Employers Must Play Active Role in Burnout Prevention

Originally published in the AAFP Fresh Perspectives blog on August 14, 2018

(Editor's note: A version of this post was originally published in the Summer 2018 issue of the New York State AFP's journal, Family Doctor.(www.nysafp.org))

Burnout terrifies me.

I have seen it destroy motivated, intelligent, skilled physicians. Most physicians start their career admiring the complex intersection of science and humanity, but while as they attempt to help maintain a fast-paced, sustainable medical system day after day and week after week, many lose the ability to enjoy their work. What should be an incredibly rewarding career ends up emotionally and physically draining and devoid of joy.

I feel burnout creeping up on me when I am unable to facilitate the care that patients need. I feel it when patients can't get their prescription filled for insurance reasons, or when they don't have the resources to eat well or improve their diabetes. I feel it when I passively click through quality indicators, or when I see the avalanche of notes to finish, messages that need replies and results that need checking. I feel it on days when no one seems to pay attention to the work I'm doing, or the ways in which I need help or support. I worry that these small but overwhelming moments will chip away at me until all that is left is a mechanical sea monster, dispassionately gnashing its way through a daily patient schedule that is as tightly packed as a can of sardines.

So, I've become obsessed with the idea of preventing burnout.

I've started reading articles, attending webinars and talking to colleagues about their experiences. A common recommendation is to build "resilience," defined in the realm of trauma psychology(www.apa.org) as "the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress." Building resilience requires steps such as boundary-setting, separation of work and home, meditation, mindfulness, spirituality, exercise, healthy nutrition, adequate sleep, vacations, connecting with loved ones and asking for help when needed.

Although resilience is valuable, I've received a loud message from my colleagues: Focusing on resilience alone shifts the burden of wellness onto the physician without addressing the problems that promote burnout in health care professionals.

Instead of establishing independent practices, more physicians are choosing to work for health care organizations with benefits, consolidated electronic health records and access to subspecialists. Employment means the burden of implementing government regulations is addressed by the employer. Employment also may allow more flexibility in location of practice, more income security and more predictable work hours.

However, it also means we've lost a good deal of control when it comes to crafting our own practice, hand-selecting our teams, and shaping the culture and support structure we desire. In some ways, employed physicians are not benefiting at all.

For example, there seems to be little difference in hours of administrative paperwork demanded of both employed and independent physicians.(physiciansfoundation.org)

Salary, bonuses and other compensation for employed physicians can be based on revenue generated, shifting the focus from quality patient care to the number of patients seen. The constant pressure to produce more revenue inherently leads to patients being treated as products -- a clash of values for the employed physician.

In cases where no effort is made to create a supportive work environment, a physician can feel unappreciated, isolated and unfairly treated.

The Maslach Burnout Inventory, a validated tool to measure symptoms of burnout, considers perception of control, workload, reward, community, fairness and values to assess the three components of burnout: emotional exhaustion, depersonalization and reduced personal accomplishment. When all these indicators are compromised, it is no wonder that more physicians and health care professionals are disengaged.

I recently participated in a webinar presented by Jessica Sweeney-Platt,(response.athenahealth.com) the executive director of physician performance research at athenahealth. She argued that burnout was directly correlated to employee capability, defined as "an employee's self-assessment of his or her ability to perform the job at hand, focusing on resources and support rather than technical skill or ability.”

This is not a new thought in organizational design. The concept was developed in the late 1990s by Len Schlesinger, M.B.A., D.B.A., who applied this concept to physician burnout last year.(hbr.org) The study found that the higher self-perceived capability physicians had, the higher their loyalty and engagement, which, in turn, correlated with increased productivity and more revenue.

Burnout, on the other hand, has been linked to decreased productivity, lower patient satisfaction scores, higher medical error rates and malpractice, higher physician turnover, addiction, substance abuse, depression, and suicide.(jamanetwork.com)

Therefore, for reasons of profit and customer satisfaction, physician wellness must become, in part, the responsibility of the employer.

Large health care organizations are beginning to understand this obligation. A handful have hired chief wellness officers to spearhead interventions to improve employee engagement, which is not a problem that can be solved simply by simply offering cupcakes in the break room. Unless interventions are thoughtful and intentionally designed to address symptoms of burnout, they will seem insincere and a waste of time.

That is why I challenge employers to ask physicians, "What do you need to do your best?" And then, to deliver those resources.

In my own workplace -- a federally qualified health center in Brooklyn -- I've informally asked medical assistants, nurses, social workers, administrators and physicians what they would need to do their best. Although my sample size is small, patterns are already emerging.

We want meaningful opportunities to bond with co-workers. We want professional development and leadership training so teamwork is optimized and the burden of work can be shared. We want management to know how to communicate expectations and how to provide and receive constructive two-way feedback. We want more positive recognition and meaningful appreciation. We want skills-based training to standardize care, instead of learning things (sometimes incorrectly) on the fly. We want options for flexibility in our schedule for child care or to take care of family. We want protected time to learn and discuss new evidence-based practices with colleagues. And, of course, we want longer visits with our patients and sufficient time to complete our daily tasks efficiently.

As we know from in-flight emergency protocols, it is imperative to put on our own oxygen mask before helping others. Everyone wants to serve patients the best they can, but it is equally as -- if not more -- important to guarantee our own capability to provide care in a joyful, positive and constructive manner. If employee engagement and loyalty lead to more revenue, better patient outcomes and more patient satisfaction, then it is a winning scenario for us, our company and, most importantly, our patients.