strategies-to-address-it.html .

3. West CP, Dyrbye LN, Shanafelt TD. Physician Burnout: Contributors, Consequences and Solutions. Wiley Online Library; https://onlinelibrary.wiley.com/doi/full/10.1111/joim.12752 .

4. McCluskey PD. Physician Burnout Now Essentially a Public Health Crisis. The Boston Globe, Jan 17, 2019; https://www.bostonglobe.com/metro/2019/01/17/report-raises-alarm-about-physician-burnout/9CGdUc0eEOnobtSUiX5EIK/story.html .

5. 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 Dec; 90:1600-13. www.mayoclinicproceedings.org/article/S0025-6196(15)00716-8/fulltext .

6. Patel RS, Bachu R, Adikey A, Malik M, Shah M. Factors Related to Physician Burnout: A Review. Behav Sci (Basel). 2018 Nov; 8(11): 98.

7. Advisory Board; Survey: Many Doctors Looking to Leave Profession Amid Burnout, Low Morale. 2016; https://www.advisory.com/daily-briefing/2016/09/26/doctors-leaving-profession?wt.mc_id=email%7Cdailybriefing+headline%7Cdba%7Cdb%7C2016sep23%7Catestdb2016sep26%7C%7C%7C%7C .

8. Davidson OB, Eden D, Westman M, Cohen-Charash Y, et al. Sabbatical Leave: Who Gains and How Much? J Appl Psychol. 2010 Sep; 95(5): 953-64. https://doi.org/10.1037/a0020068 .

9. Linnell D, Wolfred T. Creative Disruption: Sabbaticals for Capacity Building and Leadership Development in the Nonprofit Sector. Issuelab.org ; https://www.issuelab.org/resource/creative-disruption-sabbaticals-for-capacity-building-and-leadership-development-in-the-nonprofit-sector.html .

10. McDearmid RC. Time Out and Time Off: A Systematic Review of the Benefits of Sabbatical [MBA Thesis]. University of Prince Edward Island, 2014; https://www.islandscholar.ca/islandora/object/ir%3A9546/datastream/PDF/view

Potential Personal Benefits of a Sabbatical

• Reduced stress

• Improved emotional well-being and coping skills

• Re-adjusted work-life balance and changed perspective

• New skills, related to or non-related to primary career

• New networks and colleagues

• Diversified knowledge

• Enhanced compassion and strengthened relationships

• Greater confidence in team members left behind

Organizational Benefits from an Employee Sabbatical

• Reduced risk

• Enhanced employee retention

• Recruitment advantage

• Leadership development

• Improved decision making and staff engagement

• Improved governance

• Enhanced capacity

• New skills and technology

• Expanded networks

• Positive public relations