EXECUTIVE SUMMARY

While no specialty is spared, emergency physicians are particularly vulnerable to burnout, a problem that produces several negative consequences. Experts note the problem must be addressed at both the individual and system levels, but stress that effective interventions likely will deliver a return on investment.

  • In a survey of more 6,600 physicians in active practice, researchers from Stanford University found that physicians with signs of burnout are more than twice as likely to make medical errors. Physicians with signs of fatigue are 38% more likely to make errors.
  • A big warning sign for burnout is emotional exhaustion. As a result, providers may begin to depersonalize, seeing patients more as things than people. Providers may find themselves more engaged with their computers than with human interactions.
  • Experts note the causes of burnout include increasing administrative burdens and other responsibilities placed on frontline providers. They also report that emergency providers in particular tend to shoulder a lot of blame for problems over which they have little control.
  • At the systems level, effective interventions may include the use of scribes or technologies that reduce the administrative burdens on physicians while also improving efficiency.

While provider burnout has long been a concern throughout the medical profession, the issue is gaining greater visibility.

Increasing evidence shows that in addition to threatening provider well-being, burnout is a significant source of medical errors. In a survey of more 6,600 physicians in active practice, researchers from Stanford University found that physicians with signs of burnout are more than twice as likely to make medical errors. Physicians with signs of fatigue are 38% more likely to make errors.1 Researchers also found that 55% of surveyed physicians reported symptoms of burnout, 33% reported high levels of fatigue, and more than 6% had considered killing themselves in the past year.

Previous research has shown that among various specialties, emergency providers are particularly vulnerable to burnout, given the stress and time pressures they deal with daily. Laura McPeake, MD, FACEP, director of wellness for the department of emergency medicine in the Lifespan Health System in Providence, RI, notes the issue is multifactorial. “I think the ED is kind of the canary in the coal mine for a lot of changes that are happening in medicine in general, with the EMRs [electronic medical records] and a lot more administrative requirements,” she says. “We are seeing a lot of fallout from the opiate epidemic. A lot of that falls on the ED in terms of blame, but I don’t think we are actually responsible for a lot of it. I don’t think we have control over a lot of it.”

McPeake adds that the ED is the main door to the hospital, offering the biggest snapshot of what goes on in the hospital regarding boarding and crowding from the patient’s point of view. “Yet, we have very little control over the availability of inpatient beds, staffing models, and things like that,” she says. “A lot of responsibility falls on us without a lot of the power to [make changes]. We know that is a big driver of burnout. The lack of ability to control and manipulate your environment leads to burnout.”

What are the indications that burnout is an issue? A big warning sign is when clinicians become emotionally exhausted, McPeake advises.

“They may depersonalize and see patients as things rather than people,” she says. “When they are just clicking boxes and trying to get through the day, and when they are more engaged with their computers than with interpersonal interactions, those are all signs that things are off balance.” When that happens, it is important to start engaging in conversations with people, McPeake explains. “That has two benefits. It has the personal benefit of venting and getting out what is on your plate, and also [the benefit of] reaching out to others and realizing there is a community connection,” she says. “By communicating with colleagues on a personal level and finding a way to voice [your concerns] and empower yourself, you can give more voice to [the issue] at the administrative and leadership levels.”

McPeake adds that leadership teams can’t address issues if they don’t know about them. “There is a tendency among physicians in general and emergency physicians in particular ... to just keep their heads down ... and go on to the next thing,” she says. “We are good at advocating for others ... but we are not used to advocating for ourselves. We just have to remember that we are advocating for patients. The only way we can really take care of patients is if we are really taking better care of ourselves.”

While individual-level action is needed to address burnout, systems-level changes deliver much more impact. There is evidence that some healthcare organizations are taking the issue seriously. For instance, Jonathan Ripp, MD, MPH, was recently named chief wellness officer in the Mount Sinai Health System in New York City. He also serves as the senior associate dean for well-being and resilience at Mount Sinai Hospital.

