Addressing and Overcoming Burnout in Clinical Practice

W. Clay Jackson, MD, DipThClinical Assistant ProfessorDepartments of Family Medicine & PsychiatryUniversity of Tennessee College of MedicineMemphis, Tennessee

Founder and President of MidlevelUNurse PractitionerEmergency Services NetworkMidlevelU, LLCNashville, Tennessee

Erin Tolbert, MSN, FNP-C

Disclosure• The faculty have been informed of their responsibility to disclose to the

audience if they will be discussing off-label or investigational use(s) of drugs, products, and/or devices (any use not approved by the US Food and Drug Administration).

• Applicable CME staff have no relationships to disclose relating to the subject matter of this activity.

• This activity has been independently reviewed for balance.

The Hero of Modern Medicine

McKevitt C, et al. J R Soc Med. 1997;90(9):491-495.

“Illness doesn’t belong to us. It belongs to them, the patients.”

A Typical Day20 (-ish) patients

19 calls17 e-mails12 Rx refills20 lab reports11 radiographs14 specialty reports93 ancillary tasks

Richard BaronRabin RC. A growing number of primary-care doctors are burning out. How does this affect patients? The Washington Post. March 31, 2014. McKevitt C, et al. J R Soc Med. 1997;90(9):491-495.

“Doctors need to be taught to be ill.

We need permission to be ill and to acknowledge

that we are not superhuman.”

Burnout by Specialty

Peckham C. Physician Lifestyle Report 2015. www.medscape.com/features/slideshow/lifestyle/2015/psychiatry. Accessed July 9, 2018. Shanafelt TD, et al. Arch Intern Med. 2012;172(18):1377-1385.

20,000+ Surveys28 Specialties

“front-line” of patient careinterface of technology with mortality

A Smoldering Burn

Peckham C. Physician Lifestyle Report 2015. www.medscape.com/features/slideshow/lifestyle/2015/psychiatry. Accessed July 9, 2018.

Severity of Burnout: 1 = “does not interfere with my life”

to 7 = “so severe that I'm thinking of

leaving medicine”

Burnout vs Depression

Vocational Global

3 Core Characteristics of Burnout

Maslach C, et al. Journal of Occupational Behaviour. 1981;2:99-113. Shanafelt TD, et al. Arch Intern Med. 2012;172(18):1377-1385.

EmotionalExhaustion

Low Senseof Personal

Accomplishment

Depersonalization

38%

12%

29%

Burnout

Maslach C, et al. The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It. San Francisco, CA: Josey-Bass; 1997:13-15.

What people are doingWhat people are expected to do

What people are expected to do

“an erosion of the soul”

A Pre-Modern Voice

“That physician will hardly be thought very careful of the health of his

patients if he neglects his own.”

—Galen130–200 CE

What Causes Burnout?

Peckham C. Physician Lifestyle Report 2015. www.medscape.com/features/slideshow/lifestyle/2015/psychiatry. Accessed July 9, 2018.

Scale: 1 = “not at all important”

to 7 = “extremely important”

Does Type of Practice Affect Burnout?

Shanafelt TD, et al. Am J Med. 2003;114(6):513-519.

Academic Faculty37%–47%

Private Practice55%–67%

Boredom, Anxiety, and Flow

Massimini F, et al. Am Psychol. 2000;55(1):24-33.

SKILL SKILL SKILL

CHALLENGE CHALLENGE CHALLENGE

Boredom FlowAnxiety

Sources of Burnout—Further Evidence• Workload• Specialty choice• Practice setting• Patient characteristics• Sleep deprivation

• Personality type• Methods of dealing with death,

suffering• Malpractice suits• Lack of control over work

environment• Methods of dealing with mistakes• Work-life balance conflict

Freeborn DK. West J Med. 2001;174(1):13-18. Ramirez AJ, et al. Br J Cancer. 1995;71(6):1263-1269. Deckard GJ, et al. J Infect Dis. 1992;165(2):224-228. Linzer M, et al. Am J Med. 2001;111(2):170-175. Colford JM Jr, et al. JAMA. 1989;261(6):889-893. Lemkau JP, et al. J Med Educ. 1988;63(9):682-691. Meier DE, et al. JAMA. 2001;286(23):3007-3014. Charles SC. West J Med. 2001;174(1):55-58. McMurray JE, et al. J Gen Intern Med. 2000;15(6):372-380. Blendon RJ, et al. N Engl J Med. 2002;347(24):1933-1940. Campbell DA Jr, et al. Surgery. 2001;130(4):696-702.

