1. Combatting Physician Burnout Evidence Summary 2017
Chris Simmons, MD, PhD

2. Burned out about burnout?

3. Objectives Grasp the scope and impact of burnout
Investigate the driving factors behind physician burnout
Weigh evidence surrounding interventions to reduce or prevent burnout
Be inspired to equip yourselves for change

4. Burnout
Once motivated individuals experience progressive work dissatisfaction due to both external and internal stimuli

5. Maslach Index 22 Question inventory At on point, cost $0.50 per copy
Now costs $2.00 per copy...
Maslach C, Jackson SE

6. Components of Burnout Emotional Exhaustion Depersonalization
Lack of personal achievement

7. Scope of The Problem
Regardless of profession, the American workforce is facing a burnout crisis
$ billion annually in healthcare spending due to symptoms of burnout
Garton E, Harvard Business Review

8. Scope of The Problem
As few as 39% of physicians experience burnout with many estimates exceeding 50%
Burnout directly attributed to losing 1.2% of workforce between
Shanafelt TD, Mayo Clin Proc, 2016

9. Scope of The Problem

10. Scope of The Problem Example for a large academic center:
450 physician employees
50% burned out
7.5% annual turnover
Estimated $5,625,000 cost of physician turnover per year due to burnout

11. Why burnout matters to physicians
Gittlen S, NEJM Catalyst, 2017

12. The Problem
is it us?

14. Duty Litigation
Policies
Regulation
Time
Division/
Practice
Health
System
Society
Colleagues
Individual
Mental
Health
Debt
Salary
Workload
Bureaucracy

15. Where do we start?

16. Burnout
PTSD
Depression

17. Depression 6.7% prevalence in US adults
27% of medical students and residents
Up to 24% of interns suffer suicidal thoughts during their first year
Sen et al. Arch Gen Psy 2010, Rotenstein LS et al. JAMA 2016, NIMH 2016

18. 85.2%

19. Physician suicide.
physicians commit suicide every year, or ~1 physician per day
x the rate of the general population
2.5-4x higher for women
Not exclusive to the U.S.
Frank et al 1999, Schernhammer et al 2004, Sobowale et al 2014, Hope et al2014, Cuttilan et al 2016

20. How did this happen?

21. Burnout begins during medical school
Life events
First patient death
The Match
Licensure requirements
Job search
Environment
Lack of control
Work compression
Academic support
Autonomy vs. supervision
Cynicism
Lack of personal care
Adapted from Dyrbye L and Shanafelt T, Med Ed, 2016

22. “Yet, what about beneficence
“Yet, what about beneficence? We tried to be beneficent, but a slow, ghastly, death in front of strangers in white coats doesn’t seem to be good for anybody, including me. “

25. Program Structure 2,000 Resident Physicians, Academic Hospital
Wellness orientation, follow-up workshops
Suicide prevention screening (opt-out)
Resident support groups/luncheons (monthly)
Individual counseling, med management
Consultation with program leadership

27. $$$ Start-up costs of $200,000/year (GME)
85% goes toward physician FTE
5% on-site clinic space
10% administrative expenses

28. Conclusions
Can be implemented with high utilization and high satisfaction rates
Unclear if depression or suicide incidence actually reduced...

30. Interventions Faculty development
Provisions for private/university counseling services
Well-being workshops and handbook for students
Depression prior to intervention
Depression after intervention
Mild/Moderate depression
Major depression
Suicidal ideation
44 (76%)
14 (24%)
4 (7%)
10 (17%)
1 (3%)

32. Ok, I’m not depressed… But I’m still burned out

33. Duty Litigation
Policies
Regulation
Time
Division/
Practice
Health
System
Society
Colleagues
Individual
Mental
Health
Debt
Salary
Workload
Bureaucracy

35. Study Components Medical students and non-physician providers excluded
Data from both academic and community settings
15 RCTs (716 physicians)
37 unique cohort studies (2914 physicians)

36. Interventions Included:
Duty hour requirements
Shortening attending rotation length
Practice delivery changes
Modifications to clinical workflow
Communication skills training
Facilitated and non-facilitated small group curricula
Stress management & Self care
Mindfulness-based approaches

37. Absolute reduction in overall burnout of 5-14% (54->44%)
NNT = 10

38. Organizational interventions more effective than individual efforts in reducing overall burnout
Mindfulness and stress management strategies appeared more effective in reducing depersonalization

39. Limitations Many studies lacked a control arm
Personal accomplishment not specifically addressed

41. 19 studies
7 of which included in previous meta-analysis
Organization led or directed efforts may have more impact on burnout than individual-level efforts

42. “...burnout is rooted in the organizational coherence of the health care system.
If burnout is a problem of whole health care systems, it is less likely to be effectively minimized by solely intervening at the individual level. It requires an organization-embedded
approach.”

44. 25 studies from the Western Hemisphere examining the general work environment:
Job Control
Emotional Demands
Co-worker support
Work Load
Job development
Lack of feedback
Physical environment

45. “The potential importance of organizational interventions is illustrated by the findings that the development of
the burnout syndrome is influenced by structural work environment factors such as job demands, low possibility to exert control and non-supportive workplaces.”

47. Duty Hours and Burnout Improved Emotional Exhaustion
Improved?? Depersonalization

48. Impaired Personal Accomplishment???
Duty Hours and Burnout
Impaired Personal Accomplishment???

49. Adverse effects of duty hours
Decreased continuity of patient care
Less (formal/bedside) educational time
Limits assessment of resident skills, judgement and professionalism

52. “More time at the bedside.
Shared sense of teamwork.
Decreased burden of administrative tasks.
Adequate nonclinical support staff.
Mentorship and education.”
“Returning to why we entered the profession.
Practicing self-reflection.
Peer-support and a sense of community.”

53. Gittlen S, NEJM Catalyst, 2017

54. Physicians spend 49% of their time on the EHR and desk work vs only 27% of their time face to face with patients (2:1 ratio)

58. Estimated that by 2020 there will be 1 scribe for every 9 physicians.
Gellert GA et al, JAMA 2015

59. Physician satisfaction working with scribes
Outcome OR
95% CI
P-Value
Overall satisfaction
10.75
<.001
Face time with patients
3.71
Charting time
86.09
Chart quality
7.25
Chart accuracy
4.61

60. Patient Satisfaction Physician explains things to me 0.82
Outcome OR
95% CI
P-Value
Physician explains things to me
0.82
.468
Physician listens to me
0.88
.681
Physician cares about me
1.15
.609
Physician encourages me to talk
1.07
.808
Physician spends enough time with me
1.12
.642

61. April, 2016

62. Qualitative study using descriptive themes
18 physicians
17 scribes
36 patients
Documentation - requires letting go of some control
Patient Care - teaching and summarizing with patients
Teamwork - it’s like a dance...

63. “...not doing administrative things, he’s being the doctor.”
“I felt more cared for today…”
“the bulk of the time should really be on the assessment and plan and I really feel like we're having…very effective conversations about that.”

65. 5 Studies included
Satisfaction, efficiency and interaction quality all seem to improve with scribes
Productivity
RVUs increased .18 to .24 per hour
Patients increased 2.2 to 3.5 per hour
Estimated revenue increase of $2500 per hour in one cardiology clinic

66. Scribes aren’t an excuse to quit improving the EMR

67. Questions?

68. Conclusions The scope of burnout is extensive
Organizational change is likely essential, but self-care may be of beneficial magnitude
Controlled studies of medical scribes, EHR workflow and care delivery models are coming

70. Thank you!