Address burnout with a caring, nurturing environment
Expert: To promote patient safety, make physician wellness/wellbeing a priority
It’s understandable that emergency physicians are particularly vulnerable to burnout. The long hours, unending stress, and immense responsibilities that go along with the job can take a toll. However, too often physicians are unwilling or unable to recognize that they need help. And in these circumstances, it’s left to colleagues or administrators to intervene — hopefully before patient care is impacted.
While being alert to the signs or symptoms of burnout is critical, experts stress that hospital and ED leaders can make even greater headway against this occupational danger by pushing further upstream to decrease the likelihood that burnout will occur in the first place. They acknowledge that changing the culture of such a busy, high-stress environment isn’t easy, but note that a caring, supportive workplace can deliver multiple dividends — not just to patients and providers, but also to a hospital’s bottom line.
Consider the signs
Researchers have consistently found that burnout is common among medical providers. For example, when a national sample of more than 7,200 physicians agreed to take the Maslach Burnout Inventory, a survey tool used to measure burnout, nearly half (45.8%) reported at least one symptom of burnout.1 Further, researchers found the highest rates of burnout among clinicians who work on the front lines — especially emergency providers. Well over half of the emergency providers participating in this study (65%) reported symptoms of burnout.
However, in tackling the issue, it is important not use the term "burnout" too broadly, explains Gloria Kuhn, DO, PhD, the vice chair for academic affairs in the Department of Emergency Medicine at Wayne State University in Detroit, MI. Kuhn, who has looked into the issue of burnout with colleagues, notes that working too many hours may result in fatigue, but that alone does not constitute burnout. A key distinguishing factor of burnout is disappointment in a relationship or relationships with others, she explains. "People may then distance themselves from those relationships and that situation almost as a protective mechanism," observes Kuhn. "And a third component is a feeling that what they have accomplished is not worthwhile."
Burnout is a concern on many levels, not least of which is the fact that it can prompt good emergency clinicians to second-guess their chosen profession. Ricki Bander, PhD, a Los Angeles, CA-based psychologist who frequently works with physicians who are experiencing burnout, says many report that they want to leave medicine completely. "Their attitude is no longer one of wanting to help or wanting to be involved. The caring, warmth, and compassion — things we associate with doctors and healers — are no longer evident," she says. "Rather, they become more cynical, more sarcastic, and they may avoid work. They may get irritable, impatient, and moody."
Bander notes that there may also be physical changes in physicians who are burned out. "They are exhausted all the time, they don’t look well, and there may be changes in their weight or appetite," she explains. "They may be having trouble sleeping and there may be increased family issues. Some people on the extreme have difficulties in how they are handling food, alcohol, and drugs, so presuming that they didn’t have problems with these things before, you may now suddenly start to see and suspect issues."
Kuhn adds that physicians who are burned out may order more tests and prescriptions rather than interact with patients and families. "They may be terse or abrupt, and they may start downplaying patient complaints," she says. As a result, patients may be less inclined to follow through with instructions. "There may be a whole host of things that are contributing to a change in [provider] behavior, but it is one of the things that an administrator might start noticing in a formerly compliant and really good physician [who is experiencing burnout.]"
Unfortunately, for many physicians, the pathway to burnout has been established long before they begin seeing patients. "Even though some medical schools and residencies now prescribe curriculums and core values around work-life balance, the culture of medicine is to overwork, to self-sacrifice, and to put yourself last," explains Banda. "That tends to start early in medical school and people learn the culture."
Even the process of getting into medical school requires greater studiousness than many other career paths, so multiple things get delayed in order to become a physician, adds Banda. "There is a cumulative effect of stress, and people don’t necessarily recognize the toll that it is taking on them," she says. "However, in the physician world, there is a lot of reluctance to admit that you are having trouble or you aren’t enjoying your work, or that you are feeling less confident in your work."
As a result, rather than ask for help, physicians tend to muscle through their difficulties in a "maladaptive way," which can have negative repercussions on safety, patient care, medical decision-making, and their own health, explains Banda. "It is a process that starts early on but the people who manifest the problem are typically in their 40s," she says.
Talk about it
As the founder of Physicians Helping Physicians, a Richmond, VA-based group that works with physicians who are considering career transitions, Michelle Mudge-Riley, DO, MHA, hears from physicians who are struggling with burnout all the time. They tell her that lack of autonomy, the regulatory environment, and escalating responsibilities are all contributing to their stress levels and dissatisfaction with their work. "At the end of the day, physicians know they have to do some of that stuff. They are just not feeling that sense of accomplishment in their careers and what they are doing," she says. "That is what is really driving that burnout, and people don’t really talk about that."
