Article In Brief
At one institution, a wellness champion in the neurology department is responsible for identifying and helping to address drivers of burnout.
As New York's Icahn School of Medicine at Mount Sinai builds out a multi-pronged institutional effort to address burnout and support clinician well-being, Mark W. Green, MD, FAAN, professor of neurology, anesthesiology, and rehabilitation medicine, is taking notes in the neurology department.
As “wellness champion” for neurology, he serves as an information conduit—sharing the perspectives of his neurology colleagues with medical school leaders and gathering ideas for changes that could be undertaken within the department.
The program at Mount Sinai, which involves appointing wellness representatives across academic departments, is just one of many that have been established at academic medical centers across the country. Northwestern University, Emory University, The Ohio State University, Cleveland Clinic, University of Maryland, University of Utah, among other academic medical centers, have initiated similar programs—all with the same goal, to address drivers of burnout.
Neurology's burnout problem was first documented in a 2012 survey reported in Archives of Internal Medicine (now JAMA Internal Medicine) by Tait Shanafelt, MD, and colleagues. The survey of US physicians found substantial differences in burnout by specialty, with neurology reported to have one of the highest levels of burnout.
Similar findings regarding burnout among neurologists were reported in a series of 2016 surveys by the AAN reported in Neurology in 2017. And this year, Medscape's 2019 National Physician Burnout, Depression & Suicide Report, an online survey of 15,069 physician respondents, conducted in mid-2018, found that 53 percent of neurology respondents said they felt burnout out, compared with 44 percent on average for all physician specialties. Indeed, only urology—with a 54 percent burnout rate—had a worse showing than neurology.
“That was certainly a call to arms,” Dr. Green said. “We really had better deal with this.”
Mount Sinai's medical school launched a comprehensive approach to tackling burnout in 2018 when it created an Office of Well-being and Resilience. Jonathan Ripp, MD, MPH, was named senior associate dean for well-being and resilience; he is assisted by four other associate deans for well-being and resilience, administrative staff members, and a mental health advisor.
While they work at the system level, 24 department-level wellness champions like Dr. Green are tackling the issue with their immediate colleagues in mind.
“This comprehensive approach reflects what I believe to be an appropriate, although very significant, commitment to clinician well-being at the health system level, which we are seeing more and more around the country,” Dr. Ripp said.
A multi-tiered approach is needed because burnout is pervasive at all levels of the US health care workforce. At Mount Sinai, that means 40,000 employees and more than 4,000 physicians. While the system does support individuals who are trying to improve their own well-being, Dr. Ripp said, the institutional focus is on identifying and mitigating systemic issues.
“As the health care system has become more complex, there are more and more demands on the clinicians that take them away from the meaningful aspects of the practice of medicine,” he said. “Our entire goal is to try to drive change by influencing those big drivers of burnout in a way that's going to enable our clinicians to do their best work.”
What's Happening in Neurology
In his role as wellness champion for neurology, Dr. Green, director of headache and pain medicine at Mount Sinai, assembled a department wellness committee and, earlier this year, started conducting periodic focus groups. Participation is voluntary.
Each department-level wellness champion shares focus-group findings with his or her department chair who will report them to the medical school dean. While individual department leaders may be able to address some problems on their own, much of the feedback being gathered in the focus groups will require system-level attention, Dr. Green said.
Within the neurology department, focus group participants have expressed concerns that will be familiar to many neurologists across the country, Dr. Green said.
- Electronic health record (EHR) burden. The technology is clunky and subject to frequent updates, which requires retraining. Neurologists must choose between waiting until after-hours to enter their notes, risking that they will forget something, or entering data throughout a patient visit. “Patients don't like the doctor sitting in front of a computer typing,” Dr. Green said. “That's a regular complaint.”
- Use of patient-satisfaction surveys. Drug-seeking patients use satisfaction surveys “as a weapon” when their requests are refused, Dr. Green said. “Press-Ganey scores are involved in salary calculation to some degree,” he said. “They are so widely utilized and it concerns people because it isn't fair.”
- Challenges to personal wellness. Faculty members would like personal wellness days that they could use for their own medical appointments, as well as gym memberships, exercise classes, or other activities to promote mental and physical health.
- Appropriate pay for teaching. “The faculty is often concerned that there is really not much reward, even though we are a very large medical school, of any significance for teaching medical students,” he said. “This is a medical school, so faculty feel they should be rewarded similarly to the way they are for seeing patients.”
- Inadequate administrative support. Too few support staff—and high turnover among administrative staff, possibly because of low pay—to help with prior authorization requests and other administrative duties.
What's Happening Across the Institution
At the institutional level, Dr. Ripp said, initiatives fall into two main categories: workplace efficiency and workplace culture. In the efficiency category, the focus is on optimizing the way the EHR system works and changing workflows so that physicians do not have to handle administrative tasks that other team members can deal with.
Anna Pace, MD, a headache specialist in the neurology department at Mount Sinai, was “a little doubtful” that an EHR optimization session was going to make a significant improvement in her daily work life, but she was surprised to learn how much difference keyboard shortcuts could make.
“I can spend more face-to-face time with the patient as opposed to spending five minutes typing up a medication,” she said. “Prior to the optimization I spent so much time clicking—now I can do more of what I think makes a big difference in patient education and care.”
Cultural change is perhaps more challenging because, Dr. Ripp said, medical culture reflects forces from outside the Mount Sinai system.
“Across the country, medicine has become more of a business and factors external to our health system are influencing this culture,” he said. “A lot of our physicians and clinicians who got into this work because they want to provide great patient care or do the highest level of research or be educators find a lot of the demands placed on them—and placed on the health system—externally have changed the culture a bit.”
His office conducted an in-depth survey of all clinicians to identify burnout drivers, which Dr. Pace appreciated.
“The fact that they are asking physicians how they feel and what they feel like are big contributors to burnout is huge,” she said. “Just asking the questions and starting the conversation is a great first step. We still have a lot of work to do, and I think most institutions do, but it's a good place to start.”
Dr. Pace was a neurology resident at Mount Sinai when the organization made its first efforts to promote resident wellness a few years ago. Residents were grouped in triads—a junior resident and two more senior residents, for example—to serve as one another's support team.
“Once a month our groups would go out to dinner or meet for coffee to check in with each other and make sure work and life were OK,” she said. “I think this worked well because we would just be there for support for each other if one was struggling or needed to talk. And it was a good excuse to get together outside of work to talk about other things too.”
Creating a culture in which clinicians at all levels feel supported will take time, Dr. Ripp said. He intends to use evidence-based tactics to address burnout drivers identified from the clinician survey.
For example, research shows that when leaders demonstrate certain domains of leadership—say, recognition for a job well done and taking an interest in a subordinate's career—the staff members who work for them score higher on measures of well-being.
“We're going to try to take that on by creating some straightforward leadership training in that area,” he said.
One Neurologist's Perspective
Michelle T. Fabian, MD, a neurologist at Mount Sinai's Corinne Goldsmith Dickinson Center for Multiple Sclerosis, is glad to see the wellness focus at the institutional and department level. But interventions to address the burnout crisis will take time to develop, and she's not sitting idly by.
“This is the system's responsibility, and we need to be advocates—for ourselves and for everybody else—to fix the system,” she said. “But I also think that we do have power to stay well or become well, and we need to feel like we're empowered in that regard. Otherwise, it's hopeless.”
She stays motivated by framing her own wellness as a professional imperative. “I take care of hundreds of patients with MS, and I just have realized through the years, if I am not well, I cannot be a good physician to them,” said Dr. Fabian, who also serves as neurology clerkship director.