Work-life interference more contributory than work problems or home problems alone.

Burnout Rates by Age: It Gets Better

Peckham C. Physician Lifestyle Report 2015. www.medscape.com/features/slideshow/lifestyle/2015/psychiatry. Accessed July 9, 2018. Freeborn DK. West J Med. 2001;174(1):13-18. Gabbe SG, et al. Am J Obstet Gynecol. 2002;186(4):601-612. Campbell DA Jr, et al. Surgery. 2001;130(4):696-702. Johns MM 3rd, et al. Laryngoscope. 2005;115(11):2056-2061.

Same decrease in burnout with advancing age observed in other studies:• Kaiser physicians• Chairs of Ob/Gyn• Surgeons• Chairs of ENT

Psychiatrists

Burnout by Career Stage: Beware the Ides• US physicians; all specialties (N=7288)• Early Career (n=1583); 0–10 yr; mean age 38

• Hrs worked 52.5 Nights on call 1.9 Home/work conflict 59%• Highest rate of depersonalization; lowest satisfaction of career choice

• Mid Career (n=1634); 11–20 yr; mean age 49• Hrs worked 54.6 Nights on call 2.5 Home/work conflict 52%• Highest rates of emotional exhaustion, burnout• Lowest satisfaction with specialty choice and work-life balance

• Late Career (n=3906); > 20 yr; mean age 61• Hrs worked 50.2 Nights on call 2.3 Home/work conflict 36%

Dyrbye LN, et al. Mayo Clin Proc. 2013;88(12):1358-1367.

A Mid-Career Cautionary Tale?

Gunderman R. For the Young Doctor About to Burn Out. The Atlantic. February 21, 2014. www.theatlantic.com/health/archive/2014/02/for-the-young-doctor-about-to-burn-out/284005/. Accessed July 9, 2018.

Professional burnout is the sum total of hundreds and thousands of tiny betrayals of purpose, each one so minute that it hardly attracts notice.

—Richard Gunderman

Work-Life BalancePersonal vs Professional

Quill TE, et al. Arch Intern Med. 1990;150(9):1857-1861.

“Physicians who sacrifice their personal lives during training believe they will reap the rewards of a balanced life after graduation.”

A Dream Deferred

Osler W. Albany Med Ann. 1899;20:307-309.

“Engrossed late and soon in professional cares… you find, too late, with hearts given way, that there is no

place in your habit-stricken souls for those gentler influences which make

life worth living.”

—William Osler

The Effect of Burnout on Women Physicians• US physicians 34% female (2016)• Physician Worklife Study

• Non-surgical primary and subspecialty docs; N=6k• Female physicians 60% more likely to report burnout• Odds of burnout increase by 12% to 15% per +5

hours/week worked in addition to 40 hours/week

• Female physicians have increased vulnerability to specific factors

• Sexual harassment• Majority of domestic responsibilities

Young A. Journal of Medical Regulation. 2017;103(2):7-21. http://jmr.fsmb.org/Archive/2010s/A%20Census%20of%20Actively%20Licensed%20Physicians%20in%20the%20United%20States%2C%202016.pdf. Accessed July 9, 2018. McMurray JE, et al. J Gen Intern Med. 2000;15(6):372-380. Gautam M. West J Med. 2001;174(1):37-41.

“The problem for doctors is that they receive information but not a true education.”

—Bernie Siegel, MD

Spickard A Jr, et al. JAMA. 2002;288(12):1447-1450.

Compulsiveness:• Self-doubt• Guilt• Exaggerated personal responsibility

Adaptive for medical educationMaladaptive for life

Considerations for NPs and PAs

1. NP/PA-Specific Burnout Research2. Key Contributors to Burnout 3. Incentives to Change 4. Practical Tips for Reversing a Culture of Burnout

NPs/PAs: What Does the Research Show?• Deficit of NP/PA specific research concerning burnout• Most research that does exist centers around job satisfaction rather than

burnout• Literature reviews indicate NPs/PAs have “minimal to moderate”

levels of job satisfaction • “Available time, pace of work in NP jobs, potential lack of perceived

collegiality in certain NP/PA employment settings” and general unhappiness with the “everyday environment of patient care in which NPs find themselves” were cited as reasons for job dissatisfaction

• Role expansion of NPs and PAs +/- affects burnout

Hoff T, et al. Med Care Res Rev. 2017 Sep 1;[Epub ahead of print].

