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The Science of Motivation Applied to Clinician Burnout

Lessons for Healthcare

Norton, Jameson, FACHE

Frontiers of Health Services Management: December 2018 - Volume 35 - Issue 2 - p 3–13
doi: 10.1097/HAP.0000000000000049
Feature Articles

SUMMARY The science of motivation can help explain some of the root causes driving clinician burnout, a critical vulnerability in healthcare today. Research finds autonomy, mastery, and purpose to be drivers of intrinsic motivation, and healthcare leaders can use these three principles in program design and communication strategies to make progress toward rediscovering joy and passion in the life-giving work of healthcare. Leaders can achieve a competitive advantage for their organizations by applying these inherent motivators to attract, develop, and retain engaged and purposeful caregivers and by developing participative leadership to nurture a passion for caregiving.

In healthcare, we enjoy the privilege of serving with intelligent and caring people who are driven to make a difference on behalf of those they serve. But we also experience the human factors, friction, and uncertainty in a highly complex delivery and reimbursement structure. Each day in our hospitals, clinicians and staff face a marathon of adrenaline, stress, physical fatigue, mental strain, and emotional heights and depths. This reality demands grit and resilience to sustain the high standards of excellence and compassion necessary for delivering personalized care.

Before healthcare organizations launch new programs to address these challenges, however, we must align our leadership and communication approaches with the fundamental drivers of motivation that brought us to healthcare in the first place—and in a way that brings out the best in our care teams and builds their creative capacity for any future challenges.

Jameson Norton, FACHE, is CEO of Vanderbilt Psychiatric Hospital and Clinics at Vanderbilt University Medical Center in Nashville, Tennessee.

The effects of clinician burnout leave our people, our patients, and our organizations vulnerable at a critical time for healthcare as we face the challenges of payment reform, reliance on technology, and complex patient needs. The extent of burnout in healthcare is daunting: 55 percent of physicians indicate signs of burnout (Shanafelt et al. 2015), 55 percent of nurses worry that their jobs are affecting their health, and 35 percent of nurses hope they will not be working in their job within a year (AMN Healthcare 2017). Amid industry-wide signs of degraded trust and empowerment in the workplace, clinicians are losing their ability to sustain empathy, collaboration, and peer support in ways that preserve wellness and psychological safety in the workplace. As a result, too many are ending their service preemptively (Kovner et al. 2007). Worst of all, 300 to 400 physicians commit suicide in the United States every year (Center et al. 2003). Female physicians, in particular, are 2.3 times more likely to die by suicide than nonclinicians are (Whitman 2016). For so many, the life-giving work of our clinicians has, at a certain point, left them feeling hopeless, powerless, and isolated.

What exactly is burnout? Burnout has been defined as the state of emotional exhaustion and depersonalization from undue stress, frustration, and exertion characterized by a loss of passion and energy, detachment, feelings of inadequacy or resentment, and social isolation (Drummond 2015). Central to this concept is a loss of purpose, community, and empowerment. In healthcare, applying concepts from the science of human motivation can help us understand the root causes of clinician burnout and unlock renewed resilience that can have a positive multiplier effect on an organization’s readiness, well-being, and patient outcomes so that our colleagues can experience real joy in work amid the strains inherent in our profession. The few certainties of healthcare’s future include elevated complexity, payment reform, reliance on technology, and continued dependence on high-functioning, intrinsically motivated clinicians. These certainties place steady pressures on clinicians, including expectations of higher productivity, increased information flow, workplace friction, and a medical culture prone to perfectionism and deprivation of personal needs. Mitigating these personal and system factors requires examination of systemic implications and solutions. The research of Daniel H. Pink (2009) and others has identified drivers of motivation and purpose that, when viewed in the context of healthcare trends, make it clear why we have arrived at this point and suggest approaches to creating more engaged and sustainable care teams. These principles inform best practices in organizational engagement, from designing incentives to creating a culture of intentional, trauma-sensitive interventions.

