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How Neurologists in Independent and Academic Practices Are Tackling Burnout

ARTICLE IN BRIEF

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PRACTICE LEADERS should not initiate anti-burnout strategies until they have asked their physicians to identify the burnout drivers in their work setting, experts say.

Independent and academic physician practices of all sizes are beginning to develop strategies to address burnout. The strategies range from working a four-day week and hiring more advanced practice providers, to pairing with a neurohospitalist program and scheduling regular dinners and community-enhancing programs to encourage clinicians and health care professionals to connect with others.

It took a minute to digest the news: Neurologists suffer a higher rate of burnout and career dissatisfaction than any other medical specialists. Indeed, six out of 10 neurologists report at least one symptom of burnout, potentially compromising their own well-being, patient care, and the physician workforce.

But as they came to grips with the findings of research studies conducted by the Academy and others, all good practice leaders arrived at the same question: What should we do?

Colin P. West, MD, PhD, co-director of the Program on Physician Well-being at Mayo Clinic, gives a complicated answer. “There are no best practices,” he said. “Many interventions might work.”

Dr. West is one of the nation's top researchers in clinician burnout, publishing more than 40 papers on the topic in the past decade. He and others have found many drivers of burnout — and thus, many possible solutions — but they are all specific to the work environment.

For some practices, it's the hassle of fighting insurance companies that burdens physicians to the point of burnout. For others, it's the overall workload. Or it's the stress of treating patients whose condition will only deteriorate.

Practice leaders should not initiate anti-burnout strategies until they have asked their physicians to identify the burnout drivers in their work setting — and their ideas for mitigating the problems.

“A top-down solution could end up actually alienating people if it is a solution that was never the one they needed in the first place,” Dr. West said. “They will feel like ‘Well, there you go not listening to us again.’”

The leader's message should be: I'm concerned about physician burnout, I am committed to making the work environment better, and I need your help to identify the right strategies.

“You say: ‘You know what? I don't know what the best answer to this is. The first step is to work with you directly to find out what is going on in your work area that's going to suggest the best solution,” he said.

With that in mind, Neurology Today asked physicians in a range of practice settings to share their anti-burnout strategies.

TAKE TIME TO BREATHE

Abington Neurological Associates, with eight neurologists and three physician assistants, serves Montgomery and Bucks counties north of Philadelphia. Chief Operating Officer Brad Klein, MD, MBA, FAAN, says moving to a team-based model of patient care is one of his most successful anti-burnout moves.

Hiring physician assistants (PAs) and nurse practitioners requires trial-and-error to find the right people, an extensive on-boarding period, a well-executed training program, and an upfront investment in their salaries and benefits for more than a year before the practice sees a financial return.

And it's all worth it, Dr. Klein said. “They have become a critical component of my practice. I can't do without them.”

The practice's PAs work at the top of their license, doing what they are clinically trained to do, Dr. Klein said, so they can share the patient load. Dr. Klein's PAs take the last hour of each day to handle administrative tasks, such as disability paperwork, that used to fall to him.

“I've eliminated a lot of that from my daily routine,” he said. “They've taken on those roles and at the end of the day, it's working out quite well for all of us, clinically and financially.”

Medical assistants are also important members of the team. In his practice, the medical assistants enter information — medications, family history, major complaints and so forth — into the electronic medical record, as well as the quality metrics required by various initiatives.

“Many of those clicks go away,” he said. “So, when I'm with a patient, the only thing I have to worry about is the active history, the exam, the assessment, and plan —and I'm done.”

Chief among his strategies is to set boundaries. As a headache specialist, Dr. Klein has learned that after-hours phone calls will never stop — and that staying late every night is a fast track to burnout. The best thing he can do for patients is to be well-rested so he can listen to their concerns with a fresh perspective.

“Accepting that I have my limitations was an important thing for me,” he said.

Physicians at Abington Neurological see patients four days a week. “We feel very strongly about balance so we have decided, as a practice, our culture will be to work four days a week,” Dr. Klein said.

Physicians who want to work on the fifth day can work at the practice or outside the practice. But Dr. Klein likes to use the day for things not related to patient care, like attending his children's school activities.

