Faced with rising pressures to produce better outcomes at lower costs, the U.S. health care system is making big changes in how it delivers care. The shift is good for patients, but behind the scenes, health workers are burning out at alarming rates.
“This is a significant public health problem, because it affects the functioning of all of our health systems,” Bryan Bohman, MD, senior advisor to the WellMD Center at Stanford Medicine, told The Nation’s Health. “Imagine a problem that affects quality of care, results in high turnover, reduces productivity, destroys people’s personal lives and increases the risk of suicide. That’s what burnout is, except it tends to work undercover.”
In 2007, Kellie Lim, then a fourth-year medical student, checks one of her patients during rounds at the University of California-Los Angeles Medical Center pediatrics ward. New programs are working to address stress in health workers.
Photo by Mark Boster, courtesy The Los Angeles Times/Getty Images
While health care is an inherently high-stress field — after all, life and death are frequently on the line — its workers are reporting worsening rates of burnout, which is often characterized by emotional exhaustion, a low sense of personal fulfillment from work and depersonalization, which makes it harder to connect with patients in meaningful ways.
In 2012, a landmark study in the Archives of Internal Medicine surveyed more than 7,200 U.S. physicians, finding that nearly half reported at least one symptom of burnout, putting doctors at higher risk than other U.S. workers. In 2015, a study published in Mayo Clinic Proceedings found that burnout prevalence went up by 9 percent among U.S. physicians between 2011 and 2014, while remaining stable among other worker groups. In a 2018 report from Medscape that surveyed more than 15,000 physicians across 29 specialties, 42 percent reported burnout.
Beyond burnout, 39 percent of physicians report depression and about 400 physicians die by suicide each year, which is twice the rate of the general population. The suicide rate among women doctors is about 130 percent higher than the general population, while men doctors experience a 40 percent higher rate. Nurses also report high rates of burnout and depression, as well as high rates of post-traumatic stress disorder symptoms.
The high rates impact patient health, with research showing links between burnout and the risk of medical errors and health care-associated infections, as well as patient access, with burnout tied to higher turnover and higher odds of leaving medicine altogether. That is especially concerning, as projections show the country faces a potential shortage of up to 35,000 primary care physicians.
Advocates and researchers say the data point to systemic problems that demand health systems and policymakers more carefully consider how a rapidly changing work environment is driving providers out of the field and into mental distress.
In fact, a number of researchers have called for expanding the field’s guiding “triple aim” framework — which calls for enhancing patient experiences, improving population health and reducing costs — to a quadruple aim, with the additional goal of improving the working lives of health care providers. Some advocates are also calling for stronger policies, such as legislation introduced into the U.S. Senate last year that would set rules around nurse-patient ratios and is modeled after a 2004 California law that resulted in lower nurse burnout rates and greater nurse retention.
“This is no longer just a few people working behind the scenes to address this problem,” said Bohman, a clinical professor of anesthesiology, perioperative and pain medicine at Stanford. “We have America’s attention now and there’s a lot of good work happening to try to identify the problem, prevent it and treat it. But we don’t have a complete playbook just yet.”
Health systems taking action on burnout
Across the country, health systems are taking new steps to better support provider well-being, but research on what works to reduce clinician burnout is still fairly limited. Complicating matters more is that providers often cite work factors, such as excessive work hours and increasing clerical demands, as top contributors to burnout. Such factors are especially difficult to shift while maintaining expanded access to care and meeting new policy- and reimbursement-driven mandates to produce better health at lower costs.
“Many of the changes happening in the system will be better for health care in the long run, but it’s very challenging and the unintended consequence is that it’s putting a tremendous burden on physicians,” National Academy of Medicine President Victor Dzau, MD, told The Nation’s Health, describing the physician burnout trend as “epidemic.”
Dzau co-chairs the academy’s new Action Collaborative on Clinician Well-Being and Resilience, which in March launched the Clinician Well-Being Knowledge Hub, a first-of-its-kind repository of resources and best practices to help health systems combat clinician burnout.
The national collaborative, which rolled out in 2017, has three main goals: better understanding the challenges to clinician well-being, raising the visibility of clinician stress and burnout, and elevating evidence-based solutions. To date, the collaborative has received commitments from more than 150 organizations, including health systems, hospitals, medical schools and state medical boards, to improve clinician well-being and curb burnout.
Collaborative members are tackling the problem from a variety of angles, with much of the work focused on better understanding the problem and pinpointing systemic intervention points. One group, for example, is creating a conceptual model of all the inter-related issues that contribute to provider well-being and resilience, and another is tackling providers’ electronic environments, meeting with electronic medical record vendors on how to make the massive documentation systems more user-friendly. Dzau said one of the collaborative’s next big projects is to issue a report on the systemic nature of clinician burnout and offer recommendations for action.
“We’re dealing in health care with a very challenging situation and we need to come together and think about what’s happening,” Dzau said. “Many people feel like they’ve lost control.”
Collaborative member Lotte Dyrbye, MD, MHPE, a leading researcher in the field and co-director of the Mayo Clinic’s Physician Well-Being Program, said many clinicians experiencing burnout report a loss of meaning and autonomy in their work, with administrative burdens and pressures increasingly pulling them away from the reason they went into medicine in the first place — to care for patients.
