Lia Logio, MD, FACP, in a new role as Chair of Medicine at Drexel University College of Medicine, believes helping clinicians realize the importance of self-care can help mitigate burnout at the institution level.
“Part of the challenge in today’s health care environment is carving out time — time to connect with colleagues and pursue hobbies,” Logio says. “There is so much erosion of personal time for clinicians that their own time to connect and feel part of a community gets put on the back burner.”
In a recent NEJM Catalyst Leadership survey, Immunizing Against Burnout, the great majority (83%) of respondents consider burnout within their organizations a serious to moderate problem. Logio, who has served as a program director for residency and internal medicine programs at multiple institutions over more than 2 decades, finds this “unsurprising”; she deals with burnout every day. She believes the solution lies in a partnership between the organization and the individual. Our survey results show that 82% of respondents believe interventions should be targeted at the organization, while nearly half say the individual.
Although burnout has been “elevated to commonplace,” Logio says, it is still difficult to get people to assess their own burnout status, which, in turn, makes it difficult for the organization to help. “There is this very strong self-efficacy sentiment for physicians,” she says, sharing the story of a physician who, after hearing her speak about burnout, came to her office and broke down in tears. “He said to me, ‘Do you realize how hard it is for me to admit to myself that I can’t do this?’” Logio says. In our survey, practicing self-care ranks as the top tool that individuals can use to reduce burnout, indicated by half (51%) of respondents.
Elizabeth Harry, MD, Assistant Program Director of the Internal Medicine Residency Program at Brigham and Women’s Hospital in Boston, studies cognitive load and believes burnout is intricately related to an increase in the complexity of things that clinicians deal with on a daily basis, including EMRs. Although she appreciates the flexibility of being able to chart from home so she can spend more time with her family, there is a clear downside to technology.
She points to alert fatigue as an example. “The amount of data received is increasing logarithmically to where it’s not unusual for frontline clinicians to get multiple alerts while trying to admit a patient,” she says. This problem can’t be solved simply. “Everything introduced or taken away has a web of complexity so thick that when you change one node, you don’t know what else it changes and what consequences will occur down the way. It’s known as a wicked problem.”
Like Logio, she considers burnout a shared responsibility between organizations and individuals. She likens the condition to the various stages of heart failure, saying it’s important to identify and treat the problem early on. “With heart failure, we treat patients who are at risk before they have heart failure. We should do the same with burnout,” she says. “You don’t want to get to Stage B, where the clinician starts compensating for burnout symptoms; Stage C, where they start to suffer anxiety and depression; or Stage D, where they have suicidal ideation. You must create a culture where you make it easy for physicians to do the right thing and get help.”
Logio sounds a similar note. “Most people who commit suicide have mental health problems, and those problems can either be mitigated by the culture of the organization or they can be exacerbated by sleep deprivation and other clinician demands,” she says.
In Moriarity, New Mexico, Roger Felix, MD, is a staff physician at the three-clinic New Mexico Medical, a family practice and urgent care group that mostly serves an underserved population. He says the problems that lead to clinician burnout in his region are threefold: poor reimbursement, the nature of rural medicine, and the lack of medical expertise among schedulers.
“Everything in New Mexico is spread out and it’s hard to get care to the people, so physicians wind up doing more than we would normally do,” he says. He fits patients in, making sure to give them all the treatments they need while they are in the office and spending as much time as necessary with them. “We still don’t get reimbursed enough for primary care,” he says, which strains his group when patients need a little more care during their visits.
Some of that could be overcome with better scheduling, he says. “They give short visits to folks who should have long visits and vice versa,” which, he says, “blows up his day.” Offloading clerical tasks, as 54% of respondents suggest as a tool to reduce burnout, wouldn’t help him, because he uses his documentation time as an opportunity to review the care he provided and think of other ways to help each patient.
A primary care physician herself, Logio also has felt the internal pressure of changing requirements. She says the things that motivate physicians — autonomy, mastery, and purpose — are being chipped away at in the new world of medicine.
Overscheduling is a widespread and growing problem, she says. “Some docs say to me, ‘I can’t go to grand rounds because I’m expected to see 12 patients and I’m behind on my patient visits.’ It’s become about numbers and efficiency and how fast you can do things — not about how well you do them.”
Innovative programs like cross-training could help, where people are taken out of their day-to-day work and exposed to something new, Logio says. For instance, at a pharmaceutical company she visited, the management team encouraged workers to spend a portion of their work day in other divisions.
Aside from human welfare, there is also a business case for tackling burnout, Harry says. Brigham and Women’s is a self-insured institution, so paying for preventative care makes sense to avoid employees taking sick days or experiencing at-risk behavior. Burnout causes high turnover, she adds, which is even more expensive considering that “the cost of replacing a physician is so high.”