Signatories: Maryam S. Hamidi, PhD, Associate Director of Scholarship & Health Promotion, Stanford School of Medicine, WellMD; Mickey Trockel, MD, PhD, Director of Scholarship & Health Promotion, Stanford School of Medicine, WellMD; Elizabeth C. Lawrence, MD, Director, Office of Physician and Student Wellness, UNM School of Medicine; Karim Awad, MD, Medical Director, Clinician Wellness, Atrius Health; Jennifer Berliner, MD, Medical Director of the Office of the Chief Medical and Scientific Office, UPMC; Keri J. S. Brady, MPH, PhD candidate, Health Services Research, Department of Health Law, Policy & Management, Boston University School of Public Health; Vanessa Downing, PhD, Director, Content Development & Training, Center for Provider Wellbeing, Christiana Care Health System; Jessica C. Dudley, MD, Chief Medical Officer, Brigham and Women’s Physicians Organization; Elizabeth Harry, MD, Assistant Medical Director, Faculty Development and Wellbeing, Brigham and Women’s Physicians Organization; Cormac A. O’Donovan, MD, FRCPI, Director, Peer Support Program, Wake Forest Baptist Health; Thomas J. Savides, MD, Chief Experience Officer, University of California San Diego
Our modern health care system has birthed an ongoing crisis of suffering, as clinicians face ever-worsening stressors caring for patients in a system that remains challenging for provider and patient alike.
Rapid technological evolution, a disorganized patchwork of regulations and policies, and misaligned incentives have created an inefficient and ineffective health care system that lacks coherent strategy or design. This system often serves its patients poorly while simultaneously disregarding the needs of its workers.
As a result, brilliant, dedicated clinicians experience increasingly intolerable work-related distress. This distress is not a result of personal weakness or failure. Practicing medicine is an honor and a privilege that affords the opportunity to help people when they are at their most vulnerable. However, when the ability to care for patients is compromised by the system itself, clinicians experience moral injury or moral distress. When the ability to care for themselves is also compromised by the system, clinicians experience physical and psychological injury as well.
Informed and compassionate leadership is sorely needed to reverse this trend. For both practical and ethical reasons, health care institutions must develop new economic models that place far greater priority on clinician well-being. These models can only succeed through cultivating rather than exploiting the medical professional workforce that serves as part of the bedrock of the industry. Indeed, in order to provide high-quality, compassionate, and sustainable patient care, health care leaders must invest in high-quality, compassionate, and sustainable support to the very clinicians and other health care workers who provide that care. Thus, the health care industry must expand the Triple Aim of enhancing patient experience, improving population health, and reducing health care costs to include the fourth aim of improving the work life of health care workers.
Reviewing the Terminology
The term moral injury describes the devastating impact on healers when they are unable to provide the quality of care that they have pledged to give to their patients. This term has gained recent attention in social media as it invokes the full intensity of clinicians’ distress without implying that clinicians are themselves to blame. However, while moral injury represents a major source of occupational distress, the term fails to fully capture the wide panoply of challenges that clinicians experience today, with their myriad causes.
Work-related distress can occur even when clinicians know they are providing excellent care. Even in the best of circumstances, patients sometimes suffer and sometimes die, and good clinicians suffer alongside patients when there are bad outcomes. Such anguish is intrinsic to the practice of medicine as a calling. Other stressors are neither inherent nor necessary to good medicine. Stressed clinicians can experience loss of joy in work, compassion fatigue, and work exhaustion. They sometimes experience more generalized distress due to sleep deprivation, depression, loneliness, anxiety, illness, or injury. Severe occupational distress can contribute to substance use disorder, and in extreme cases, self-harm or suicide. Terminology that captures the broad range of these experiences adds value to our understanding — and points to solutions.
There is great benefit in continuing to include the term burnout in our lexicon. We share others’ concerns regarding its inappropriate use — especially when it may be used to blame clinicians for their own suffering. Indeed, clinician wellness programs have, at times, overlooked the importance of system change by focusing initiatives solely on bolstering personal resilience. We also recognize the utility of terms such as operational stress injury, which have been explicitly coined to avoid blaming the sufferer. Nevertheless, abandoning the term burnout because of misguided usage would be shortsighted; half a century of research on burnout has helped pave the way for the systems-based reforms that clinicians so desperately need.
The term burnout refers to an occupational syndrome described by Herbert Freudenberger in 1974, and has inspired a large body of research by organizational scientists across workers of all fields and occupations. The World Health Organization recently recognized burnout as a well-defined occupational phenomenon related to chronic workplace stress. There are currently more than 14,000 manuscripts on the topic recorded in PubMed alone, with many additional thousands of papers published in the social science and organizational science literature. This rapidly growing field of research has generated two critical insights:
- The occupational distress being experienced by clinicians is largely precipitated by a dysfunctional work environment. It is neither a failure of personal resilience nor a medical condition; and
- Clinician burnout affects not only clinicians, but also negatively impacts patients, staff, and health systems through multiple mechanisms including adverse effects on quality of care and reductions in the physician workforce.