One reason I chose the hospital setting when I transitioned from active duty service in the US Marine Corps was the opportunity to work alongside people who cared deeply about their mission in an environment where the work truly matters. This environment was familiar to me from the military, and I wanted to be inspired each day in the same way by teams who shared my passion for making a difference in a transcendent cause. I had experienced the bonds that form among colleagues and drive us to be our best not only in our life-giving mission but also for each other. In these environments, we find ways to do more than we ever thought possible. Compared with other professions, the compelling mission of healthcare gives us a unique advantage that helps us attract and sustain our workforce. Whether our passion to serve in healthcare comes from life experiences, family values, religious faith, or other personal factors, we are united by a call to compassion. Internal rewards motivate us to continually improve on behalf of those we serve. Unlike extrinsic motivation, this personal drive does not come from mere financial reward but rather from the experience of healing itself. In fact, when it comes to solving highly complex problems that require sharp thinking, enhanced creativity, and nonobvious solutions (as the challenges in healthcare today do), financial incentives actually lead to poorer performance as long as basic needs are met (Pink 2009). Recognizing, harnessing, and sustaining the power of community, personal fortitude, shared purpose, and individual passion already present in our clinicians has become an organizational responsibility—and a competitive advantage when applied effectively.

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Three Drivers of Intrinsic Motivation

Part of creating a culture of wellness that prevents burnout and leads clinicians to their full potential is effectively harnessing three fundamental drivers of intrinsic motivation: autonomy, mastery, and purpose.

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Autonomy

Preserving autonomy or a sense of self-direction in work can increase engagement and personal ownership in a way that leads to renewed vigor (Pink 2009). In healthcare, feelings of helplessness and lack of control can induce burnout in clinicians. Over the past several decades, physicians—both employed and in private practice—have experienced feelings of reduced professional autonomy because of regulatory burdens, technology-driven workflows, clerical duties, and countless new but inadequate productivity and quality metrics that define daily achievement. When leadership imposes changes related to new contracts and expectations without first securing buy-in, resentment can result.

In contrast, effective approaches to trust and engagement among physicians are based on the unifying elements of respect and vision. We can gain insight into how these elements relate in different delivery models. Private practice affords physicians a high degree of autonomy and empowerment with regard to personnel changes, practice improvements, and system developments, but consolidation trends over the past decade have made sustained profitability more difficult. Most physicians who switch from private practice to an employment model do so because of the growing financial risk and business functions associated with running a practice. Their largest complaint about employment, however, is that it gives them “limited influence in decision-making” (Kane 2014, 8). Seventy percent of physicians who left employment in favor of self-employment claim to be happier now, whereas fewer than half of those who left self-employment are happier in the employment model (Physicians Foundation and Merritt Hawkins 2016). Others had no choice but to become employed.

Regardless of the model, healthcare organizations will empower their most precious resource to be creative and resourceful if they treat clinicians as partners by inviting feedback or new ideas regularly and communicating with vision and intent. Many organizations have instituted leadership academies to develop clinicians’ communication and management skills, recognizing that such skills are mutually beneficial in instilling a growth mind-set, strategic intent, and sense of autonomy. These programs enable clinicians to become part of the change effort and help shape how care is delivered. Clinicians who see their role through the lens of positive change and have a sense of shared ownership and accountability will feel less burdened by friction created in a complex healthcare delivery system.