NP/PA Role Expansion and Burnout• Role expansion – a strategic necessity for health care system and viewed favorably by

these professions on a macro scale• Significant implications for feelings of job satisfaction, burnout, and work-related

stress• Two possibilities:

• Job Enrichment Theory – more complex work and roles, such as increased task variety and task autonomy, enhance worker motivation while producing positive worker responses to their jobs, expressed in feelings such as improved job satisfaction and reduced burnout

• Increased Stress/Burnout – Increased job demands lead to frustration about ability to feel empowered, and exhibit lower job satisfaction, increased burnout, and greater role strain; role expansion becomes internalized by the workers less as a favorable opportunity for themselves and more as something externally put upon them, characterized by heavier and faster moving workloads, some work that may be beyond perceived capabilities or competencies, and increased expectations by the organization

Hoff T, et al. Med Care Res Rev. 2017 Sep 1;[Epub ahead of print].

Can Non-MDs Provide Equivalent Care?• 11 randomized clinical trials and 23 observational studies

• Patient satisfaction highest for patients seen by NPs• Comparable outcomes between NPs and physicians

• Health status• Prescriptions• Return visits• Referrals• Appropriateness of diagnostic studies ordered and interpretations of X-rays

• NPs • Spent more time with their patients• Offered more advice/information• Had more complete documentation• Had better communication skills than physicians

Horrocks S, et al. BMJ. 2002;324(7341):819-823.

Can Non-MDs Provide Equivalent Care?• Review of 37 published studies

• Compared NP outcomes with those of physicians• Outcomes comparable

• Patient satisfaction• Patient perceived health status• Functional status• Hospitalizations• Emergency department visits• Biomarkers such as blood glucose, serum lipids, blood pressure

Newhouse RP, et al. Nursing Economics. 2011;29(5):1-22. www.nursingeconomics.net/ce/2013/article3001021.pdf. Accessed July 9, 2018.

Education vs Reality• NPs and PAs theoretically can manage about 80% to 90% of the care

provided by primary care physicians• But…they may have just 5% to 10% of the number of clinical practice

hours as part of their education• The result? Job stress, dissatisfaction, and frustration

Provider Education Comparison(the process)

Provider Education Comparison(actual clinical experience)

Systemic Factors• The problem – providers want to help people• System not set up to help people

• Often rewards more care and not necessarily better care (fee-for-service model)

• Employers feel increasingly pressured by regulations, changes in reimbursement rates

• Often, employers address this problem by passing these stressors on to providers; incentivize based on metrics (eg, productivity-based compensation)

• The results? • Job dissatisfaction• Stress• Ultimately burnout

Examples…“Exhausted”“Stressed out”“No help”“Leave it all behind’“Overwhelming”

Why Should Employers Care about Burnout?1. Influences recruitment and retention 2. Affects productivity of team3. Affects quality metrics4. Affects patient satisfaction5. Ultimately, affects bottom line ($)!

Do Burnout, Depression, and Satisfaction Affect Patient Care?Maslach Burnout Inventory (22 items)

• Internal medicine residents; N=115; 76% met criteria for burnout• Self-report of suboptimal patient care 53% if burned out; 21% if not

• Depersonalization only factor that demonstrated correlation, dose-response relationship

• Not emotional exhaustion• Not low sense of personal accomplishment

Shanafelt TD, et al. Ann Intern Med. 2002;136(5):358-367.

Do Burnout, Depression, and Satisfaction Affect Patient Care?Maslach Burnout Inventory (22 items)

• Surgeons; N=7905; 9% reported major medical error in last 90 days• Work factors associated with errors (P<.05)

• Younger age (49 vs 52 yrs)• Longer work week (63.5 vs 58.9 hrs/wk)• More time in OR (18.2 vs 17.1 hrs/wk)• More night call (2.8 vs 2.6 nights/wk)

• Personal factors associated with errors• Burnout domains

• Emotional exhaustion each 1 point increased likelihood of reporting error by 11%• Depersonalization each 1 point increased likelihood of reporting error by 5%• Personal accomplishment each 1 point decreased likelihood of reporting error by 4%

• Depression screen (+)• 28% in those not reporting errors• 55% in those reporting errors

Shanafelt TD, et al. Ann Surg. 2009;250(3):463-471.

Do Burnout, Depression, and Satisfaction Affect Patient Care?

• Physician satisfaction affects—• Prescribing habits• Test ordering• Patient adherence• Patient satisfaction

Melville A. Soc Sci Med Med Psychol Med Sociol. 1980;14A(6):495-499. Schmoldt RA, et al. HMO Pract. 1994;8(2):58-63. DiMatteo MR, et al. Health Psychol. 1993;12(2):93-102. Haas JS, et al. J Gen Intern Med. 2000;15(2):122-128.

