The quality and safety of patient care, and indeed the very vitality of our health care systems, depend heavily on high-functioning physicians. Yet recent data have revealed an extraordinarily high — and increasing — prevalence of physician burnout, defined as emotional exhaustion, interpersonal disengagement, and a low sense of personal accomplishment. In light of compelling evidence that burnout negatively affects patient care, health care leaders are rightly alarmed and are searching for answers.
The resulting national dialogue on physician burnout presents an opportunity to address physician well-being more broadly, in that physician well-being should be viewed — to paraphrase the World Health Organization’s well-known definition of health — as an optimal state of physical, mental, and social well-being, and not merely the absence of burnout. Professionally fulfilled physicians (defined as those who experience happiness or meaningfulness, self-worth, self-efficacy, and satisfaction at work) are better equipped not only to practice the art and science of clinical care, but also to lead the effort to identify and implement much-needed improvements to our systems of care.
The many drivers of both burnout and high professional fulfillment fall into three major domains: efficiency of practice, a culture of wellness, and personal resilience. Efficiency of practice and a culture of wellness are primarily organizational responsibilities, whereas maintaining personal resilience is primarily the obligation of the individual physician. Each domain reciprocally influences the others; thus, a balanced approach is necessary to build a stable platform that will drive sustained improvements in physician well-being and the performance of our health care systems.
While it is important to promote the well-being of all members of the health care team, we focus here on physician well-being for two reasons. First, physicians have been hard-hit by the organizational transformation of the health care system, resulting in an epidemic of burnout and declining professional fulfillment. They have suffered a reduction in their sense of professional autonomy, have experienced a significant increase in clerical duties, and are beholden to a growing array of imperfect and inconsistent quality and productivity metrics. Second, medical training has historically acculturated physicians to deny their own self-care in the service of others.
In this context, it is counterproductive to ask physicians to “heal themselves” through superhuman levels of resilience even as the practice environment continues to deteriorate. Yet the majority of interventions and research related to physician wellness have focused on personal resilience (e.g., mindfulness), while organizational interventions are more difficult and are only beginning to emerge.
Health care organizations must embrace their responsibility to build an efficient practice environment and to foster a culture of wellness while also supporting physicians’ efforts to improve their own resilience. This model in no way relieves physicians of their own professional obligation to build and nourish their personal resilience while simultaneously playing key roles in helping their organizations to build a culture of wellness and to improve the efficiency of practice. While this model is broadly applicable to any professional calling, many of the specific drivers within each domain are unique to physicians and demand tailored interventions.
Efficiency of Practice
Efficiency of practice is defined as the value-added clinical work accomplished divided by time and energy spent. Factors that contribute to physicians’ efficiency of practice include workplace systems, processes, and practices that help physicians and their teams to provide compassionate, evidence-based care for their patients.
Physicians have a deep intrinsic desire to provide optimal care for their patients. Excessive time pressures and chaotic work environments that impair patient care are thus associated with burnout. It follows that strategies that help clinicians to efficiently deliver high-quality care by re-engineering and continuously improving care processes and clinical workflows will improve physician well-being. Key targets for improvement include the usability of electronic medical records, adequate staffing (allowing physicians to spend more time doing work for which they are uniquely trained), mitigating regulatory and documentation burdens, maximizing user-friendly decision support, and facilitating reliable care coordination.
Efficiency of practice reciprocally affects the other two domains in that those who practice in an efficient clinical setting will have more capacity to improve their personal resilience by engaging in positive health behaviors. As their well-being improves, they can also better contribute to their organization’s culture of wellness through healthier interpersonal interactions and by encouraging others to care for their own wellness. This virtuous cycle of reciprocity is complete when a more resilient medical staff, embedded in a culture of wellness, is better able to partner with administrative leaders to drive further improvements in efficiency of practice.
Culture of Wellness
Culture of wellness is defined as a set of normative values, attitudes, and behaviors that promote self-care, personal and professional growth, and compassion for colleagues, patients, and self. Health care organizations that recognize physician well-being as a vital quality indicator will monitor and attend to it with sustained resourcing and an accountability structure that includes both clinical and administrative leadership. They will select leaders who exhibit characteristics and skills associated with the promotion of well-being and professional fulfillment and will support the development of those skills when there are gaps.
Clinical leaders are particularly well-positioned to lead a paradigm shift in rejecting the historic “iron doc” culture by encouraging physicians to extend to themselves and their colleagues the same natural compassion that they show to their patients. Leaders should expect physicians to attend to their own well-being and should view self-care as a professional core competency, abandoning the antiquated and dangerous misconception that self-care and patient care are competing interests.
It is essential to build a culture of appreciation, support, and compassion along with a deep sense of community. For example, peer support programs that train clinicians to provide emotional support to colleagues may be effective ways to prevent harmful stress while contributing to a culture of compassion and a sense of community. Medical teams also can reduce harmful stress by ensuring that all team members feel safe when pointing out problems, rather than fearing retaliation or other negative reactions from colleagues or superiors.
A culture of wellness also exerts a reciprocal effect on the other two domains, as physicians who feel supported by their organizations tend to contribute more to improvement efforts that increase the efficiency of their practices. They are also more likely to attend to their own personal resilience when they are embedded in a culture that values and encourages this behavior.
Personal resilience is defined as the set of individual skills, behaviors, and attitudes that contribute to personal physical, emotional, and social well-being — including the prevention of burnout. It is vitally important, in our inherently stressful profession, that physicians internalize a professional duty to pursue these healthy personal behaviors. Messages linking physician wellness to clinical care outcomes may be critically important to attenuate medical culture norms that characterize self-care as selfish. When cultural norms support self-care and clinical practice efficiency allows sufficient time margins for self-care, physicians are likely to strengthen their own personal resilience.
There are numerous strategies that physicians can use to improve their resilience. For example, optimal nutrition, exercise, and sleep not only reduce the risk of burnout and improve general well-being but also have the potential to improve cognitive performance. Engaging in mindfulness-based stress reduction and compassion cultivation are also promising approaches to enhance personal resilience. Organizational strategies to promote personal resilience-enhancing behaviors include limiting work hours (for physician trainees and other busy clinicians), providing convenient access to low-cost or free healthy food, providing on-site exercise facilities, and providing convenient places to take a nap (or relax or meditate) during on-call, overnight, or long-shift responsibilities.
Personal resilience exerts a reciprocal effect on the other two domains because healthy physicians are better contributors to their organization’s culture of wellness. They tend to “preach what they practice,” meaning that they are more likely to encourage positive health behaviors in colleagues (as well as patients) when they are engaged in these behaviors themselves. They are also more capable of embracing their vital role in improving their care processes to enhance efficiency of practice for themselves and their colleagues.
A Balanced Approach to Physician Well-Being
It is increasingly clear that the growing threat to physicians’ well-being directly threatens the quality of the care that they deliver as well as the health and effectiveness of the organizations in which they practice. Thus, it is highly appropriate that health care organizations are beginning to take responsibility for developing programs to address the crisis of physician burnout, and this research is rapidly expanding. We need comprehensive, systematic, and sustained efforts to improve physician well-being. These efforts will be most effective when they address drivers of physician well-being from each of the three reciprocally related domains of practice efficiency, a culture of wellness, and personal resilience. A balanced approach is necessary to build a stable platform that will drive sustained improvements in physician well-being and the performance of our health care systems. All of us who work in health care owe it to ourselves, to our patients, and to the next generation to work together to improve our practices, our culture, and ourselves.
This article originally appeared in NEJM Catalyst on April 26, 2017.