Consequently, Mudge-Riley notes that a first step in confronting the issue is to make burnout a safe topic for discussion. "There has to be an understanding that it is not shameful and that a person is not a failure if they are feeling this way," she explains. "Being willing to talk about this and being aware that it is probably in your facility are very important pieces of this."
One way to get the issue of burnout out into the open is to have a physician generate a discussion about burnout, perhaps using a recent article or published research on the topic to get the conversation started, suggests Mudge-Riley. "Physicians will talk to each other," she says. "Everyone understands the background or life of another doctor, so I think that is the best way to start to combat this because once someone is willing to listen and willing to talk, then solutions can be identified."
Another way to encourage such discussion is to make it a policy to link incoming physicians who are new to the health care system or to the department with a mentor who can bring them up to speed on the culture of the organization, who the medical leaders are, and how to get involved, suggests Bander. The idea is to establish an ongoing relationship of trust between colleagues. "The mentor doesn’t have to be someone in administration. It could be someone involved with clinical leadership who understands the physicians’ goals and desires," she explains. "That is the person physicians will speak to about work-related problems they are seeing."
When such relationships are established early on, along with a culture of caring and collaboration, physicians are less inclined to feel isolated when problems arise, says Bander.
Prioritize physician wellness and well-being
A big issue with physicians these days is that many of them feel like they are not being heard by the hospital administration, observes Bander. This adds to their stress level and makes them feel like their thoughts don’t count, she says. To counter this impression, Bander encourages hospital administrators and clinical leaders to make sure that when patients write letters of thanks to the hospital for the care that they received, these messages get passed along to the providers involved. "It is really important for physicians to hear that thank you, and if it comes from the CEO or the leader of the ED — whoever received the letter — it makes a huge difference," she says.
Further, when physicians make the case that they need more ancillary staff or other resources, administrators should give such requests a fair hearing. "The argument [against such requests] is often around costs but it will cost you more if a physician’s productivity drops or they leave," says Bander. "One of the reasons why hospitals should want their physicians to be happy, healthy, satisfied people is because turnover is remarkably costly."
The types of incentives that corporations now commonly provide to employees to engage in preventive health activities should definitely be available to physicians because they tend to delay their own health care, observes Bander. "Have a dialog to find out what would help them get [to the gym] and then follow up," she says. "If there was [a fitness center] on site that was just dedicated to physicians at certain hours, they would use it, and that is a big thing for work-life balance."
Bander has a consulting contract with one health care system that regularly sends physicians to see her for a work-life balance check-up. "I see the physicians every year, so if they have troubles in between those appointments they are identified and they have extra sessions with me," she says. It is an ongoing relationship that helps physicians make adjustments or work through issues before they become larger problems, adds Bander.
Even small things — like making sure that healthy food is readily available so that providers don’t have to rely on chocolate bars to sustain themselves through a long shift — can make a difference, especially in hectic settings like the ED, says Bander.
While such steps contribute to the health and well-being of physicians, they also send the message that the physicians are valued. "If you are promoting the goals of physician health, physician retention, and patient safety, I think you have to do what it takes," stresses Bander. "That sometimes means considering things that are more costly in the short term, but over the long term balance out or maybe even result in greater dollars."
Create a supportive environment
Kuhn emphasizes that it is the job of administrators to create as supportive an environment as possible, and to have open lines of communication with the physicians and nurses. "When a complaint comes in, find out both sides of the story without automatically blaming the physician or concluding that the physician was wrong," she advises. "Also, I have not noticed that we have a good support system for physicians who are experiencing a grief reaction because of a bad patient outcome. We also don’t have good support for physicians who are involved in litigation, and these things do tend to contribute to burnout."
Administrators need to be particularly careful with schedules so that providers have time to recover from long shifts before returning to work, adds Kuhn. She suggests that administrators enable as much self-scheduling as possible so that providers have the ability to work around important personal- or family-related activities. Giving providers more autonomy over when they work may create new challenges when trying to put together a budget, but Kuhn stresses that health care leaders need to take a larger view.
"Everybody is concerned about patient safety, but very few people are concerned about physician wellness," says Kuhn. "The question is how do you create a healthy, safe environment for patients, and you do that by creating systems that support all the personnel involved."
- Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among U.S. physicians relative to the general population. Archives of Internal Medicine 2012; 172:1377-1385.
- Ricki Bander, PhD, Psychologist, Los Angeles, CA. E-mail: firstname.lastname@example.org.
- Gloria Kuhn, DO, PhD, Vice Chair for Academic Affairs, Department of Emergency Medicine, Wayne State University, Detroit, MI. E-mail: email@example.com.
- Michelle Mudge-Riley, DO, MHA, President, Physicians Helping Physicians, Richmond, VA. E-mail: firstname.lastname@example.org.