Clinician Turnover—High Rates; High Costs• Annual turnover levels for acute care NPs and PAs found in one national

survey to be between 8% and 11% • In primary care, annual turnover rate for NPs and PAs is approximately

12% (double that observed for primary care physicians)• Cost of replacing one FP: $357k (estimated 2018 dollars)

• Replacement costs of clinician range 1.5 to 2× annual salary• Direct costs• Lost revenue

Hoff T, et al. Med Care Res Rev. 2017 Sep 1;[Epub ahead of print]. Buchbinder SB, et al. Am J Manag Care. 1999;5(11):1431-1438.

Words to Live By… and to Practice By

Peabody FW. JAMA. 1927;88(12):877-882. Candib LM. Medicine and the Family. New York, NY: Basic Books; 1995.

“The secret of caring for the medical patient is in caring for the medical patient.”

“The secret of the care for the patient is caring for oneself while caring for the patient.”

The Bias of Medicine: The Focus on Health as the Absence of Illness Rather than the Presence of Wellness

Articles in the last 115 years of psychologic literature:• Depression 70,000• Anxiety 57,000• Life satisfaction 5700• Happiness 2958• Joy 851

Majority of interface with physician health, function arises from impaired physician population

Myers DG. Am Psychol. 2000;55(1):56-67. Yamey G, et al. BMJ. 2001;322(7281):252-253.

Increasing Physician Well-Being: The Evidence

Warde CM, et al. J Gen Intern Med. 1999;14(3):157-165. Weiner EL, et al. West J Med. 2001;174(1):19-23. Lemkau J, et al. Fam Pract Res J. 1994;14(3):213-222.

Marriage Spirituality Children

Connection Matters!

Peckham C. Physician Lifestyle Report 2015. www.medscape.com/features/slideshow/lifestyle/2015/psychiatry. Accessed July 9, 2018.

The Power of Giving Back

Peckham C. Physician Lifestyle Report 2015. www.medscape.com/features/slideshow/lifestyle/2015/psychiatry. Accessed July 9, 2018.

What Docs Do to Turn Down the Heat• Survey of wellness practices of 130 primary care physicians

• Religious or spiritual practices• Spending time with family, friends• Self-care• Adopting a healthy philosophical outlook• Setting limits at work• Finding meaning at work

Weiner EL, et al. West J Med. 2001;174(1):19-23. Spickard A Jr, et al. JAMA. 2002;288(12):1447-1450.

“Work is not merely a domain of energy expenditure but also of energy renewal.”

Organizational Practices Promoting Clinician Wellness• Promoting clinician autonomy*• Providing adequate support services, resources*• Cultivating a collegial work environment*• Being value-oriented• Minimizing work-home interference• Promoting work-life balance

• JCAHCO/The Joint Commission: All organizations must have a process to address physician well-being

Shanafelt TD, et al. Am J Med. 2003;114(6):513-519. Freeborn DK. West J Med. 2001;174(1):13-18.

*These factors were found to predict physician burnout in a large Kaiser study

Mentorship• 74% of employers believe providing mentorship to physicians helps

reduce turnover• Only 56% assign a mentor to new physicians• Mentorship should include:

• Responding to questions• Observation• Procedural training• Patient panel selection

Misra-Hebert AD, et al. Am J Med Qual. 2004;19(2):56-66.

Practical Tips for Preventing Burnout in NPs/PAs1. Recognize level of training/education2. Meet the clinician where he/she is3. Compensation structure that rewards desired behaviors4. Provide real-time mentorship5. Give role clarity with specific expectations6. Reinforce growth and achievement (stop assuming)

How Common is Depression among Physicians?• One-quarter Canadian practicing MDs (N=3213) reported 2-week period

of depressed mood• More common in female physicians, GPs

• First 2 months 2014 to 2015: 2 NYC intern suicides• 740 interns; 13 US hospitals

• First 3 months of training: • Incidence of depression rose from 3.9% to 27.1%• Suicidal ideations increased 370%

Compton MT, et al. Compr Psychiatry. 2011;52(5):542-547. Goldman ML, et al. JAMA Psychiatry. 2015;72(5):411-412. Sens S, et al. Arch Gen Psychiatry. 2010;67(6):557-565.

