By Gary Evans, Medical Writer

Healthcare facilities and employee health professionals have responded to an epidemic of physician burnout with programs to build resiliency, such as yoga and mindfulness meditation. However, even advocates of these approaches say they are not a panacea, as larger system-level problems are driving physician frustration and subsequent burnout.

The president of the American Medical Association (AMA) recently explained that a major source of physician burnout is the inability to deliver the patient care that clearly is needed.

“I hear these frustrations all the time,” Barbara L. McAneny, MD, said in June in Chicago at the annual AMA conference. “There is clear evidence that burnout for employed physicians stems from a lack of control of their day-to-day work environment. It is also when they identify a clinical need but can’t convince their employers to invest and try to solve it.”

For example, physicians may see a need for more addiction medicine specialists in the current climate, but the hospital system has committed resources toward building a new wing, she said.

“For physicians in private practice, the frustrations are generally fewer resources to confront growing administrative requirements,” McAneny added. “We cannot afford to provide social workers or dietary consultations because the physician fee schedule doesn’t cover it.”

Work structure interventions and changes can address some burnout issues. For example, a recent study1 revealed that shorter rotations in ICUs blunted the effects of burnout. Shortening the length of rotations in a medical ICU from the traditional 14-consecutive day schedule to only seven days reduced reports of burnout by some 40% and increased measures of job fulfillment. Essentially, the reduced the number of consecutive days per rotation allowed sufficient recovery time for clinicians.

These system changes can be a critical adjunct to mindfulness, which remains an important method to build resilience. Often practiced in the context of meditation, mindfulness focuses on the present moment with nonjudgment and a sense of compassion. One of the essential concepts is to interrupt and silence the internal negative voice that can undermine the present and escalate anxiety and stress. (For more information, see the October 2018 issue of Hospital Employee Health.)

Mindfulness exercises are used in more hospitals to combat burnout, but larger system factors also must be addressed, says Lisa Podgurski, MD, medical director of palliative care services at the University of Pittsburgh Medical Center. Podgurski established a short mindfulness-based curriculum within the regular work schedule, focusing on self-care for palliative care providers.

“I got into this as a clinician seeing patients and recognizing certain skills that were helpful in coping with clinical work,” she says. “Some of the things that I turned to personally were not what I had been taught in my professional background. They had more to do with things that I was taught at home. My grandmother used to tell my mother to ‘make sure you keep your mind and your body in the same place.’ That is sort of a very homespun version of the mindfulness message.”

In a study2 of her program, Podgurski and colleagues found that “participants reported high satisfaction with the series and showed statistically significant improvements in dimensions of mindfulness and mindfulness practices, sustained for seven months. Burnout levels in this group were much lower than reported national rates, [but] no statistically significant change was seen in burnout over the study period.”2

Mindfulness practice can improve patient care by helping providers achieve a better mental state and ability to be more present with patients.

“Mindfulness is often touted as an individual approach, but burnout is a group issue to some extent if you look at the data,” she says. “While it is helpful for each of the individuals in a group to build their own skills, that doesn’t necessarily address systemwide issues like the volume of expectations for how many patients they see and time pressures for other things. Mindfulness alone is not sufficient.”

Kimberly J. Templeton, MD, who recently authored research3 on burnout and female physicians, said mindfulness interventions should work for both genders, but the effects are limited and the approach may be sending the wrong message.

“To some degree, we are blaming the victim,” says Templeton, an orthopedic surgeon at the University of Kansas. “We are telling the physician that ‘The reason you are burned out is you don’t take time out to do yoga and mindfulness training,’ when the issue really is that they don’t have time to get done everything that they need to do.”

This feeds into the perception that burnout is an individual problem and not the result of a poorly structured healthcare system, she says.

“The onus should be on the healthcare organization to address burnout because there are issues like working in a culture where sexual harassment and gender bias are tolerated,” she says. “Or, they are working with an electronic health record that is not adapted to the needs of the physicians.”

Physicians can find themselves in “moral distress” when they see a patient in need but face barriers to care. “That leads to stress,” says Templeton. “There is a disconnect between how they would like to practice — the control they would like to have over how they treat their patients — and what they are allowed to do.”

The Joint Commission echoed this point in a recent paper on burnout in nurses, concluding that “mindfulness and resilience training alone cannot effectively address burnout unless the leadership is simultaneously reducing and eliminating barriers and impediments to nursing workflow, such as staffing and workplace environment concerns.”4 (For more information, see related story in this issue.)

The staggering costs of burnout would seemingly support most efforts to prevent it. Economic researchers conservatively estimated in a mathematical model5 that physician burnout is costing the U.S. healthcare system some $4.6 billion annually, due in part to the churn of turnover and reduced clinical hours, says lead author Joel Goh, PhD, a visiting professor at Harvard Business School and a faculty member in the Department of Analytics and Operations at the National University of Singapore.

“We looked at this from a turnover point of view,” he says. “When someone leaves, there are costs associated with that. These include advertising the new position, hiring benefits, loss of a period of productivity, training. All of this is costly. We often call this ‘friction,’ or transactional costs. As has been shown in previous studies, burnout increases risk of turnover. Turnover is a costly event. So, what we are saying is if you reduce that risk of turnover, it reduces the costs.”