A Need for Organizational Improvements
This intense scientific and programmatic attention to clinician burnout highlights the need for organizations to improve the work lives of clinicians. The literature on burnout, vitality, and well-being offers guidance on where to focus efforts to better meet the needs of patients and clinicians. A widely used model developed at Stanford postulates that efforts to enhance professional fulfilment should focus on improving efficiency of practice, enhancing the culture of wellness, and supporting personal resilience. This framework and others (e.g., AMA’s STEPS Forward) help delineate priorities for improvement across these domains.
Efficiency of practice encompasses operational changes such as better-designed electronic health records and information systems, adequate staffing, team-based models of care, and sufficient clinical resources. Respect for clinicians’ time necessitates crafting reasonable job expectations and adhering to them, and eliminating hours of work that are invisible, unaccounted for, and often create little meaning or value. Common sense also dictates adoption of reasonable quality measures alongside elimination of documentation and regulatory requirements that do little to benefit patients. Workflow design should allow all team members to operate at the top of their license with the goal of ensuring that clinicians are able to maximize distraction-free face-to-face time with patients.
Enhancing the culture of wellness requires prioritizing clinician well-being alongside other institutional priorities. Health systems should invest in regular, rigorous assessment of clinician well-being based on reliable, well-defined, properly benchmarked measures, and should share the results institution-wide together with other measures of well-being and professional satisfaction at both the individual and organizational level. These metrics should incorporate principles of diversity, respect, equity, and fairness as important dimensions of well-being. Institutions should adopt specific goals for improvement in clinician well-being on a par with other institutional performance measures. To attain these goals, health systems must solicit clinician input on major enterprise decisions and demonstrate a commitment to responding to that input in substantive ways.
Legislators and regulators share in the responsibility of improving working conditions for clinicians by ensuring that clinicians are not penalized for seeking mental health care. Licensure applications should be crafted so as not to discourage clinicians from seeking this support for fear of negative consequences to their license. Treatment of clinicians with substance use disorders should adhere to best practices, prioritizing the protection of patients without unnecessarily punitive policies or reprisals toward clinicians. Similarly, clinicians should have access to stigma-free opportunities to process the occupational stress of chronic exposure to death and suffering, whether through peer support programs or professional mental health services. Formal processes should be developed such that clinicians can support each other when patients have unexpected outcomes without fear of discoverability and medicolegal consequences.
Legislators and health care industry leaders also have a role to play in a culture of wellness by advocating for more robust services to address the underlying social determinants of health that often leave clinicians feeling helpless to properly care for their patients. Clinicians cannot combat these forces alone; they need legislative and societal partners to help address diseases rooted in homelessness, untreated mental illness, substance related disorders, lack of paid family leave, food insecurity, and other social ills.
Supporting personal resilience requires an ongoing organizational commitment to a healthy work environment. Health care systems should reduce the barriers that clinicians can face in meeting their simple physical needs at work: food, hydration, sleep, bathroom breaks, and physical safety. On-site fitness facilities, streamlined medical appointments, resources to learn resilience techniques like mindfulness, and enabling decompression opportunities to gather and build community are other ways that organizations can support clinicians in maintaining their health.
Building on Successes and Bending the Arc of Change
In many ways, the essential work of transforming the health care system has already begun, led by physicians, advanced practice providers, nurses, social workers, psychologists, patients, educators, administrators, and others. Through their efforts, health care organizations and society share a growing understanding of the costs and a commitment to addressing this global problem of clinician burnout. Emerging evidence shows early signs of improvement in clinician well-being that buttresses the hope for further improvement.
To build on these early gains and successfully transform the health care industry, we need new financial and operational models that prioritize clinician well-being. All stakeholders — individually and collectively, on an organizational and a national level — must be accountable for addressing the root causes of burnout. Like quality and safety, marketing, and financial strategies, the well-being of health care professionals must become a permanent agenda item at leadership, staff, faculty, and finance meetings. In addition to addressing the current challenges, health care leaders must remain alert to new and emerging barriers to clinician well-being, with attention to both threats and opportunities for improvement.
As one of our authors, Dan Marchalik, MD, noted in a recent commentary in The Lancet, “A successful approach to addressing burnout must be preemptive — a mindful modernization that considers the well-being implications of technological, economic, and administrative changes before they are implemented.” It took time for the health care industry to arrive at this high-stress state, and it will take time to recover. Now is the time to bend the arc of change toward high-quality, sustainable care that is compassionate to all.