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Welcome to PREVENTING CLINICIAN BURNOUT:
PERSONAL AND PROFESSIONAL ISSUES AND PLANS
Presented by: Mark Linzer, MD, FACPThe presentation will begin shortly
This webinar will be recorded and used for future presentations.
Funds for this webinar were provided by the U.S. Department of Health and Human Services (HHS), Health Resources and Services
Administration (HRSA) with the American Recovery and Reinvestment Act (ARRA) funding for the Retention and Evaluation Activities (REA)
Initiative.
This webinar is being offered by the California Statewide AHEC program in partnership with the Office of Statewide Health Planning and Development
(OSHPD), designated as the California Primary Care Office (PCO).
Center for Patient and Provider Experience at
WELCOME EVERYONE!
Thank you for joining us today
Raising your hand to ask a question
Sending Notes
Muting your phone
Preventing Clinician Burnout: Improving the Provider and Patient
ExperienceMark Linzer MD
General Internal Medicine Center for Patient and Provider Experience
Hennepin County Medical Center
Center for Patient and Provider Experience at
Research supported by Federal Agency for Healthcare Research and Quality (AHRQ)
No conflicts of interest
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1. Identify features of a healthy work environment and how to create one.
2. Discuss ideas of self-care to protect against burnout.
3. Process collaborative approaches to develop and maintain a healthy workplace.
Objectives
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Burnout is in the news…
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New York Times, 6-17-08“It will take real structural change in the work environment for physician satisfaction to improve. Fortunately, the data show physicians are willing to put up with a lot before giving up.”
Mark Linzer, Madison, WI
Physician Worklife Study Funded by Robert Wood Johnson Foundation
1996-98: national survey of >5000 MDs Findings:
◦ Satisfaction promoted by long term relationships with patients
◦ Time pressure diminished satisfaction◦ Stress related to lack of work control◦ Burnout predicted by work-home interference
Linzer. J Gen Intern Med. 2000;15(7):441-50.
Research Base
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Burnout model
SexAgeChildrenSolo practiceAcademic practiceWork hours
Stress
Satisfaction
Work control
Work-home
interference
Home
support
Background variables
Mediating variables
Variableoutcomes
Burnout
From Linzer M. Am J Med 2001; 111:170-75.
Center for Patient and Provider Experience at
Funded by AHRQ; 2002-2006 119 PC clinics; 422 MDs; 1785 patients. To determine relationships between work
conditions, physician reactions (stress and burnout) and patient care (quality and errors).
Linzer M, et al. Ann Intern Med 2009;151:28-36.
MEMO study: aligning physician and patient
outcomes
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MEMO Study conceptual model
Structure
Culture
Workflow
Policies,
processes
Patient
demands
Satisfaction
Trust
Quality of care
Medical errors
Satisfaction
Stress
Burnout
Intent to
leave
WorkplaceCharacteristic
s
Physician Reactions
PatientOutcomes
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Measuring Quality
Up to 6 patients per primary care physician with diabetes and/or HTN
Assess: Patient satisfaction
Quality of life
Disease management
Patient Survey
Chart review
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Confidential chart reviews for errors in processes of care (e.g., wrong medications, missed preventive activities)
Determining Errors
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50% need more time for visits 27% burning out or burned out 30% moderately likely to leave job in 2
years Strong relationships between work
conditions (time pressure, work control, chaos, organizational culture) and physician satisfaction, stress, burnout, intent to leave
Many patient care outcomes linked to work conditions
MEMO results: physician outcomes
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MEMO Results: patient care
Variable Outcome p-value
Moderate to high work control
Higher diabetes care quality
<0.05
Time pressure Lower overall quality
Poorer care for HTN patients
<0.05
<0.05
Linzer et al. Ann Intern Med 2009
Center for Patient and Provider Experience at
MEMO Results: patient care
Variable Outcome p-value
Information and communication emphasis
Higher overall quality
Better HTN quality care
<0.05
<0.01
Values alignment
Better diabetes care quality
Fewer prevention errors
<0.001
<0.01
Linzer et al. Ann Intern Med 2009
Center for Patient and Provider Experience at
Percent providers reporting... Your clinic (n= providers) Comparison (n= providers)
Work control (high) 25% 68%
Job satisfaction (high) 37% 68%
Alignment of values with leadership (strong) 42% 70%
Workplace chaos 65% 40%
Time pressure ( high) 65% 30%
Stress (high) 80% 39%
Burnout (high) 50% 30%
Intent to leave practice within 2 years 65% 15%
The first column of numbers provides data specific to your clinic. The second column reports comparison data from __ primary care clinics from your site. Patients whose data are reported in this document have hypertension and/or diabetes.
