The Open Mind: The Open Mind

Antifragile Systems and Physician Wellness

Tsai, Mitchell H. MD, MMM^*†; Muller, Imelda R. BS^*; Stelzer, Shelly R. MD^*; Urman, Richard D. MD, MBA^‡; Adams, David C. MD^*

Author Information

From the ^*Department of Anesthesiology and ^†Department of Orthopaedics and Rehabilitation (by courtesy), University of Vermont College of Medicine, Burlington, Vermont; and ^‡Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts.

Accepted for publication May 30, 2017.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Mitchell H. Tsai, MD, MMM, Department of Anesthesiology, Department of Orthopaedics and Rehabilitation (by courtesy), University of Vermont Medical Center, 111 Colchester Ave, Burlington, VT. Address e-mail to [email protected].

Anesthesia & Analgesia 125(3):p 1056-1059, September 2017. | DOI: 10.1213/ANE.0000000000002328

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In April 2016, the US Surgeon General reported that physician burnout is on the rise in the United States, stating “if health care providers are not well, it is hard for them to heal the people for whom they are they caring.”^¹ For the past 3 decades, multiple researchers have noted a slow disenfranchisement of the medical profession that has impacted physician well-being.^{^2–7} Anesthesiologists often lead the pack when burnout rates and work dissatisfaction scores are broken down by specialty.^⁷^,^⁸ Furthermore, anesthesiologists reported higher rates of emotional exhaustion than other specialties when faced with new technologies designed to improve operating room efficiency.^⁹ Burnout among anesthesiologists has been attributed to an overload of bureaucratic tasks, a high-pressure environment, increasing compliance requirements, and a higher clinical workload.^{^9–11} These issues affect everyone in anesthesiology, from junior anesthesiologists in small private groups to leaders of large academic departments.^¹²

How do anesthesiologists turn the tide against this national health crisis?^¹³ A constructive discussion needs to focus on 3 areas. First, there needs be a common framework for future discussions. Here, we borrow the concept of antifragile systems. Second, we need to recognize the limitations of interventions implemented at the individual level and apply a systems-based framework. Finally, as wardens of a high-pressure, complex perioperative system, anesthesiologists face disproportionate rates of burnout. As advocates for improving patient safety, increasing efficiency, and reducing costs, our responsibility to address the safety concerns, productivity risks, and financial burden of physician burnout cannot be overlooked.^{^14–16}

ANTIFRAGILE SYSTEMS

In Antifragile: Things That Gain From Disorder, Taleb^¹⁷ explores an exhaustive list of supposed antonyms, including rigid, robust, and resilient (Table). For instance, “rigid” structures, such as a wine glass, will break on impact. By contrast, robust systems have the ability to accommodate stressors with no change in underlying structure. Resilient systems also do not respond with underlying changes, however they resist, rather than accommodate shocks. Ultimately, Taleb^¹⁸ defines antifragile systems as those which respond to stressors by developing new capabilities to withstand and predict future sources of harm.

To illustrate, the Bell Commission’s original recommendations about resident work hours changed the landscape for graduate medical education in the 1980s.^¹⁹ In a sense, these regulations separated programs into rigid, robust, or resilient categories. “Rigid” programs did not adopt the recommendations until financial penalties were instituted. Anesthesiology programs, which rarely required more than 24 hours of clinical duties, were an example of “robust” residencies that inherently possessed capacity to accommodate work hour regulations. Recently, Prielipp and Birnbach^²⁰ were more accurately encouraging anesthesiologists to embrace antifragile systems when they called for anesthesiologists to become “resilient” by supporting a culture of mindful adaptation and continual learning.

AN ANTIFRAGILE SYSTEM FOR REDUCING PHYSICIAN BURNOUT

In 2012, the Joint Commission mandated that health care organizations provide the basic resources for physician wellness and self-care (eg, rest, recovery, and nutrition).^²¹ Epstein and Krasner^²² have argued that resilience includes the capacity for mindfulness, self-monitoring, limit setting, and constructive health engagement. Modalities that have proven effective in improving workplace wellness include yoga, short cognitive behavioral stress management courses, and development of programs that create a common language, culture, and strategy promoting wellness.^{^23–25} These practices have demonstrated simple physiologic changes such as decreases in stress markers, as well as more complex changes in well-being.^²⁶^,^²⁷ In addition, regular meditators report more focus, increased engagement, and greater happiness.^²⁸ Many of these strategies, however, mistakenly focus solely on activities outside of work.^²⁹ Individual interventions will only maintain the status quo.

Moreover, recent literature indicates that structural organizational strategies can result in meaningful reductions in burnout among physicians.^³⁰^,^³¹ Epstein and Krasner^²² suggested that connections between individuals (or topography) serve as the foundation of any system. Accordingly, the growing disenfranchisement of the medical profession may have its underpinning not only in the physician-patient relationship, but also the physician-physician relationship. Similarly, McKenna et al^³² describe the concept of “social resilience” as the basis for physician wellness and the “missing link” in physician education. Therefore, approaching physician burnout from an antifragile systems framework must include cultivation of healthy connections among physicians and their colleagues.

