1. Mark Linzer, MD Office of Professional Worklife, Division of General Internal Medicine Hennepin County Medical Center, Minneapolis MN

3.  Demands balanced by control  Stress increases if demands rise or control diminishes  Support can facilitate impact of control  Bottom line… support and control moderate stress Karasek et al. Am J Public Health 1981;71:694-705 Demands ControlSupport

4. Study design  119 PC clinics; 422 MDs; 1785 patients  Longitudinal study of work conditions in primary care Linzer M, et al. Ann Intern Med 2009;151:28-36. Results  49% said jobs stressful  50% need more visit time  27% burning out  30% likely to leave in 2 years  Relationships between work conditions (time pressure, control, chaos, values) and burnout  Many patient outcomes related to work conditions

5. 1. Overall, I am satisfied with my current job: Strongly disagree DisagreeNeither agree nor disagreeAgreeAgree strongly 2. I feel a great deal of stress because of my job Strongly disagreeDisagreeNeither agree nor disagreeAgreeAgree strongly 3. Using your own definition of “burnout”, please circle one of the answers below: 1. I enjoy my work. I have no symptoms of burnout. 2. I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out. 3. I am definitely burning out and have one or more symptoms of burnout, e.g. emotional exhaustion. 4. The symptoms of burnout that I’m experiencing won’t go away. I think about work frustrations a lot. 5. I feel completely burned out. I am at the point where I may need to seek help. 4. My control over my workload is: 1 – Poor2 – Marginal3 – Satisfactory4 – Good5 – Optimal 5. Sufficiency of time for documentation is: 1 – Poor2 – Marginal3 – Satisfactory4 – Good5 – Optimal 6. Which number best describes the atmosphere in your primary work area? Calm Busy, but reasonable Hectic, chaotic 12345 7. My professional values are well aligned with those of my department leaders: Strongly disagreeDisagreeNeither agree nor disagreeAgreeAgree strongly 8. The degree to which my care team works efficiently together is: 1 – Poor2 – Marginal3 – Satisfactory4 – Good5 – Optimal 9. The amount of time I spend on the electronic medical record (EMR) at home is: 1 – Excessive2 – Moderately high3 – Satisfactory4 – Modest5 – Minimal/none 10. My proficiency with EMR use is: 1 – Poor2 – Marginal3 – Satisfactory4 – Good5 – Optimal *This survey was developed by Dr. Mark Linzer (Division Director, General Internal Medicine) and his team at Hennepin County Medical Center in Minneapolis MN as part of his ongoing research in Clinician Worklife and Satisfaction. Disclaimer-this is adapted from the OWL (Office and Work Life™ measure); more detailed surveys are often needed for second stage work.

6. Key findings (response rate 76% ) UCSF National rate ◦ High stress: 88% 65% ◦ Burnout: 56% 33% ◦ Poor control: 63% 38% ◦ EMR time pressure: 81% 54% ◦ Effective teamwork: 66% 76% ◦ Excess EMR home time:81% 50%

7. Score items 5, 9 and 10: % (#5 + #9) – (0.1 x % #10)) x 0.5  Hennepin scores by dept range from 0 to 60.  UCSF Parnassus score: 77

8. Stratified Hennepin’s 16 departments; intervened in highest EMR-stress departments: ◦ New templates ◦ Scribes (cost shared with hospital) ◦ Desk top (blocked) slots ◦ Standing order sets ◦ Individual elbow-to-elbow IT support ◦ Reduction in required EMR activities ◦ Sufficient time for non-face-to-face activities

9. Suggestion 1 Develop clinician “float pools” for life events Workforce 10% short Cost-effective ($250K cost to replace) Linzer M, Am J Med. 2002;113: 443-48. Suggestion 2 Decrease EMR stress; “right-size” EMR-related work Longer visits* scribes** Desk top slots *Babbott S. JAMIA. 2013;0:1-7. **Sinsky C. Ann Intern Med. 2014; 160:727-8. Suggestion 3 Ensure that quality metrics include clinician satisfaction and well-being* *Wallace JE. Lancet. 2009;374: 1714-19.

12. Workflow redesign Communication improvement Chronic disease QI projects MA data entryImproved teamwork Establishing quality metrics with clinician input Improved clinic efficiency projects Improved communication between provider groups Automated R x refill line Assessed workflow with staff Routine clinician meetings discussing meaningful topics Med reconciliation project Provided time for MAs and RNs to perform tasks Surveyed providers for “wish list” issues Screening project for diabetics Paired MAs and providersRoutine emails from leadersScreening for depression Non-physician staff assist with forms Clinicians meeting with leaders Improved patient portals

13.  Explicitly value teaching time  Use desktop slots for EMR catchup  Offload non-clinician work (“share the care”)  Pilot remote work and attendance at meetings  Move away from RVUs  Partner with resilience trainers  Measure stress and burnout annually, demonstrate improvement

14.  Anecdote #1: me ◦ Totally transformed my practice ◦ Re-established connections with my patients ◦ Had not realized how much I had lost  Anecdote #2: my colleague with a broken finger ◦ “I’m never going back!” Bank, et al. ClinicoEconomics and Outcomes Research, 8 August 2013

15.  We have to solve GIM worklife, at UCSF, and nationally  Short office visits with complex patients are detrimental to EMR users  More teamwork, less chaos, and more control will diminish burnout  Making wellness a priority will lead to concrete solutions Hoping we have plenty of time for questions! Mark.linzer@hcmed.orgMark.linzer@hcmed.org and the MS Squared team