In 1999, the Institute of Medicine (IOM) published the landmark To Err Is Human report, exposing widespread dangers to patient safety from medical errors. Two years later, its Crossing the Quality Chasm report acknowledged an open secret: The U.S. health care delivery system does not provide consistent, high-quality medical care to all people.
American health care has never been the same. Those reports inspired the patient-safety and quality movements that have spread to every corner of health care.
Now the National Academy of Medicine (NAM)—successor to the IOM—has turned its attention to clinician well-being. A NAM ad hoc committee is working on a consensus study, the same process that resulted in To Err is Human and Quality Chasm.
“Those drove transformative change in health care delivery, and it is our vision that this report on clinician well-being will have a similar impact for the field,” said Charlee Alexander, a NAM program officer.
Why a Consensus Study Is Needed
The topic of burnout among physicians and other clinicians began to attract attention several years ago but it took a 2016 survey, funded by the AAN, to understand its full impact on neurologists. That study showed that nearly 60 percent of respondents reported at least one symptom of burnout, and neurologists reported higher levels of career dissatisfaction and career-life imbalance than their peers in other specialties.
As the scope of the burnout epidemic began to be understood, researchers turned their attention to the reasons behind it and found plenty to things—electronic health record (EHR) technology, lack of autonomy, work overload, regulations and others—to focus on.
What remains unknown is how to prevent burnout and mitigate the damage it is doing. As individual organizations experiment with strategies—for example, EHR training and mentorship programs—to address issues they can control, the NAM committee is focusing on regulations, the move to outcomes-based payment, and other burnout-inducers at the systems level.
The consensus report, expected late this year, will carry the weight of one of the most influential organizations in health care.
“The only official National Academy of Medicine recommendations come as a result of a consensus study process,” said Neil A. Busis, MD, FAAN, chief of neurology at UPMC Shadyside in Pittsburgh.
Dr. Busis, principal investigator of the AAN's research studies on burnout, career satisfaction, and well-being in neurologists, is the only neurologist on the 17-person NAM consensus study committee.
That committee, chaired by Christine K. Cassel, MD, former president and chief executive officer of the National Quality Forum, and Pascale Carayon, PhD, director of the University of Wisconsin's Center for Quality and Productivity Improvement, started its work last October. It is spending about a year examining the scientific evidence about the causes of clinician burnout, the consequences for clinicians and patients, and the evidence about which interventions work.
Dr. Busis hopes the consensus study will elevate clinician wellness to the same level of priority given to health care's so-called “Triple Aim” of improving the health of populations, health, the patient experience of care, and reducing the per capita cost of care.
“We need to move toward the ‘Quadruple Aim,’ where clinician wellness is just as important as all those topics,” he said,” adding that clinician wellness should be used as a scorecard in health care organizations.”
The NAM Action Collaborative
The NAM consensus study is related to, but different than, the NAM Action Collaborative on Clinician Resilience and Well-being. The Collaborative, which started in January 2017, is a forum for sharing resources and perspectives rather than making recommendations for national policy.
“Due to the convening power of the National Academy of Medicine and our ability to bring together many different stakeholders to a neutral playing field, we really try to tackle organizational systems and culture change,” said Alexander, director of the Action Collaborative.
The Collaborative will work through December 2020. That will give its participant organizations a full year to work together as they begin implementing recommendations from the consensus study, she said.
The Collaborative is chaired by Darrell G. Kirch, MD, president and chief executive officer of the Association of American Medical Colleges; Thomas J. Nasca, chief executive officer of the Accreditation Council for Graduate Medical Education; and NAM President Victor J. Dzau, MD.
Among other things, they are convening experts for public meetings that delve into specific aspects of clinician burnout. A meeting last year, for example, explored how loneliness and isolation contribute to burnout; in May, a public meeting will focus on redesigning the clinical learning environment.
Meanwhile, about 65 individuals representing a wide range of health care stakeholders are organized into five working groups to carry out the Collaborative's work. Dr. Busis, the only neurologist with an official role in the Collaborative, serves on the steering committee and co-chairs the messaging and communications work group.
That group is responsible for the Knowledge Hub, a searchable database of peer-reviewed studies, reports, toolkits, opinion articles, and other resources about clinician well-being. The hub includes descriptors of and links to the AAN's burnout studies and its Live Well, Lead Well toolkit, along with resources specific to other medical specialties and other types of clinicians and trainees.
“We are bringing those resources into one comprehensive place where people can go to learn about burnout and also search for resources that are most relevant to them,” said Kyra Cappelucci, the NAM communications officer who is staff lead of the working group.
What Works in the Real World?
Despite the vast amount of knowledge about burnout that has been accrued in recent years, many, perhaps most, physicians are working in academic departments or private practices that are doing little or nothing to address the problem. Even in major health systems with high-profile anti-burnout initiatives, it takes a long time for a strategy to be piloted, tested, adjusted and rolled out throughout the organization.
Thus, at the moment, many physicians and practice managers are on their own to address the burnout-drivers that are affecting them or their colleagues. Dr. Busis wants the Knowledge Hub to be the go-to resource for individuals who are looking for guidance on what they can do right now.
In the months ahead, the hub will publish case studies and reports of well-being improvement projects so individuals can learn from what others are doing.
“We're going to offer in-depth interviews with leaders that explain how their initiatives work and what they could do better,” he said. “This will be the type of information that you can't find anywhere else.”