“There’s one more field to complete in the medical record or one more question to answer, and that one more thing doesn’t look like a big deal, but the problem is that we have a gazillion one more things,” Dyrbye, a professor of medicine and medical education at Mayo, told The Nation’s Health. “We have a lot of these ‘one more things’ and no one is stepping back and asking what the implications are for the workforce. Are we losing connections with our patients? — which is how we get meaning from our work.”
Key components of Mayo’s Physician Well-Being Program are measuring provider well-being and creating spaces to talk about the problem. Every other year, the program surveys clinicians across the Mayo system about their work environments. The detailed data, Dyrbye said, generates localized action planning and teases out common risk factors. For example, data showed that how well a doctor rates her or his physician supervisor is often an indicator of burnout.
In 2000, nurse practitioner Joan Magit speaks with a patient at a health clinic in Pacoima, California. A greater emphasis on better outcomes at lower costs is putting stress on health workers.
Photo by David Bohrer, courtesy The Los Angeles Times/Getty Images
In response, the Mayo program created leadership scores that display on leaders’ electronic dashboards with a goal of boosting their accountability for clinician well-being. If scores are lacking, leaders are offered coaching to help them improve.
The Mayo program hopes to impact policies and systems outside its walls, too. Dyrbye said the program is working with the Federation of State Medical Boards to change medical licensing questions regarding mental health. In particular, the goal is to focus questions on clinician performance, rather than asking overly broad questions about past and current mental health, which studies show may prevent physicians from seeking treatment.
“The amount of spotlight on this problem gives me hope that we can make some system changes that will advance care for patients while making the work-life balance more manageable for physicians,” Dyrbye said.
Jonathan Ripp, MD, MPH, chief wellness officer at Mount Sinai Health System in New York City, said practicing medicine has always come with emotional and stressful challenges. But like Dyrbye, he said recent shifts toward even more metric-driven, formulaic care delivery is “eroding” the meaningfulness in work that often serves as a protective buffer against clinician burnout.
“I’m not sure this is a new crisis — it’s been brewing for some time — but we’ve seemed to have passed a tipping point where things have gotten worse,” Ripp told The Nation’s Health. “It’s an issue that just about every major health care organization is thinking about.”
At Mount Sinai, Ripp said the system takes an “80-20” approach to the problem, which recognizes that while the bulk of burnout drivers are systemic, work to improve individual resilience can also help, especially if it reaches providers early in their educations and careers. For example, Mount Sinai’s Icahn School of Medicine, where Ripp serves as senior associate dean for well-being and resilience, offers peer support groups for students, runs a mental health clinic focused on medical students and residents, and offers every medical student a wellness visit with a social worker.
Nationally, research shows that compared with peers in other fields, medical students and residents experience higher rates of burnout, which is linked to an increased likelihood of suicidal ideation. The student burnout rates are particularly striking, as studies show medical students often begin their educations with better mental health profiles than their fellow college graduates.
“What’s driving this is a systems issue,” Ripp said of rising burnout. “Some of it can be addressed at the individual level, but even the most resilient person has a breaking point.”
Ripp also co-chairs the national Collaborative for Healing and Renewal in Medicine, which this March co-published a first-of-its-kind charter in the Journal of the American Medical Association that outlines fundamental principles for supporting provider well-being. The charter has been endorsed by more than a dozen organizations, including the American Medical Association and Association of American Medical Colleges.
“Our trainees and providers are our greatest resources,” Ripp said. “If they’re suffering, our system is suffering.”
At Stanford Medicine, the WellMD Center also zeros in on systems issues and offers resources to build individual resilience among providers, residents and students. For example, on the systems side, Bohman said the center is developing leadership training courses to help those in supervisory roles better support provider well-being.
The center is also working with operational leaders to identify early signs of provider distress and expand opportunities for early intervention. For instance, he said if data show a primary care clinician is spending disproportionately more time in the electronic records system than with patients, it could be a sign of problems. The effort, he said, is akin to a public health effort to move upstream to find the roots and early signs of burnout.
On the resiliency side, the center is working to build a community of support for struggling providers. One example, Bohman said, is known as the Camaraderie Project, in which the center provides a small subsidy to a group of physicians to gather for dinner once a month and just talk and connect. In the department where the project was piloted, about half of the doctors signed up to participate, he reported.
Bohman said with so much more attention to the problem of provider burnout, he is “optimistic” that health systems can continue improving the value of patient care and still turnaround rising burnout trends.
“Burnout is one of the biggest occupational health risks that health providers face,” he said. “We helped create this burnout crisis because there’s rightly a lot more pressure to improve care. But we can’t accomplish those goals if we ignore the wellness of the people who care for patients.”
Provider burnout is explored during a number of sessions at APHA’s 2018 Annual Meeting and Expo, which convenes Nov. 10-14 in San Diego. To view sessions, visit the meeting’s online program, at www.apha.org/annualmeeting, and search for “burnout.”
In 2013, internal medicine doctor Nathan Samras pauses while consulting with an HIV-positive patient in Washington, D.C. Stress and burnout in health workers is a growing concern.
Photo by Chip Somodevilla, courtesy Getty Images
For more information about health worker burnout and mental health, visit www.nam.edu.
- Copyright The Nation’s Health, American Public Health Association