Office & Work Life Feedback
W L
Mock OWL (problematic setting). OWL construct discussed in Linzer M et al. Ann Intern Med. 2009;151:28-36.
Mock OWL (problematic setting). OWL construct discussed in Linzer M et al. Ann Intern Med. 2009;151:28-36.
Practice data… Your clinic (y/n) Comparison clinics (n= )
Technology Electronic medical record 100% 75%
Computerized lab results 75% 75%
Computerized patient notes 75% 90%
Computerized medication lists 50% 85%
Computerized problem lists 50% 85%
Patient communication via email/MyChart
100% 75%
Resources Staffing ratio (RN+LPN+MA / MD+NP+PA) 1.2 1.7
Exam rooms per physician 2.2 2.7
Bottlenecks _X_Yes __No Phone access _X_Yes __No Exam room wait
(your clinic only) _X_Yes __No Follow-up appointments _X_Yes __No Interpreter access
_X_Yes __No Patient check-in/check-out __Yes _X_No Insurance approvals/pre-authorizations
_X_Yes __No Scheduling tests __Yes _X_No Pharmacy services
The first column of numbers provides data specific to your clinic. The second column reports comparison data from __ primary care clinics from your site. Patients whose data are reported in this document have hypertension and/or diabetes.
Office & Work Life Feedback
W L
Randomized trial of QI interventions to improve work conditions and care quality
34 clinics in Rural WI; Chicago; NYC Use OWL to measure work environment and
patient outcomes at baseline and after 6-12 months in intervention and control sites
Current AHRQ grant: Creating Healthy
Workplaces
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Clinics shown their OWL data and comparison clinics data
Data spurred meaningful conversations and movement towards solutions
Activated managers may be key link to clinic transformation
The power of the data
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Harvard Business School: stocks rose 147% when employee satisfaction rose
In 7900 businesses: productivity and income tied to employee satisfaction
Sears: when employee satisfaction rose 4%, sales increased by $200 million, with a rise in customer satisfaction
Job satisfaction: business case
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(Brown & Gunderman. Acad Med 2006;81:577-82)
Outcomes of dissatisfaction
Burnout Linzer et al. Am J Med 2001;111:170-75.
Turnover: $250,000/departing physician Buchbinder et al. Am J Manag Care 1999;5:1431-8
Instability (larger patient load for remaining providers)
Brown & Gunderman. Acad Med 2006;81:577-82
Reduced patient: 1) access to care, 2) satisfaction, 3) medication adherence
Linn et al. Med Care 1985; 23:1171-78; DiMatteo. Health Psychol 1993;12: 93-102
Increased patient disenrollment Brown & Gunderman. Acad Med 2006;81:577-82
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Prevalent (20-40%) in practicing physicians (Linzer. Am J Med. 2001;111:170-75), higher in medical students (Dyrbye L. Ann Intern Med 2008;149:334-41).
Associated with perceived errors by medical housestaff (West C. JAMA. 2009;296:1071-78)
1.6 x higher in women physicians than men Mediated by home support, work control, and
work-home balance (Linzer et al. Am J Med 2001;111:170-5)
Present in 46% of US MDs (Shanafelt T. Arch Intern Med 2012)
Burnout: long-term stress reaction
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Demands balanced by control Stress increases if demands rise or
control diminishes Support can facilitate impact of control:
more support, less stress Bottom line… support and work control
prevent stress
Demand-control model of job stress
(Karasek et al. Am J Public Health 1981;71:694-705)
Demands Control Support
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US vs Netherlands: Less gender difference in burnout in Netherlands due to a) fewer work hours and b) better work control in women vs men MDs
(Linzer et al. J Am Med Women’s Assoc 2002;57:191-3)
More burnout in US women MDs due to gendered expectations for listening
US women MDs describe faster pace, less values alignment with leadership (Horner-Ibler et al. J Gen Intern Med 2005; 20(s1):194)
Gender differences in burnout
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MEMO study looked at relationship between EMR functionality and stress, burnout and dissatisfaction.
Two findings: ◦ Burnout and dissatisfaction increased as EMR
functions increased; then decreased as EMR became fully functional – but not to original levels.
◦ In fully functional EMRs, shorter visits associated with more dissatisfaction, burnout, intent to leave.
(Babbott. JGIM, abstract, 2011)
Burnout, Dissatisfaction and the EMR
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Career fit: If % time clinicians are able to do what they
are most passionate about falls below 10%, burnout rises dramatically (>50%).