“When new docs come in, they question whether they want that extra day off because it costs us money, of course,” he said. “But once they experience it, even though they are taking a financial hit, they don't want to go back to five days.”

Dr. Klein, past president of the Pennsylvania Neurological Society, is a graduate of the Academy's Advocacy Leadership Forum and is vice chair of the AAN Medical Economics and Management Committee. He has worked in advocacy at the state and federal level for more than a decade.

The time and effort involved in advocacy work is offset by the empowerment of pushing for positive change. “That's actually become my release valve,” he said. “When I'm involved in advocacy, I feel like I'm helping change the system for the better so I can take care of my patients the way I feel is necessary. I want to be in control of how things operate and the only way of doing that is to be involved in the advocacy to make it happen.”

MAINTAIN AUTONOMY

Andrew Gordon, MD, a partner in Northwest Neurology, a five-office practice in the Chicago area, believes the autonomy that comes with an independent practice is its own anti-burnout strategy.

His practice includes 17 neurologists, four mid-level practitioners, and one neuropsychologist. Because of its large size, it can afford to offer many onsite services: infusion, magnetic resonance imaging (MRI), encephalography (EEG) and video-EEG, electromyography, ultrasound, sleep studies, botulinum toxin for neurological conditions, and neuropsychological testing. Because the services are offered onsite and are typically less expensive than hospital-based services, clinicians have the satisfaction of knowing they are making life easier for their patients. And those services add revenue streams that reduce the financial pressure to constantly increase the patient load.

“One of the prevailing ideas out there is you have to sell your practice and be employed by a health system, and let someone else do everything for you,” Dr. Gordon said. “We are the opposite. We own our practice and, professionally and clinically, I think we have a higher level of autonomy for our physicians.”

The key, in Dr. Gordon's view, is building a practice that is large enough to allow investment in a high-performing administrative staff as well as in the space, equipment, and staff needed to offer infusions, imaging, and other services.

“We have done a really nice job of developing an autonomous practice model that is sustainable despite all the challenges in modern health care, without having a lot of physician burnout,” Dr. Gordon said.

Northwest Neurological's other success factor is a neurohospitalist program, involving five neurologists and three advanced practice nurses who work at all the area hospitals.

“We don't work for a hospital system, but we partner with the hospitals,” he said. “If we didn't partner with the hospitals, they might be tempted to hire neurologists to compete with us.”

The neurohospitalist program is organized with an eye toward preventing burnout for both the hospital clinicians as well as their office-based colleagues. Because the neurohospitalists handle hospital call duty and round on Northwest Neurology patients, their long hours are rewarded with 20 weeks off-duty each year.

“On the outpatient side, we fill our doctors' schedules with patients, of course, but we don't have them taking hospital call and rounding at the hospitals,” Dr. Gordon said. “So they don't have that difficult situation of being pulled in too many directions, which contributes to burnout.”

PUT BURNOUT ON THE FRONT BURNER

Amy Sullivan, PsyD, serves as director of behavioral services at the Mellen Center for MS Treatment and Research in the Neurological Institute at Cleveland Clinic. The Neurological Institute is comprised of about 1,300 staff, including more than 300 medical, surgical, and research specialists.

One of her professional interests is workforce happiness, which is why Dr. Sullivan was reviewing the Cleveland Clinic's physician-engagement data a couple of years ago. Soon, she was in the office of Neurological Institute Chairman Andre Machado, MD, PhD, talking about the prevalence of significant physician burnout: “I said ‘we have to do something about this,’ and he said, ‘You're right, we do.’”

Thus, in January the Neurological Institute became the first institute in the Cleveland Clinic enterprise to have a physician-engagement team. Dr. Sullivan serves as its chair. Her work started with a deeper dive into the institute's Press-Ganey physician engagement data to identify the top areas of concern: staffing levels, stress, work/life balance, support needed to provide the best care for patients, and feeling valued at work.

She recruited a team of physicians, advanced practice providers, nurses, researchers, and administrators to help with the engagement effort. The burnout epidemic extends to nurse practitioners, physician assistants, nurses and other clinicians, so a holistic approach is needed, she said.

“Although I was appointed for physician engagement, I believe this is an enterprise-wide problem with varying levels of degrees,” she said. “We are developing a plan of attack for provider engagement, meaning everyone who works here because we all provide a service of some sort.”

