Article In Brief
A new report from the National Academy of Medicine calls for action and change in addressing physician burnout. AAN leaders and other neurologists praise the report for focusing on systems-based strategies.
Neurologists who focus on the growing crisis of physician burnout are praising “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being,” a new report from the National Academy of Medicine (NAM), as a seminal work in the field that will have an impact similar to that of the Institute of Medicine's landmark 1999 report on medical errors, “To Err is Human.”
“This is a gamechanger” said Heidi Beck Schwarz, MD, FAAN, professor of clinical neurology at the University of Rochester Medical Center and the co-chair of the AAN's Joint Coordinating Council on Wellness.
“I was wondering if this report was going to be a bit noncommittal, and when I saw it I was so enthused and heartened by the fact that it has very strong statements that are backed up by facts and figures. It is a clarion call to the health care community that we need to acknowledge burnout as a major issue with implications that ripple throughout health care, and if left unaddressed will lead to fewer providers, poorer quality care and patient disengagement. Burnout will bring down the health care system. Nothing less than that.”
During a press briefing announcing the release of the report on October 23, NAM President Victor J. Dzau, MD, spotlighted the scope of the crisis. “Over 50 percent of physicians and 45 percent to 60 percent of medical students and residents have symptoms of burnout,” Dr. Dzau noted. “There are high prevalence rates of symptoms of post-traumatic stress disorder and emotional exhaustion among nurses and many other professionals.”
And as Neurology Today and Neurology have frequently reported, neurologists are disproportionately affected by burnout, with surveys showing that they have some of the highest burnout rates of any medical specialty.
The report could not come too soon for clinicians like Dr. Schwarz and others on the AAN's work group, who have been vocal advocates for systemwide attention to the issue of clinician wellness. “There hasn't been a lot of traction at the leadership level at many institutions acknowledging that this needs to be done. When you don't have that kind of buy-in, you may get one-time lectures and in-services, but you don't get real change,” she said.
AAN leaders praised the report's authors for focusing on systems-based strategies rather than individual coping mechanisms. “While individual resiliency is a factor it is a relatively minor one compared with the ‘system incompetence’ that is a root cause of the burnout problem,” said Deborah Young Bradshaw, MD, FAAN, associate chair for education and residency program director in the neurology department at State University of New York Upstate Medical University in Syracuse.
The report lays out six critical areas of focus for improving clinician wellness and combating burnout, including creating positive work environments, addressing burnout in the training and early years, reducing administrative burden, improving the usability and relevance of health information technology, reducing the stigma and improving burnout recovery services, and creating a national research agenda on clinician well-being.
Leaders of health care systems should consider how their business and management decisions, such as implementation of new technologies, will affect clinicians' jobs, taking into account the potential to add to their levels of burnout, the report authors wrote. They call for continuous monitoring and evaluation of burnout levels, with reports on the issue at least annually. The report also recommends that health care organizations establish an executive leadership role—like the “Chief Wellness Officer” positions that have been established at institutions like Stanford—dedicated to clinician well-being.
“We need good leadership to establish a working and learning environment that is conducive to help people grow and do their best work,” said Jennifer Rose V. Molano, MD, FAAN, associate professor of neurology at the University of Cincinnati and chair of the AAN's Live Well, Lead Well initiative, which seeks to empower neurologists to mitigate burnout and promote wellness at the individual and organizational level.
“In the clinical space, is the team working well together? Are they able to work in a way that allows them to care for the patient as well as take care of themselves? Are there systems that allow the clinical team to identify what is causing barriers to their workflow and figure out ways to solve them?”
The science of human factor design should play a much bigger role in the way medical centers are set up, said Dr. Bradshaw. “I think a lot of frustrations we experience in the hospital and the clinic is due to poor workflow engineering and poorly designed workspaces. The same is true of electronic health records. I don't think clinicians were brought in early enough to design them to be intuitive for clinicians. I'm glad to see that the report emphasizes human factor design.”
To mitigate burnout during training and early clinical careers, medical, nursing, and pharmacy schools should consider steps such as monitoring workload, implementing pass-fail grading, improving access to scholarships and affordable loans, and creating new loan repayment systems, the report said,
The report also recommends that federal and state bodies and organizations such as the National Quality Forum reconsider how their regulations and recommendations contribute to burnout. Organizations should seek to eliminate tasks that do not improve patient care—specifically evaluating regulations and standards related to payment, health information technology, quality measurement and reporting, and professional and legal requirements for licensure.
“I'm very happy to see the report calling for accurate assessments of the total workload and measuring the complexity of the tasks expected of clinicians—including things like continuing medical education, maintenance of certification, and institutional learning modules,” said Dr. Bradshaw. “I would say that a lot of the frustration experienced by clinicians is non-RVU based work, which also includes things like answering patient phone calls, completing forms, and answering portal requests. None of those are reimbursable or tracked in any way, yet often those are the things that exhaust us.”