As one of the largest academic medical centers and multihospital health systems in the Southeast, Vanderbilt University Medical Center (VUMC) in Nashville, Tennessee, takes a unique approach to fostering autonomy among more than 20,000 employees. One highlight is StrategyShare, an annual event that serves as a showcase for exciting work by clinicians who share personal stories about what it means to be part of the VUMC community. The event includes strategy talks, 60-second “power pitches,” panel discussions, “mission moments,” and networking. The first phase is IdeaShare, a time for colleagues across disciplines and departments to share ideas about challenges, perceived vulnerabilities, and opportunities in the medical center. IdeaShare enables systemwide listening and flow of ideas to help shape the future of VUMC by identifying new services, approaches to care, and ways to relate to each other. Using an online crowdsourcing tool on desktops or mobile devices, participants weigh in on specific topics during “campaigns.” The IdeaShare pilot in 2017 collected ideas on communication approaches, employment benefits, and strategic alignment. This platform shared ideas among as many people as possible to give voice to each individual and build trust through engagement, transparency, and community. Implied was the notion that, no matter one’s role, experience level, or skills, everyone has good ideas and can believe in the institution as a worthy home for their contributions and talents. Strong organizations tap into the creativity and experience of as many diverse perspectives as possible. For example, IdeaShare helped people at VUMC learn together and raise ideas to instill initiative, build bonds among employees, and inform leadership with strategic insights.

Integral to StrategyShare and IdeaShare is an authentic message from VUMC leadership that we do not know all the answers, but we trust our team to help us deliver on our mission of personalized care, teaching, and discovery. Through a fundamental respect that enables autonomy first and then engagement over time, we can help lead our clinicians through a challenging healthcare landscape by inviting participation, building trust, and inspiring action.

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Mastery

The drive toward mastery in a profession that makes a difference in the world is a foundation for motivation that can also help prevent burnout. Supportive organizations foster mastery through investment and belief in the capabilities of their clinicians, while the clinicians must believe in the potential for continuous growth through relentless effort and perseverance. An organization that harnesses the power of mastery among its clinicians creates conditions for advancement through mentorship and coaching that lead to both personal and clinical breakthroughs.

As we live in a “never enough” culture obsessed with success, one prime contributor to burnout in healthcare today is the systemic challenge of measuring the things that truly matter in a results-oriented work environment. The limited time physicians spend with their patients makes it difficult to see real outcomes or lasting improvements relative to the social determinants of health influencing patients’ lives. Ever-present administrative duties and productivity requirements can lead to feelings of helplessness and loss of control because “physicians’ sense of professional fulfillment [is] positively correlated with patients’ adherence to medication, exercise, and diet regimens” (Nedrow, Steckler, and Hardman 2013, 25). These feelings are compounded by widespread consumer confusion over quality metrics because it is not always clear what we are measuring. Providing better care by improving the patient experience has been thwarted by disagreements about standardized measures, not to mention the unintended consequences of existing measures. For example, good intentions to treat pain and reduce patient suffering contributed to the current opioid epidemic. Regulatory agencies evaluated pain scores as an outcome metric, which translated directly to reimbursement and reputation scores for physicians and hospitals (Rummans, Burton, and Dawson 2018). As we know now, this approach to pain contributed to increased opioid prescription rates, user dependence, overdoses, and mistrust and uncertainty among caregivers.

Confusion over metrics has also led to distrust of and resentment about quality assessments, which can obscure the notion of mastery in one’s practice. For example, physicians with top patient satisfaction scores may have poor mortality rates; hospitals with top Hospital Quality Alliance process-of-care measures may have poor outcomes and patient satisfaction scores; hospitals with top Agency for Healthcare Research and Quality (AHRQ) patient safety indicators may have high mortality rates; and hospitals with good AHRQ inpatient quality indicators may have high complication rates. This apparent inconsistency and uncertainty about what defines quality affects the patient and frustrates the provider, who wants to improve performance and develop a sense of mastery by reducing harm and measuring consequential outcomes that matter to patients.

Multidimensional composite scoring that integrates core process-of-care measures, patient safety indicators, mortality rates, complication measures, readmission rates, and patient experience scores are one avenue to achieve some gauge of true north. However, it is difficult for clinicians to connect such a complex composite to their own performance as a meaningful incentive and purposeful metric. Another option is to measure larger societal outcomes, such as impact on the economy, policymaking, and population health because each is significant in its own way and can contribute to personal fulfillment. But again, the farther we move away from the bounds of an individual physician’s control, the harder it is for the clinician to show how personal mastery can create positive change. An absence of this true north for outcomes can contribute to clinician burnout and distrust of each new wave of performance metrics.

