Analysis of the NEJM Catalyst Insights Council Survey on Leadership: Immunization Against Burnout. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.
By Stephen Swensen, Steven Strongwater, and Namita Seth Mohta
We were not surprised that 83% of respondents — who are clinicians, clinical leaders, and health care executives — call clinician burnout a “serious” or “moderate” problem in their organizations. That could be considered a slight improvement from the findings of our fall 2016 survey on burnout, when 96% of Insights Council members said physician burnout was a serious or moderate issue. It is clear, however, that the problem remains prevalent.
This most recent survey also finds burnout a major concern for registered nurses (78% say it is a serious or moderate problem), advanced practice nurses (64%), clinical leaders (56%), and health care executives (42%).
With such a large swath of health care organizations affected, leaders and frontline clinicians have become thirsty for solutions. After all, the damage to their business and culture can be quite severe — from straightforward pocketbook issues (at Steven Strongwater’s employer, Atrius Health, it costs between $500,000 and $1 million to replace a physician) to a well-studied breakdown in patient satisfaction and the quality of care. Clinicians feel the impact of burnout by reducing their hours, switching to administrative roles, or leaving health care altogether, taking them away from why they chose medicine in the first place: to treat patients.
While it might seem a trivial place to start, many organizations have stopped referring to the condition as “burnout,” realizing the word has something of a contagious effect. Instead, they are using more positive and aspirational nomenclature such as “esprit de corps” and “joyfulness in work.”
No one is under the illusion, though, that simply swapping to more optimistic language will solve this predicament. Instead, interventions must be targeted at multiple levels: provider organizations, regulators (specifically around payer/documentation requirements), the work unit leader, and individual clinicians. In the survey, 82% of respondents place the onus on organizations, through system and infrastructure improvements, but we believe interventions should be a shared responsibility with the individual (chosen by 47% of respondents).
What complicates the organizational approach to burnout is that physicians and nurses experience burnout in very different ways. We have found the drivers of physician burnout to be workload, work/life balance, cognitive dissonance, and clerical work, while nurses more often suffer burnout due to compassion fatigue, moral distress, and work environment issues such as psychological safety and hostility. There is also variation between specialties and practice locations.
There is broad agreement on the need for more face-to-face time between clinicians and patients and less time spent on the electronic medical record and documentation. A little over half of survey respondents recommend offloading clerical tasks to scribes, pharmacy technicians, or population health facilitators. That way, physicians and nurses (and all clinical team members) can work appropriately at the top of their licensure. The next most popular solution, chosen by 46% of respondents, is improving the functionality and interactivity of EMRs and other IT systems.
That theme came up consistently in verbatim responses to the survey, with one respondent hoping to “treat patients rather than treat the chart.” At Atrius, efforts are under way to improve clinician workflow in the EMR, ranging from reducing inbox messages to changing staffing patterns, but deployment of those processes is two years out. Some organizations have shared with us that they don’t have the resources to invest in better systems, workflow, and people to alleviate burnout, so it has fallen on clinicians to be more resilient.
In addition to improving IT systems, we believe organizations should focus on improving the communication and management skills of their point-of-care leaders. After all, employees don’t tend to leave organizations, they leave their managers.
Self-care is another important part of the solution to burnout. Clinicians cannot resolve these complex issues on their own, but neither are they helpless victims. Until structural changes are deployed, individual mitigation strategies can be effective. Just over half of survey respondents rate self-care as the top tool to reduce individual clinician burnout, which can include meditation, yoga, and engaging in a hobby.
Where organizations and individuals can work together is in creating incentive models and positive role models that encourage wellness. Together they can strengthen camaraderie, time for creativity, purposefulness, and personal resilience. Leaders can encourage self-care by setting up protected, guilt-free personal time for clinicians.
Leaders should get in the habit of measuring clinician joy, camaraderie, engagement, and satisfaction, just as you would a patient’s vital signs. You can use regular unit-based voluntary surveys to measure these characteristics. Only measure them, however, if you are committed to improving them. It may also be helpful to collect and manage metrics on the efficiency of EMR use, such as how many clicks are required for certain conditions and unit workflows. When there is substantial variation, super users can help colleagues improve their efficiency and reduce their work hours. Unless you measure it, it won’t get better.
While a majority (60%) of Insights Council members believe clinician burnout will worsen over the next two to three years, 15% of respondents believe the situation will improve over the next two to three years. Count us in the optimistic camp, as we already see EMR vendors trying to make improvements to their technology and organizations trying to return meaningfulness to clinician work.
VERBATIM COMMENTS FROM SURVEY RESPONDENTS
What is the one thing you would do to reduce clinician burnout at your organization?
“It has to be more than one thing: 1) Does the organization have a robust improvement department and have all administrators, physicians, and clinicians agreed to actively pursue and participate in improvement, this is critical. 2) EMR optimization. 3) All clerical and documentation work (see #1 for how to fix). 4) Culture & camaraderie.”
“Engage clinicians in decision making and innovation activities.”
“Develop a more team-based approach to care instead of our current model which places the burden of documenting and education on the physician. Reducing the clerical tasks currently burdening physicians will help considerably as will revamping physician compensation as the drive to see more patients to rack up RVUs is a contributing factor to physician satisfaction.”
“Improve efficiency of busy work so they can focus on the real purpose.”
“Improve ability to care for self.”
Download the full report for additional verbatim comments from Insights Council members.
Charts and Commentary
by NEJM Catalyst
We surveyed members of the NEJM Catalyst Insights Council, who comprise health care executives, clinical leaders, and clinicians, about clinician burnout. The survey covers the extent of clinician burnout at their organizations, the extent of burnout among other groups at their organizations, the level of clinician burnout over the past 2–3 years and expected during the next 2–3 years, where interventions to reduce burnout should be targeted, and tools that individuals and organizations are using to reduce burnout. Completed surveys from 703 respondents are included in the analysis.
Nearly all respondents (96%) say physician burnout is a problem in their organizations to some degree. Just over a third consider it a serious problem, while nearly half say the problem is moderate. Respondents at health systems (44%) are more likely to say it’s a serious problem than those at hospitals (36%). Executives, clinical leaders, and clinicians agree about the extent of the problem. In a written comment, one Insights Council member attributes burnout to the change in the business of medicine. “We are not a corporate culture. Medicine is a practice and tying a physician to a corporate model is the one driving force that leads to burnout,” the respondent says.
Download the full report to see the complete set of charts and commentary, data segmentation, the respondent profile, and survey methodology.
Join the NEJM Catalyst Insights Council and contribute to the conversation about health care delivery transformation. Qualified members participate in brief monthly surveys.