She noted that insurance companies and regulators, in a well-meaning effort to prevent fraud, often place further burdens on physicians. “Several years ago, there was a lot of durable medical equipment [DME] fraud, and Medicare lost millions on unnecessary medical equipment. Now, when I see a patient in the muscular dystrophy clinic, I have to fill out a very specific form using a very specific template with very specific information to verify that, yes, this patient needs this particular wheelchair. Often getting the paperwork right requires multiple iterations. It's meant to prevent fraud, but it's quite a lot of work placed on the clinician. That work is completely invisible to chairs and administrators.”
To improve the usability and relevance of health information technology, medical organizations should develop and buy systems that are as user-friendly and easy to operate as possible. They also should look to use IT to reduce documentation demands and automate nonessential tasks, the report said.
Surveys done at the Icahn School of Medicine at Mount Sinai in New York have identified overwhelming documentation requirements as near the top of the list of day-in-day-out burdens that make modern medical practice so stressful.
“It's set up so that you can't really complete your electronic documentation while in the office, so you have to do it at home, which interferes with family and personal time,” said Mark W. Green, MD, FAAN, professor of neurology, anesthesiology, and rehabilitation medicine, who serves as a “wellness champion” for neurology at Mount Sinai. “With our electronic health record, if you have a problem, getting them to fix something takes forever, and sometimes prevents you from seeing a patient because you can't access their information.”
Reducing stigma and improving burnout recovery services is an important goal, the report said. State officials and legislative bodies should make it easier for clinicians to use employee assistance programs, peer support programs, and mental health providers without the information being admissible in malpractice litigation.
The report noted the recommendations from the Federation of State Medical Boards, the American Medical Association, and the American Psychiatric Association on limiting inquiries in licensing applications about a clinician's mental health. Questions should focus on current impairment rather than reach well into a clinician's past, the study authors wrote.
“Even the language we use can put the burden on the person with the issue,” said Dr. Green. “We talk about ‘wellness,’ but if the implication is that if you're burned out or ‘not well,’ there's something wrong with you. Like you're a wimp and you should have done better. People want to feel like they can be helped, not like they're weak.”
Cormac O'Donovan, MD, associate professor of neurology and director of the peer support program at Wake Forest Baptist Health, has spoken publicly about his own experience with burnout.
“About five or six years ago, there was a difficult case in the hospital and things didn't go well. It was very stressful for all team members including myself, and I ended up taking time off for personal concerns about burnout,” Dr. O'Donovan said. “Over [in] that process I learned about how to improve self-care and met with many other physicians struggling to deal with the practice of medicine despite excellent reviews from their patients. Many physicians, when they're distressed or depressed, will seek care off the radar screen and out of the EMR. This is because that stigma still exists and they are worried about their licensure and reputation. More than half of us are burned out but no one's talking about it because they fear the risk to their career.”
Dr. O'Donovan hopes that by describing his experience, he can help and encourage other physicians who may be suffering in silence to come forward and connect with peers and gain support and acknowledgement for their struggles.
Several of the experts noted that prompt recovery and assistance services for clinicians in crisis are virtually nonexistent at many institutions.
“We need something like an ID card for doctors in terms of what is available for psychological crisis and other mental health issues in their institution,” Dr. Green said. “When you're having a crisis isn't the time to figure it out. We have emergency numbers and resources for what to do if the building catches on fire—but what happens if you catch on fire? It's important that every institution identify very easily what facilities available to their faculty in terms of psychological and medical problems, meaning where you can go and get care immediately, not ‘here's the number for the suicide hotline.’”
“Timely access to confidential services is a big problem,” agreed Dr. Bradshaw. “If I have a trainee who's in crisis, there's not a good system where I can pick up the phone and get that person to see a mental health provider quickly. I think that's a pretty common situation.”
Finally, the NAM report recommends that by the end of 2020, federal agencies—including the Agency for Healthcare Research and Quality, the National Institute for Occupational Safety and Health, the Health Resources and Services Administration, and the US Department of Veterans Affairs—should develop a coordinated research agenda on clinician burnout, the report said.
“Wellness work takes money,” said Dr. Molano. “There are some initiatives, like the ACGME's ‘Back to Bedside’ program, designed to empower residents and fellows to increase their time with patients and improve their well-being, but it's important for organizations to think more extensively about how we can fund research into wellness and well-being. It's a research need just like the need for clinical trials funding.”
Dr. Schwarz called for the AAN to use its advocacy platform to push such a research agenda forward. “We have money that we dedicate for different research projects. I feel strongly that we should create opportunities for people to apply for research funding to evaluate systems-based changes to promote wellness. We really need to put this on the map. Everybody likes prizes, right? Well, the AAN should think about creating a competition to highlight those institutions that are being forward-thinking and making changes, and can prove that those changes are affecting physician wellness and quality of care in a positive way.”
“This report sets a standard,” said Dr. Schwarz. “If institutions don't meet that standard, if they turn a blind eye to this or say that this is someone else's issue, they ignore this report at their own peril. If you choose not to consider these recommendations and their implications, if you choose not to make meaningful changes to improve your own system, then you will be subject to public shaming. Don't wait for somebody else to figure out a solution: you have to figure out your own.”