Solutions to this challenge—achieving mastery by engaging clinicians through efficient workflows and outcome measures that matter—must use a multifaceted approach. The work of the International Consortium for Health Outcome Measurement (ICHOM), which is creating worldwide standards for measurement and patient outcomes reporting, can help provide a foundation. ICHOM uses input from physician leaders, outcomes researchers, and patient advocates to define standard sets of outcomes per medical condition. It starts by asking questions about patients’ health after treatment—for example, are they able to return to work? Are they capable of caring for themselves? Do they see improvement in specific symptoms? Applying these measures in a new payment model and tracking them in efficient workflows would be a step toward our goal. Mapping outcomes that matter to the mission is critical not only for delivering great patient care but also for reinforcing the “why” or purpose behind one’s contributions that leads to fulfillment. For example, if we seek to deliver personalized care, we must track our organization’s capabilities to integrate care in ways that meet individual patient needs and preferences consistently.

Even with reliable measures that support professional fulfillment and purpose, continuous technological developments in electronic health records (EHRs) complicate the alignment between mastery and trust because they can create an additional barrier to understanding how changes in workflow translate to the best care for patients. As Exhibit 1 indicates, the largest contributors to burnout are in areas that erode this sense of mastery, such as bureaucratic tasks and the increasing computerization of practice.

To help clinicians be their best and avoid burnout, we as leaders must optimize the time they spend with patients by designing efficient processes and prioritizing information technology support for clinical decision-making. VUMC’s transition to an EHR system in November 2017 entailed potential compromises to each clinician’s productivity and confidence. As one approach to that challenge, we reviewed thousands of clinical workflows in use across the medical center to analyze and design patient care processes that reflected best practices. This investment in the design process, with deference to the expertise of the clinical teams, created a virtuous cycle of ownership in developing workflows specific to each area. This investment supports mastery and, with the efficiency that is introduced, fulfillment.

The engagement of clinicians proved critical during the transition because it fostered resilience, which enabled rapid improvement during the EHR stabilization phase. As VUMC continues to optimize the system, this investment in the autonomy and mastery of our people has been an important step in clinician engagement and retention.

Another opportunity to cultivate mastery is creating a culture of support and community that is guided by the strengths-based principles of trauma-informed care. A trauma-informed approach to care recognizes that a healing environment starts with a commitment to safety for both the patient and caregiver, physically and psychologically. This sense of safety is only possible with trust, peer support, and collaboration in a shame-free workspace; it recognizes that both clinicians and patients can experience trauma in service delivery and deserve to be understood. Every individual has a role in this approach to care. For support, VUMC has set aside safe spaces, affectionately labeled “zen dens,” where clinical staff can find peace after difficult patient encounters or during periods of transition. Peer-support programs, such as clinical process groups, are offered regularly to help clinicians build resilience through understanding and learn how to emotionally support others.

In a broader way, VUMC has established a colleague support system that starts with intentional “coffee conversations.” The goal of these conversations is to intervene on behalf of a coworker from a place of support, accountability, and compassion to prevent egregiously unprofessional behavior from escalating—conduct that can arise from daily frustrations, hectic schedules, or personal issues that carry over into the care setting. This nonjudgmental approach to peer support comes from a place of respect. Simple conversations between peer clinicians can make individuals aware of their misbehavior and promote self-reflection and positive change. Such conversations are successful more than 75 percent of the time and can be followed by formal, guided interventions if the patterns of disruption persist (Dubree et al. 2017). Facilitating these conversations in an intentional way and providing follow-up support with a peer clinician or through an employee assistance program can build confidence based on mutual respect, high standards, and community values.

Finally, to celebrate progress at VUMC’s Vanderbilt Behavioral Health, those who exhibit exemplary behavior and our shared values (as nominated by their peers) receive awards at monthly community gatherings. Creating opportunities for natural fellowship and peer relationships, whether during meals, on outdoor excursions, or over coffee, can reinforce interpersonal growth, challenge, and fulfillment that fosters a trusting work environment where we can be our best for those we serve.