Recently, Sikka et al^³³ commented that the backbone of an effective health care system is “an engaged and productive workforce” that “thinks and acts in a positive way about the work they do.” Health care providers and the underlying network behind the day-to-day interactions with others are the basis for an antifragile system. Individual interventions targeted at physician wellness need to be part an integrated, larger system that recognizes physicians are the back bone of a healthy health care system. For example, mindfulness techniques have been associated with an improvement in burnout scores among health care providers, and employees who utilize mindfulness training in the work place report less emotional exhaustion and more job satisfaction.^³⁴^,^³⁵ Building a “continually adaptive system, where every component interacts and impacts the actions of every other component” will require a coordinated, organizational effort.^²⁰ It is therefore imperative that an antifragile systems framework utilizes organizational and social strategies to address physician burnout and wellness.

FINANCING AN ANTIFRAGILE SYSTEM: INVESTMENT AND COST SAVINGS

There are still limited data on which interventions are most beneficial and how to go about studying, instituting, and financing interventions that target physician wellness. The question of who is responsible for the individual and collective health of a workforce has not been addressed. One can argue that it is the moral responsibility of the organization to create a healthy work culture given that employees spend a large portion of their day in the workplace.^³⁶ This process will require a long-term structural investment by physicians, hospital administrators, and health care policy makers.^²¹

The financial costs of physician burnout can be largely attributed to reduced productivity and loss of full-time physicians as a result of turnover, early retirement, or leaving the field to pursue other careers entirely.^¹³^,^¹⁶ Both burnout and decreased work satisfaction have been associated with increased turnover and desire to leave employment among physicians.^{^37–39} Among anesthesiologists over the age of 50, career dissatisfaction played a role in their decision to retire or stop providing care, even among physicians who chose to retire early.^⁴⁰ Finally, physicians who work part-time report less burnout than physicians in full-time positions, and a transition to working part-time may represent an increasingly appealing strategy for physicians to combat burnout.^¹⁶^,^⁴¹ In a seemingly negative feedback loop, physicians reporting higher rates of burnout were also more likely to decrease their effort in clinical work.^¹⁷ In short, greater workloads lead to burnout and lower productivity.

The cost (eg, lost revenue, start-up, recruitment, interview, bonuses) of replacing a physician is estimated to be from as low as $150,000 to $300,000, to as much as $1,200,000.^⁴²^,^⁴³ For an institution with a revenue stream of $1,000,000,000 and a profit margin of 2.5%, the cost of replacing a physician represents 1% of the profit or opportunity for reinvestment. For an independent practice association with fewer resources, the relative costs may be even greater. Here, the cost of turnover should also include the increased workload for the remaining partners and loss of vacation time, thereby negatively impacting work-life balance. These financial considerations are even more concerning against the impending shortage of physicians in the country.^⁴⁴^,^⁴⁵

For practicing anesthesiologists, the long-term investment and development of an antifragile system to address physician burnout will vary, depending on the financial and administrative arrangements of the group. Satiani and Vaccaro^⁴⁶ argue that the size of the physician group, location, health system resources, practice patterns, administrative commitment, and economic climate are factors that affect how physicians interact with prospective hospital systems. Naturally, the specific antifragile strategy appropriate for each physician-hospital model will vary, as will the cost of implementation. In addition, although methodology for studying the cost-effectiveness of stress-reducing practices has been proposed, literature on this topic as it relates to interventions in the health care sector is scant.^⁴⁷ A discussion of the various combinations of potential antifragile systems, the logistics behind their implementation, and individual cost-benefit analyses of each system is therefore premature and beyond the scope of this article. However, financing an antifragile system to reduce physician burnout should be viewed as an investment with important cost savings from increased physician retention and decreased turnover rates. In truth, health care organizations that have already embraced elements of an “antifragile” system may have improved physician well-being, as well as retention, thereby reducing the potential costs of physician turnover.^²³^,^⁴⁸

CLOSING

For far too long, physician wellness has been the missing management metric and quality indicator.^⁴⁹ From an organizational perspective, creating an antifragile system falls under the direct purview of anesthesiologists, management administrators for large anesthesiology conglomerates, and hospital administrators employing anesthesiologists. Antifragile systems and processes need to ensure that anesthesiologists do not suffer unnecessarily from bureaucratic or institutional demands, are afforded opportunities to balance their personal lives and professional career, and are offered the platform to find meaning in the work that they do.^⁵⁰ Ultimately, we can ignore the trend that unwell physicians negatively impact the clinical, operational, and financial performance of a health care organization. Or we can recognize and accept that “the real challenges we must face are not future events that we imagine or dismiss….they are existing trends.”^⁵¹