The cost analysis is conservative because burnout has ripple effects that are difficult to quantify. These intangibles include reduced quality of patient care, lower patient satisfaction, malpractice lawsuits, and the effect on other members of the care team.

“Intuitively, I believe these are all a major source of costs,” Goh says. “The big problem is that we did not have the data to quantify this. We tried to be as vigorous as we could and used the data that we had in the study. Intuitively, I and my co-authors as well, think these [costs] are pretty large, even if they are not so easily quantifiable.”

There is a need to perform research on individual interventions, but burnout is taking a major toll on the healthcare system, he says.

“Different levels of interventions have different levels of efficacy, so they may not see the level of gains,” he says. “The way we see it is even if you can only reduce a part of it, that is significant. Our study will hopefully encourage people to look into things that can be done to help prevent physician burnout.”

Burnout in Women Physicians

Are women physicians more prone to burnout than their male colleagues? Templeton and co-authors cite studies that show they are, but note a caveat that could affect the findings.

“One of the biggest issues in trying to define this is that there are differences in how men and women experience burnout,” she says. “Women tend to suffer more from emotional exhaustion. Men tend to experience depersonalization. Emotional exhaustion is much easier to identify in yourself and others than depersonalization.”

These are two of the classic categories of burnout in the frequently cited Maslach triad,6 with the third diminished feelings of professional accomplishment. As the name implies, healthcare workers who are emotionally exhausted have no more to give. Depersonalization often manifests as cynicism and a negative attitude toward patients and colleagues.

“I don’t think women are inherently more susceptible to burnout,” Templeton says. “I think it is that they are subjected to more of the factors that can lead to burnout.”

For example, women physicians may lack role models and mentors, face a shrinking number of years to bear children, may not be paid equally to men, may be passed over for promotions to leadership positions, and experience higher rates of sexual harassment, Templeton and colleagues noted in the paper.

“They are more subject to gender expectations, meaning that they’re doing the majority of the work at home,” she says. “There is only so much time in a day for everything they expect themselves to do as well as what their family and society expect them to do. It is less an inherent propensity to burn out, but rather that they are facing more issues that can lead to burnout.”

Defining gender differences in burnout is important because women are comprising a larger proportion of physicians in training. The retention of women will be critical given the predicted physician shortage.

“Women now make up at least half of incoming medical students,” she says. “They are a growing proportion of physicians that are in practice. Not only is it an issue now, but unless we address the system and societal issues that lead to this, we are going to have an even bigger problem down the road.”

A clear majority of women physicians report experiencing gender discrimination, with much of it related to pregnancy or maternity leave, she adds.

“It should extend beyond maternity leave to what I call family leave,” Templeton says. “What are the needs of women physicians over age 60? There are going to be more and more of them, and that is an area that has been neglected up to this point.”

Throughout their lives, women are expected to be the caretakers of their families, she notes.

“A study that we did that we hope will be published soon found that about half of women physicians over the age of 60 were doing some caretaking for somebody,” she says. “We need to expand the discussion to family leave.”

What about delivering clinical care? On average, women physicians spend two minutes more on each patient visit than male physicians and are more likely to explore emotional and psychosocial issues, Templeton and co-authors reported.

“That improves patient care, but there are constraints on the time they are allotted in the clinic,” she says. “You know what is going to benefit the patient, yet you are being told you don’t have time to do that. That gets women really frustrated.”

Women physicians are 2.27 times more likely to die by suicide compared to women non-physicians, the researchers reported.

“We think it is because women know how to do it. They’ve got the expertise to know the lethal dose of drugs, and they have access to them,” Templeton says.

Healthcare institutions should prioritize the mental health of all physicians, with specific tactics employed for women clinicians, she says.

“I think they should bring attention of this to women to let them know about this issue and that it is not something they have to deal with on their own,” she explains. “Hopefully, employee health can provide them some opportunities or help. They can also go through the physician health programs that are in most state medical societies. Women physicians should be told it is OK to seek help. This happens to a lot of women. Don’t just go home and ruminate and think you are going to make it better by working harder, because that only makes it worse.”

REFERENCES

  1. Mikkelsen ME, Anderson BJ, Bellini L, et al. Burnout, and fulfillment, in the profession of critical care medicine. Am J Respir Crit Care Med 2019;Jun 25. doi:10.1164/rccm.201903-0662LE. [Epub ahead of print].
  2. Podgurski L, Greco C, Croom A, et al. A brief mindfulness-based self-care curriculum for an interprofessional group of palliative care providers. J Palliat Med 2019;22:561-565.
  3. Templeton K, Bernstein CA, Sukhera J, et al. Gender-based differences in burnout: Issues faced by women physicians. NAM Perspectives Discussion Paper, National Academy of Medicine, Washington, DC. Available at: https://bit.ly/2WTyx8M.
  4. The Joint Commission. Quick Safety 50: Developing resilience to combat nurse burnout. July 15, 2019. Available at: https://bit.ly/2LEfcDc.
  5. Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med 2019; May 28. doi: 10.7326/M18-1422. [Epub ahead of print].
  6. Maslach C, Jackson SE. The measurement of experienced burnout. J Organiz Behav 1981;2:99-113. doi:10.1002/job.4030020205.