The team's mission statement: To be leaders in creating a culture of well-being at work. One of the first goals is to raise awareness about the importance of recognizing signs of burnout and prioritizing self-care.

Dr. Sullivan writes a monthly blog on burnout-related issues. A recent post was devoted to loneliness, which is an emerging topic in the literature of burnout.

“We are finding that, even though we are connected with our phones, on the internet, and with the electronic medical record — and we are working in these large interdisciplinary teams — many people are very lonely because they don't interact with each other like they used to,” she said.

The physician-engagement team, along with other groups at the institute, recently hosted grand rounds and a forum featuring two experts in the fields of resiliency, self-care, and burnout. Every other month, she and Dr. Machado host engagement dinners, in which about 20 physicians are invited to share their concerns and suggest ways to mitigate burnout.

In addition, Cleveland Clinic started offering an annual “well-being” day to help physicians focus on the importance of taking care of themselves. “Whatever it is, we encourage people to do something that is going to benefit their well-being.”

MEET FOR DINNER

The more than 3,700 physicians and scientists on staff at all Mayo Clinic locations are invited out to a restaurant meal — at Mayo's expense — once a week and again in two weeks, and twice a month for the next five months.

The only catch is that those meals must be taken in the company of six or seven colleagues who have convened as a COMPASS (Colleagues Meeting to Promote And Sustain Satisfaction) group.

The program launched in October 2015; since then, nearly 1,500 physicians and scientists have joined a group, said Dr. West. The goal is to build community within the workplace.

“No matter if they're in a solo practice or in a large group practice, physicians very often will report that they don't feel connected to their colleagues and they feel isolated,” he said. “It may not matter how much an institution does to set up a good working environment if the physicians within that working environment aren't working within a positive social structure.”

COMPASS group participants spend part of each shared meal together discussing a question — anything that promotes introspection and sharing. Questions might include, for example, why are you a physician? Or what do you value about this profession? A randomized trial, conducted before COMPASS expanded across the organization, found that participating in these meetings over several months led to an improvement in physicians' “meaning in work” and a reduction in burnout.

That strategy — cultivating community at work — is one of nine anti-burnout strategies at Mayo described in a Mayo Clinic Proceedings article earlier this year. (See the box, “Anti-Burnout Strategies.”) The Clinic launched many of those strategies in 2014 after a survey found that its physician burnout rate, historically below the national average, was on the rise.

By 2015, Mayo's physician burnout rate had dropped to 32.9 percent, compared to 48.8 percent for physicians nationally. This suggests that its anti-burnout strategies are working, but Dr. West said none should be considered a magic bullet for all organizations.

Rather, the list of strategies can provide a starting point for thinking about how to mitigate burnout.

“It's certainly a very powerful menu to get that conversation started, but the individual work settings have to be empowered to adapt that larger menu to their local circumstances,” he said.

ANTI-BURNOUT STRATEGIES

Nine anti-burnout strategies used at Mayo Clinic are described in detail in a Mayo Clinic Proceedings article published earlier this year:

  • Acknowledge and assess the problem
  • Harness the power of leadership
  • Develop and implement targeted work unit interventions
  • Cultivate community at work
  • Use rewards and incentives wisely
  • Align values and strengthen culture
  • Promote flexibility and work-life integration
  • Provide resources to promote resilience and self-care
  • Facilitate and fund organizational science

Source: Shanafelt TD and Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc, Jan 2017: 92(1): 129-146.

LINK UP FOR MORE INFORMATION:

• Busis NA, Shanafelt TD, Keran CM, et al. Burnout, career satisfaction, and well-being among neurologists in 2016 http://www.neurology.org/content/88/8/797.short. Neurology 2017;88(8):797–808.
• Levin KH, Shanafelt TD, Keran CM, et al. Burnout, career satisfaction, and well-being among US neurology residents and fellows in 2016 http://www.neurology.org/content/89/5/492.short. Neurology 2017;89(5):492–501.
• Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout http://www.mayoclinicproceedings.org/article/S0025-6196(16)30625-5/abstract. Mayo Clin Proc 2017;92(1):129–146.