Chronically high levels of physician distress are creating a dangerous practice environment. Interventions to help reduce clinician burnout need to occur at multiple levels to make our health system safer.
by Michael R. Privitera, MD, MS; Franziska Plessow, PhD; and Alan H. Rosenstein, MD, MBA
The stressors that cause burnout may vary from profession to profession, but the human condition that results is common to all. Burnout is defined by three factors:
- Physical and emotional exhaustion despite attempting to rest
- Depersonalization including dysfunctional coping mechanisms, cynicism, sarcasm, and compassion fatigue
- An objective and/or subjective lack of efficacy
Burnout is a frequent phenomenon across many health care professions, including nursing, medicine, pharmacy, social work, and other roles. Research on physician burnout shows lower levels of patient satisfaction, job satisfaction, and productivity; higher levels of medical errors, malpractice claims, leaving medicine, and early retirement; and higher personal levels of depression, heart disease, suicide, divorce, and substance abuse.
The average burnout rate among doctors in the US has been estimated to be 46%, while only 2% to 4% of physicians are disruptive in the workplace. In many cases of disruptive behavior, burnout from high chronic occupational stress has been found, suggesting a direct relationship between the two. The Joint Commission has issued a sentinel event alert warning that disruptive behavior can compromise patient safety and foster medical errors.
The biopsychosocial model was coined by George Engel to encourage consideration of biological, psychological, and social contributions to and consequences of clinical conditions. Applying this approach, we can see commonalities in cause and inter-relationships between physician burnout, altered safety of medical decision-making, and disruptive behaviors. Social components (health care reform environment, consequent occupational stress when unharmonized and uncoordinated) interact with psychological (rationality in decision-making, emotional control) and biological aspects (intrinsic biology of the physician and changed biology of their body from chronic high levels of stress), which then impacts the community that needs sufficient health care workforce to take care of patients.
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Many national, state, government, insurance company, and regulatory agencies separately make mandates that affect the workflow of the physician. However, there is no central agency that oversees their coordination, let alone the harmonizing of these multiple mandates. While expected, it is not known whether full compliance with all mandates is possible.
Patient: 60-year-old male smoker, new patient to the practice with headache, fatigue, and disturbed sleep, comes in to see a hyper-stressed, burned out physician for a 20-30 minute slot. BP 148/92 Pulse = 96.
Physician behavior: The physician acts based on habit memory, i.e., reflex reactions, hyper-focuses on one symptom—sleep—instead of required cognitive flexible memory involved in pros and cons analysis. Regulatory demands require the physician to counsel on stopping smoking, make sure all Meaningful Use criteria are checked and reviewed, complete new patient history form, populate problem list, cover alcohol and drug use, immunization, preventive measures, and send for old record.
Resulting treatment: Sleep medication with refills, low sodium diet, return visit in 6 months for full physical.
What was missed: Major depressive episode. Insomnia was only one of the symptoms. Patient had suicidal ideation, intent, and plan to kill himself. As a result of poor functioning from his depression, he was about to lose his job. The physician missed the patient’s increased risk of stroke and heart disease from his major depressive episode especially in combination with smoking.
Lack of coordination to unify and simplify health care regulation and mandates draws the physician’s limited cognitive resource away from the intrinsic load being used to solve the clinical problem presented by the patient. The trouble is that no one would argue or attempt to push back when something gets labelled as a “quality” intervention due to the so-called halo effect. The halo effect is a cognitive/confirmation bias where positive feelings get generated toward something ambiguous or unproven. In this case, a quality initiative may lose closer scrutiny to potential impact just because it has the term “quality” attached to it (e.g., a person is wearing a halo, thus this person must be good).
|| "We as a health care system
need to be concerned about
how much occupational stress
we are imposing on physicians
and other health care professionals
from extraneous cognitive load."
