Analysis of the second NEJM Catalyst Insights Council Survey on the Leadership theme. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.
For the first time since NEJM Catalyst began surveying our Insights Council members, there is overwhelming concurrence on an issue: 96% of executives, clinical leaders, and clinicians agree that physician burnout is a serious or moderate problem in the health care industry.
Let that sink in: 96%.
Physician burnout has gained notoriety of late, in part because of two Mayo Clinic–AMA studies (co-authored by TS) that showed rates of burnout among responding physicians at 54% in 2014, a 10% increase from 2011.
Burnout is a syndrome of depersonalization, emotional exhaustion, and a sense of low personal accomplishment. Physicians often develop burnout incrementally due to chronic increases of stress, inefficiency, and excessive workload.
A Widespread Problem Without Responses
Despite increasing recognition of the problem and intense media coverage, when asked what their organization is doing to address the issue of physician burnout, many of the NEJM Catalyst survey respondents replied “nothing,” “not enough,” “paying lip service,” and “talking about the problem in committees but no action plan yet.”
The NEJM Catalyst survey reveals something of a disconnect between how respondents perceive the problem in the industry as a whole versus in their own organization. While two-thirds (65%) of respondents say physician burnout is a serious problem across health care, just over one-third (35%) rate it likewise in their own organization.
Are respondents fooling themselves about their own workplaces? Two-thirds (65%) of respondents say a quarter or more of the physicians they know personally are burned out.
While it seems no region of the country is spared from the problem, more Council members in the Northeast (46%) say burnout is a serious problem within their organizations than those in the West (32%), Midwest (31%), and South (31%).
NEJM Catalyst Council members cite decreased quality of care, which scores 63%, as the top reason to address burnout. Clinicians (67%) are more adamant than executives (57%) about this ranking. Well below that concern, at 38%, is the effect on the attitude of the rest of the health care team. Physician burnout creates an unsafe environment and can be contagious among team members.
The least cited reason to address burnout is physician suicide (indicated by 8% of respondents). This is a concerning number given the severity of the outcome. Approximately one physician commits suicide each day in the United States.
VERBATIM COMMENTS FROM SURVEY RESPONDENTS
What is your organization doing to address the issue of physician burnout?
“The first step is to recognize the issue. That is just beginning.”
“Lots of talk, not much action.”
“Improving EMR Usability, trying to transfer tasks to other members of health care team.”
“Mostly lip service. I’m constantly reminded of how differently administrators and physicians see the world.”
“Discussion and scheduled time off.”
“Mindfulness training / resilience training.”
“In theory, working on job doability by creating teams to share the work.”
“Trying to improve the focus on providing more efficient, cost-effective, patient-centered health care — a very difficult task with far too many bureaucratic, non-patient care barriers.”
“Improve staff training to better assist the physician. Improve data accessibility.”
“Presentations to physicians and staff, but administrative denial.”
“Very little. Within our group, we have created a ‘relaxing’ or ‘time out’ zone to take a break. We are also trying to equally manage and control workload.”
“Working to support acceptance of the changes occurring within and from without the profession. If they would lead more of the change and shape it, it would feel less of a burden.”
“Aggressively telling us to get over it or leave. It’s very hostile.”
“Enlighten the masses to the fact it is a real thing, and establishment of the fact that contrary to belief physicians are subject to the limitations of a normal human being!”
Clerical Burden Is the Leading Cause
Pinning down the cause of burnout is difficult because many personal and professional factors contribute. For the purpose of this survey, we focused on the day-to-day workload factors that can contribute to physician burnout.
Respondents rate “increased clerical burden,” which is heavily influenced by expanded and more comprehensive use of electronic health records, as by far the biggest cause. In their current form, EHRs disrupt the workflow that many physicians have established over years in their practices, forcing them to carry their workload into off-hours, or “pajama time,” as it is often termed.
Ironically, one of the hopes for EHRs has been to improve the quality of care through improved documentation and measurement, yet it appears that quality may instead be decreasing because of the burdensome nature of EHR-related work.
A higher percentage of executives (72%) than clinicians (59%) point to increased clerical burden as the top issue behind burnout. Respondents say their organizations are solving some of these problems by using scribes for certain documentation tasks and redesigning EHR systems to align better with physician workflow.
More than half of survey respondents say increased productivity requirements/expectations contribute to burnout. Untenable payment/reimbursement models and erosion of professionalism tie for third in the results at 21%. Although excessive metrics score less than 20% as a contributing factor, metrics could be considered a sub-dimension of the increased clerical burden.
How Providers and Professional Organizations Can Respond
With a physician shortage under way and demand for access on the rise, health systems, hospitals, and physician practices can’t afford to lose valuable clinical talent. Some physicians who experience burnout choose an exit strategy such as retirement (early/accelerated attrition in some cases), part-time practice, or leaving practice altogether for other industries such as insurance or pharmaceuticals.
It’s time for the health care system to address the problem of physician burnout. To begin, leaders must understand the state of their organization’s physicians, through a staff survey or other method of assessment. Once the level of burnout/well-being is assessed, leaders can begin to correct processes and introduce programs to intervene. Measure again, and organizations can assess whether the changes are making a difference.
While the majority of change has to come from within each organization, there is room for guidance from national and professional organizations such as the American Medical Association or American College of Surgeons. More than a third of survey respondents say such organizations should lobby to reduce regulations for medical documentation and other clerical work. Just over a quarter want to see these organizations encourage best practices for EHR/health IT design and use.
The health care industry as a whole — regulators, payers, EHR vendors, medical centers, and physicians — must work together to alter the burnout trajectory for physicians before it worsens and further jeopardizes patient care.
METHODOLOGY AND RESPONDENTS
In October 2016, an online survey was sent to the NEJM Catalyst Insights Council, which includes U.S. health care executives, clinical leaders, and clinicians at organizations directly involved in health care delivery. A total of 570 completed surveys are included in the analysis. The margin of error for a base of 570 is +/- 4.1% at the 95% confidence interval.
The majority of respondents were clinicians (49%), followed by clinical leaders (28%) and executives (23%). Most respondents described their organizations as hospitals (37%) or health systems (16%). These hospitals were predominantly midsized (34% had 200–499 beds) or larger (49% had 500 or more beds).
Only 7% of respondents indicated that their major affiliation was with a physician organization. Those physician organizations tended to be big — 56% had 100 or more physicians.
Nearly three-quarters of the organizations (73%) were nonprofit, with the remainder of respondents coming from for-profit organizations. Every region of the country was well represented.
Join the NEJM Catalyst Insights Council and contribute to the conversation about health care delivery transformation. Qualified members participate in brief monthly surveys.