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Purpose

At the heart of mastery and autonomy is a belief in one’s identity and personal “why” or mission. The purpose motive is the foundation for personal resilience. Strength of purpose has long been a hallmark of healthcare, guiding committed clinicians through sleepless nights and long years of effort to tackle complex problems related to our nation’s health. Unfortunately, the imbalance between caregiving and administrative requirements in healthcare has contributed to burnout because the endless creep of these administrative functions detracts from this vital sense of purpose. In an ambulatory practice, clinicians spend twice as much time on administrative activities (e.g., documentation, order entry, billing, coding, e-mail) as they do on visits with patients (Arndt et al. 2017). Empirical work using observation and time studies to reveal the underlying sources of administrative distractions can lead to meaningful insights and help prioritize improvements for developing best practices. We can measure the impact of interventions against certain targets and the overall goal of reducing the weight of this administrative burden. VUMC has begun studies to identify EHR functions that can be moved from clinicians to administrative support staff to improve professional satisfaction. To fully appreciate the growth of the administrative burden as a result of regulations, third-party payers, and evolving EHRs, one need only look at the growth in the cost of healthcare relative to the number of administrators and clinicians since 1970 (Woolhandler and Himmelstein 1991).

Fortunately, there are several ways to protect a sense of purpose to prevent burnout among clinicians. A human-centered approach to leadership and communication across the organization can reinforce the “why” in each clinical team. Utilizing all channels to engage stakeholders, from e-mail and signage to face-to-face meetings, organizations can incorporate inspirational elements that remind clinicians how they are changing lives in a very personal way. Communication that orients clinicians toward the desire to heal, rather than merely to boost a ranking or beat competitors, can help sustain this sense of purpose. The organization can set purpose-driven goals and policies to support the deeply motivated healthcare workforce. This commitment must be a central part of any effort to build a compassionate culture that nurtures individual resilience and wellness because it can help develop healthy patterns of thinking.

Resilience training also prevents and treats symptoms of burnout among clinicians. This training can create a positive multiplier effect by building self-awareness and personal capacity that can mitigate the human factors that lead to fatigue and stress. This training also can empower clinicians with new skill sets to succeed on teams and in leadership positions.

Wellness programs and diversity initiatives that promote engagement can contribute to this resilience effort. VUMC has instituted systemwide unconscious-bias training (including in all residency programs) to make diversity and inclusion intentional. This training does more than identify personal biases to improve self-awareness of one’s role in the community. It also empowers individuals to recognize unhealthy patterns of thought that can be detrimental toward themselves and others—fear, protectionism, racism, and feelings of personal inadequacy, to name a few. Training can help limit the negative cycles associated with these patterns of thought, such as recurrent frustration or regret due to circumstances beyond one’s control. Diagnostic questions for self-care and personal reflection are a good way to start this process (Nedrow, Steckler, and Hardman 2013). For example:

  • How can I take care of myself so that I can be of service to others?
  • How can I strive for excellence and, at the same time, have compassion for myself when I don’t have all the answers or make a mistake?
  • How can I offer my expertise to cure illness while staying open to what my patients can teach me about their own healing?
  • How can I maintain an empathetic connection with patients and simultaneously protect myself?
  • What did I learn today? What am I grateful for today? What inspired me?

A worthy organizational goal might be to offer individual skills training and resources that will help clinicians address the risks often embedded in medical culture and associated with their relentless exposure to complex patient needs and compressed schedules.