Chronically high levels of physician distress are creating a dangerous practice environment. The irony is that a portion of this distress comes from uncoordinated, unharmonized, and sometimes unproven “quality measures,” which by accumulation actually may be humanly impossible to attain and may even cause harm. Cognitive processes that occur because of excessive stress can lead to medical errors. This neurocognitive issue can be identified as a neurocognitive ergonomic (NCE, sometimes referred to as neurocognitive engineering) problem and is solvable by incorporating NCE principles with new initiative roll outs. Ergonomics is the applied science concerned with designing and arranging things people use so that the people and things interact more efficiently and safely (also called biotechnology, human engineering, human factors). Neurocognitive ergonomics applies ergonomic principles that use knowledge of brain function and thinking processes to lower cognitive strain and improve efficiencies.
We as a health care system need to be concerned about how much occupational stress we are imposing on physicians and other health care professionals from extraneous cognitive load. Our society has made the connection between cognitive workload and the safety of recipients of services in such professions as nuclear power workers, air traffic controllers, airline pilots, and others. It is becoming clear that physicians, nurse practitioners, physician assistants, and nurses need to be on this list for both their own and the patient’s safety.
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Burnout is both preventable and reversible, which gives us an opportunity to provide support on two levels:
- The individual level, by promoting clinician’s physical and mental health
- The institutional level by decreasing sources of occupational stress through improved design, improving efficiencies of workflow, finding ways as an organization to reduce administrative burden on clinicians, and allowing bottom-up input in decisions that affect the practice environment
Urie Bronfenbrenner describes an ecosystem model that is relevant to conceptualizing the health care ecosystem. Various levels interact with each other and create feedback systems affecting the other levels:
a) Macro-level—national, state, insurance industry level decisions
b) Meso-level—health care system level decisions
c) Micro-level—individual physician and patient interaction in delivery of care
d) Exo-level—the interaction of physician with his or her family and with others in the community.
Interventions to help reduce burnout need to occur at all four levels to help more rapidly reduce the extent of burnout that exists.
In summary, there are certain things that we cannot take away from the cognitive workload of physicians that are intrinsic and germane to the practice of medicine. What we can change (by better design) is to be very careful and parsimonious about administrative, mandate, and regulatory demand. (See Table 1 below for suggestions for safer implementation of innovations in health care.) We can do a better job of being clearer and selective about what the essential and relevant quality issues are, what should be universally used, and what should be only indicated by the clinical situation, especially when implementing innovations in the health care system. We need to bear in mind the physical, emotional, time, and cognitive limitations that humans (who happened to be trained as physicians) have. In doing so we will be improving the safety of our health care workforce, which then is inextricably linked to the safety of our patients.
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Suggested Questions for Safer Implementation of Innovation in Health Care:
- Is there evidence that what we are suggesting as a new innovation in healthcare delivery—by itself—does not cause harm and in fact creates enough benefit to be worth the risk of imposing it on a currently time-challenged, overburdened, and burned-out healthcare workforce?
- Has the new innovation in delivery accounted for existing demands on the physician plus any new demands put upon them by other agency new innovation demands?
- Has there been sufficient collaboration between authoritative agencies with each other and the front-line providers of care, being respectful of each other’s concerns and intentions?
- Are there built in fail-safe mechanisms with the innovation to allow for mid-stream corrections in course? This requires the implementation of the suggestions in Question 3.
Conceptual Issues for Discussions:
- Awareness of down-steam consequences that occur by accumulation of unharmonized duties
- Efforts to assess and recognize potentially negative impact on delivery of physician services before policy decisions are agreed upon
- Efforts for stakeholder agencies to better coordinate plans and logistics
- Need for health care organizations to provide sufficient resource services (career/ business/ administrative/ clinical/ behavioral) to lower occupational stress and Burnout of physicians by assisting them with innovation rollout and ongoing operations
- Are there ways in the meantime to have authoritative sources of mandates and regulations to attempt a collaborative effort? The goal would be to pare down the total cognitive load on the physicians to a safer level
Have you participated in any efforts or programs to reduce burnout among physicians and other health professionals? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.
About the Authors:
Michael R. Privitera, MD, MS, is professor of psychiatry and director of the Medical Faculty and Clinician Wellness Program at University of Rochester Medical Center, Rochester, NY.
Franziska Plessow, PhD, is with the Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA.
Alan H. Rosenstein, MD, MBA, is an educator and consultant in health care management based in San Francisco, CA.
Submit correspondence about this article to Dr. Privitera at Michael_Privitera@urmc.rochester.edu