Thus, be sure clinicians have time (at least 10%) to devote to what they care most about (“career fit”)
(Shanafelt T. Arch Intern Med. 2009;169(10):990-995.)
One more burnout predictor
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Flexible/part-time work (Linzer. Acad Med 2009;84:1395-1400)
Leaders model work-home balance; value well-being (Saleh. Clin Orthop Relat Res 2009;467:558-65; Dunn. J Gen Intern Med 2007;22:1544-52)
Promote work control; limit EMR time outside office; provide sufficient time to use it inside
Alter our “culture of endurance” (Viviers. Can J Ophthalmol 2008;43:535-46)
How can we prevent burnout?
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Less time pressure, more control Extend appt times, or offload non-clinician work “Desk top” slots during sessions Time to catch up (2 hrs?) after vacation/leave
More order, less chaos Maximally utilize space Pilot unique schedules: “7 on, 7 off”
Support for work-home balance Support part-time practice and practice styles
supportive of parents of young children
A healthy work environment
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Creating healthy work environments
Build forms work into practice
flow
Don’t wait until
the end of the day
Respect the lifecycle
Hire float
clinicians to
cover parenta
l/sick leaves
Build workplace
teams
Address work
flow and quality
measures
MDs, APPs, MAs, RNs,
Pharm Ds
Supportive Culture
Be sure values
are aligned (betwee
n clinician
s and leaders)
Take time to listen
Action often not
needed
Kenny C. Transforming Health Care: Virginia Mason Medical Center's Pursuit of the Perfect Patient Experience, CRC Press; 1 edition (November 8, 2010).Linzer M, Respecting the lifecycle: rational workforce planning in a section of general internal medicine. Am J Med. 2002;113: 443-48.
Time to:◦ Reflect together on challenging cases
◦ Exercise 3-4 x per wk
◦ Eat all meals
◦ Complete work at work
◦ See a patient, listen, provide empathy, attend to quality measures, and use the EMR
◦ Huddle with your team (who can help with all of the above)
◦ Meet with leaders and discuss values, direction and purpose
Wellness in work life
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Hard workers; usually at more than their FTE
Loyal, connected, good morale Patient satisfaction is high Full time clinicians may wish to go part time
(e.g. for children, end of career)!
Mechaber H et al. J Gen Intern Med. 2008;23(3):300-3.
Remember part-time physicians are key:
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1. Overall, I am satisfied with my current job:
Strongly disagree Disagree Neither agree nor disagree Agree Agree strongly
2. I feel a great deal of stress because of my job
Strongly disagree Disagree Neither agree nor disagree Agree Agree strongly
3. Using your own definition of “burnout”, please circle one of the answers below:
1. I enjoy my work. I have no symptoms of burnout.2. I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out.3. I am definitely burning out and have one or more symptoms of burnout, ex. emotional exhaustion. 4. The symptoms of burnout that I’m experiencing won’t go away. I think about frustrations at work a lot. 5. I feel completely burned out and often wonder if I can go on. I am at the point where I may need to seek help.
4. My control over my workload is:
1 – Poor 2 – Marginal 3 – Satisfactory 4 – Good 5 – Optimal
5. Sufficiency of time for documentation is:
1 – Poor 2 – Marginal 3 – Satisfactory 4 – Good 5 – Optimal
6. Which number best describes the atmosphere in your primary work area?
Calm Busy, but reasonable Hectic, chaotic 1 2 3 4 5
7. My professional values are well aligned with those of my department leaders:
Strongly disagree Disagree Neither agree nor disagree Agree Agree strongly
8. My professional values are well aligned with those of our organizational leaders:
Strongly disagree Disagree Neither agree nor disagree Agree Agree strongly
*This survey was developed by Dr. Mark Linzer (Division Director, General Internal Medicine) and his team at Hennepin County Medical Center in Minneapolis MN as part of his ongoing research in Clinician Worklife and Satisfaction. Disclaimer-this is adapted from the OWL (Office and Work Life™ measure); more detailed surveys are often needed for second stage work.
Mini-OWL
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1. Visible site for clinician wellness2. Wellness Champions in each setting3. Periodic, brief surveys of stress, burnout
and remediable predictors4. Focused action plans to promote wellness5. Role for managers – oversee the wellness
focus and transformation
One way to get there – Create an Office of Professional Worklife and Wellness
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Been a privilege to share our research with you. Thank you for listening and
participating!
Thank you
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