In all healthcare organizations, especially during periods of high stress, finding ways to personalize the mission and nurture individual passion can increase the sense of purpose; enhance the energy needed to overcome daily obstacles; and build capacity for resilience, fortitude, and perseverance. The online publication Pulse: Voices from the Heart of Medicine (https://pulsevoices.org) exemplifies this effort by sharing personal accounts and insights from the experience of loss, healing, and caring. These stories give hope, inspiration, and comfort. Similarly, VUMC uses “credo stories” to bring alive care moments and teamwork that reflect our core values in a very personal way and remind ourselves why we do what we do every day for patients and for the mutual support and wellness of our colleagues. Work diaries and interviews are other ways to evoke the “why” in our reflections each day. This process reinforces trust in the organization’s foundational values and confidence in ourselves as we face each day’s marathon. Nothing replaces the human connection to remind our people how powerful and absolutely central it is to be person centered in our caring process. Caring for patients and caring for each other are equally important and are mutually supportive. This humanistic approach to communication and training not only leads to emotional intelligence, which in turn supports good leadership and team building, but also enables perseverance and grit, which are integral to wellness and long-term achievement.

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New Models

Transformational business models are being adopted by healthcare organizations to improve clinician wellness. CareMore, for example, is a health plan and integrated healthcare delivery system whose mission is to make healthcare more accessible, affordable, and simple for the high-risk Medicare and Medicaid patients it serves. The model uses primary care providers as the hub, while patient extensivists and case managers add support beyond the traditional healthcare setting (e.g., personalized fitness regimens, patient transportation via Lyft, post-discharge meal plans). CareMore aims to make the care process more fulfilling for caregivers and improves outcomes for patients through personalized care that identifies the root causes of their needs across the determinants of health, whether behavioral, economic, environmental, or social.

The efficacy and scalability of CareMore and other new caregiving models and wellness programs in reducing long-term clinician burnout remains to be seen. What is compelling about these potential disruptors is their systemic approach to addressing the underlying stressors in healthcare, rather than focusing on incremental improvements such as hiring support staff for administrative functions or teaching coping mechanisms. Applying organizational design approaches to mastery, autonomy, and purpose invites new opportunities and transformative incentives that can align with patient needs and the hearts of clinicians.

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Conclusion

Although turnover and burnout vary across markets and organizations and although new policies and disruptors come and go, the role of leadership in engaging clinicians and designing participative systems to harness motivation as a force multiplier will endure. Leaders who listen with humility to their clinicians, connect through shared values, and instill a sense of shared responsibility for the culture and joy that we all seek are vital in helping organizations attract, retain, and develop talented clinicians. Leaders can provide clear vision in uncertain times, help clinicians stay connected to their teams, and create a community of fellowship that can serve as a renewable well of passion and fortitude.

The human factors and uncertainty associated with healthcare are ever present given patients’ evolving needs and a highly complex industry structure. Leaders must exemplify and nurture passion in clinicians and care teams. Tracing the word passion to its ancient Latin root passio, meaning “suffer” or “endure,” reminds us why passion always carries some degree of suffering for love. Our clinicians and staff face a marathon of stressors each day. Anticipating their physiological and psychological strain, ensuring space and support during the inevitable crash that occurs in quiet moments, and knowing their capabilities and limits while making good decisions on their behalf are essential qualities of the healthcare leader.

Developing leaders who have this participative competency and emotional intelligence and who can remove sources of frustration and inefficiency will continue to be a pillar of organizational success. Aligning organizational goals and incentives for engagement, retention, and patient experience will help ensure appropriate focus and investment in our people during this critical period of vulnerability and opportunity in healthcare.

Healthcare organizations today need servant leaders who are patient focused and willing to adapt boldly on behalf of the intrinsically motivated clinicians they support and the patients they serve. It is the role of the leader to ensure sustained commitment to the promise of making healthcare personal for patients in a safe and healing environment as new technology expands access to care, new regulations standardize the delivery of care, and new payment models disrupt reimbursement. Through this constant change, the healthcare workforce remains paramount among all industries in compassion and dedication. It is our privilege and duty to protect and nurture this uncommon virtue in ways that promote wellness, initiative, and innovation to overcome the challenges ahead.

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    © 2018 Foundation of the American College of Healthcare Executives