A National Tragedy: Physician Suicide

Wible PL. Physician Suicide 101: Secrets, Lies, and Solutions. November 13, 2014. www.medscape.com/viewarticle/834434. Accessed July 9, 2018. Shrira I. The occupation with the highest suicide rate. August 1, 2009. www.psychologytoday.com/blog/the-narcissus-in-all-us/200908/the-occupation-the-highest-suicide-rate. Accessed July 9, 2018. Sibert KS. Burnout: the perfect storm of physician stress. August 5, 2013. www.kevinmd.com/blog/2013/08/burnout-perfect-storm-physician-stress.html. Accessed July 9, 2018.

• Greater stress, burnout• Social isolation • Access to powerful drugs• Barriers to getting treatment/stigma• Women – Greater role conflict and sexual harassment

400 per yearBUT WHY?

Risk Factors for Suicidal Ideation among Physicians• Patient demands• Patient complaints• Role conflicts• Lack of control over working conditions• Degrading experiences (eg, harassment)• Conflict with coworkers

Lindfors PM, et al. Acta Anaethesiol Scand. 2009;53(8):1027-1035. Fridner A, et al. Gend Med. 2011;8(4):269-279. Fridner A, et al. GendMed. 2009;6(1):314-328. Wada K, et al. Int J Behav Med. 2011;18(4):384-390. Bourne T, et al. BMJ Open. 2015;5(1):e006687.

Completed Physician Suicide: Contributing Stressors• Not statistical predictors (ie, the usual suspects)

• Conflict with current, former intimate partner (OR 1.08; CI 0.73–1.59)• Problems in another relationship (OR 0.91; CI 0.49–1.69)• Physical health problem (OR 0.90; CI 0.64–1.25)• Financial problems (OR 0.81; CI 0.50–1.31)• Legal problem (OR 0.94; CI 0.49–1.83)• Suicide of family member in past 5 years (OR 1.83; CI 0.67–5.00)

Gold KJ, et al. Gen Hosp Psychiatry. 2013;35(1):45-49.

Completed Physician Suicide: Contributing Stressors• Less likely (clinicians are good at managing crises)

• Crisis in last 2 weeks (OR 0.61; CI 0.41–0.90)• Death of a friend or family member (OR 0.37; CI 0.15–0.90)

• More likely (clinicians strongly identify with work role)• Job problem (OR 3.12; CI 2.10–4.63)

Gold KJ, et al. Gen Hosp Psychiatry. 2013;35(1):45-49.

American Balint SocietyAn Organization Dedicated to Improving Clinician Wellness

www.americanbalintsociety.org.

Vision Statement…relationships of profound trust, such as those between physicians and patients…creative engagementwith trusted peers in a safe environment…so that patients and clients are increasingly heard, supportedand empowered to become healthier and happier.

“‘Grinning and bearing it’ is not an acceptable coping mechanism.”

—Starla Fitch, MD

Tools for Assessing Burnout, Resiliency• Maslach Burnout Inventory Human

Services Survey for Medical Personnel (MBI-HHS-MP)

• $2.50 per copy; minimum purchase 50 copies

• WHO-5 Wellness Scale• Free PDF at www.who-5.org

Identify Areas of Control

When possible, arrange schedules to reduce

pressure

Plan for lunch breaks with colleagues

Cultivate Meaning and Purpose in Life

Focus on empathy and emotional connection to

patientsFocus on how you make a

positive difference

Volunteer

Stay Connected to Others

Talk to colleagues about professional rewards and

challenges

Seek out supportive and trustworthy friends

Refresh or Broaden Skills

Consider a CME course on resilience

Seek a mentor or offer to be a mentor

Practice Self-care

Develop a hobby

Target one lifestyle behavior to improve (eg, exercise)

Ways to Avoid Burnout

Miller MN, et al. Psychiatric Times. 2010. http://pro.psychcentral.com/strategies-to-avoid-burnout-in-professional-practice/00144.html. Accessed July 9, 2018.

Practical Steps You Can Take Next Week

Practical Take-Aways• Burnout must be openly and actively addressed as it plays a role in the

clinician health and patient outcomes• Actively implementing personal and organizational burnout prevention

practices can mitigate risks• Use the MBI or WHO-5 to assess burnout or resiliency

• The stigma of mental illness is magnified among health care professionals, who may underreport mental health challenges

• Stressors that threaten the professional role are particularly important in predicting clinician suicide

• “Doing no harm begins with one’s self.”

Spickard A Jr, et al. JAMA. 2002;288(12):1447-1450.

“Although we work in a system that is broken, our work is not broken.”

—Rachel Naomi Remen, MD