“The literature has become much more in-depth and robust in demonstrating some of the problems nationwide across specialties,” says Ripp, in advocating for more attention to the issue of provider well-being. “There are pretty high numbers of burnout [cases] and very serious concerns and consequences associated with burnout like medical errors, quality of care, malpractice, and also, on an individual level, depression and even suicide.”

Ripp offers three key reasons why it is in a hospital’s interest to confront burnout. First, if someone is suffering, it is the right thing to do, he says. “If you have a medical problem that is affecting 50% of the population, you would have a sense of urgency to address it. That is what we are dealing with here,” he explains. “Some would argue over whether burnout is a medical condition or not, but it doesn’t matter. We see there is this condition that is affecting most physicians. That is a problem.”

Second, Ripp notes that some regulatory bodies are beginning to mandate organizations address well-being in training programs. Third, there is a strong business case for taking action in this area. “Burnout is associated with decreased productivity as well as turnover where people are simply leaving their jobs,” Ripp stresses. “There is less meaning derived from work because of all the administrative and clerical tasks that are being placed on physicians. In many ways, this is a systems issue.”

Certainly, individual responsibility is important, but the onus is on the system to create a workplace where clinicians are enabled to perform their jobs, Ripp offers. “If you remove some of the clerical work so that it no longer falls on the physician, and you can improve team-based care ... practices can run much more efficiently,” he explains, noting this development could help physicians derive more meaning from their work. “It is about trying to identify ... systems-level changes that both improve efficiency of practice and the well-being of physicians.”

Hiring scribes is one way that some health systems are removing some of the documentation burdens from physicians, Ripp notes. If one scribe helps one clinician, Ripp estimates that clinician can visit two additional patients per day, thereby offsetting the cost of hiring the scribe.

Another potential solution involves fully leveraging speech-to-text software, which has advanced considerably in recent years, or other technologies that may be able to reduce the clerical burdens on physicians, Ripp offers. Even maximizing the current functionality of existing EMRs may offer some relief.

“That is an area we are working on. We are essentially giving additional training on how to use what currently exists, but to use it more efficiently,” Ripp observes. “Sometimes, people learn how to use the EMR when they first start using it, and then they are still using it the same way five years later. There have been improvements, so you can give them just a little additional training, and suddenly you’ve shaved off minutes out of their day.”

For clinical and administrative leaders, a first step toward addressing burnout is simply to keep an open mind about just how significant a problem the issue is and what the real consequences are, Ripp explains. “Also, be a willing partner in assessing locally the well-being of the population for whom you are responsible,” he says. “There are a lot of really well-validated instruments that can be used to measure well-being ... you can’t fix a problem until you have first diagnosed it. Diagnose it by measuring it.”

Ripp cautions that there may be some resistance to exploring interventions that are costly. However, he notes there is likely to be a return on investment (ROI) when it comes to investing in physician well-being.

Ripp advises administrators consult the American Medical Association’s “Steps Forward” website, which is part of the organization’s effort to promote provider well-being (https://bit.ly/1MSg91r).

“[The website] includes a business-case calculator where you can plug in the amount of burnout at your institution, the number of physicians, and the turnover rate. It spits out the amount of money lost per year to physician burnout,” Ripp says. “There is a real potential ROI, but it does require a leap of faith.”

REFERENCE

  1. Tawfik DS, Profit J, Morgenthaler TI, et al. Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Mayo Clin Proc 2018 Jul 4. pii: S0025-6196(18)30372-0. doi: 10.1016/j.mayocp.2018.05.014. [Epub ahead of print].

SOURCES

  • Laura McPeake, MD, MPH, Director, Physician Wellness, Department of Emergency Medicine, Lifespan Health System, Providence, RI. Email: laura_mcpeake@brown.edu.
  • Jonathan Ripp, MD, MPH, Chief Wellness Officer, Mount Sinai Health System; Senior Associate Dean, Wellbeing and Resilience, Mount Sinai Hospital, New York City. Jonathan.Ripp@mountsinai.org.