The Massachusetts Medical Society, the Massachusetts Health and Hospital Association, the Harvard T.H. Chan School of Public Health, and the Harvard Global Health Institute have officially labeled physician burnout a public health crisis that is slowly destroying the mental health of physicians and threatens to undermine the delivery of care throughout the country.
In January, the organizations released A Crisis in Health Care: A Call to Action on Physician Burnout,(www.massmed.org) a report designed to inform physicians and other health care leaders about the challenges that burnout creates and to prompt appropriate steps to address the issue. The report also includes a series of recommendations for short-, medium- and long-term interventions.
"The issue of burnout is something we take incredibly seriously because physician well-being is linked to providing quality care and favorable outcomes for our patients," said Alain Chaoui, M.D, a practicing family physician and president of the Massachusetts Medical Society, in a news release(www.hsph.harvard.edu) from the Chan school.
The report comes as recent evidence has shown burnout rates have reached more than 50 percent in some specialties,(www.medscape.com) and as estimates show that the United States could experience a shortage of more than 120,000 physicians in little more than a decade.(aamc-black.global.ssl.fastly.net)
- Four health care organizations in Massachusetts have released a report that labels physician burnout a public health crisis.
- The authors attributed burnout to a variety of factors that have caused additional stress and affected the way physicians can practice.
- The report also contains three action steps designed to provide short-, medium- and long-term benefits to those affected.
"We need our health care institutions to recognize burnout at the highest level and to take active steps to survey physicians for burnout and then identify and implement solutions," Chaoui continued. "We need to take better care of our doctors and all caregivers so that they can continue to take the best care of us."
Tracing the Origins of Burnout
The authors didn't pin the blame for the burnout crisis on any one event, but rather on a variety of contributing factors, including a provision in the American Reinvestment and Recovery Act of 2009 that mandated "meaningful use" of electronic health records (EHRs)(www.ncbi.nlm.nih.gov) by eligible physicians and hospitals who participated in Medicare and Medicaid.
They also pointed to a gradual erosion of professional autonomy and authority within the medical profession and the subsequent emphasis on metrics, rewards, punishments and costs. It's this conflict between the old and new ways of practicing medicine, the authors suggested, that lies at the root of the crisis.
Diagnosing the Problem
Most surveys of physician burnout have used tools such as the Maslach Burnout Inventory to document their feelings and experiences. The authors recommended taking steps to standardize and benchmark surveys, which will make it easier to compare results and track trends among physicians overall, as well as by specialty, gender and stage of career.
The authors also made clear what will happen if burnout is not adequately addressed. "If we do not immediately take effective steps to reduce burnout," they stated, "not only will physicians' work experience continue to worsen, but also the negative consequences for health care provision across the board will be severe." Those negative consequences could include fewer physician work hours, a reduced workforce, lower quality care, decreased patient satisfaction with care and an increased risk of medical errors.
Resolving the burnout crisis, the authors said, "will require action by all stakeholders across a range of domains impacting physician practice." They presented three action steps which, if implemented, could address burnout while physicians are still in training and could provide additional benefits in the medium and long term.
1. Support proactive mental health treatment and support for physicians experiencing burnout and related challenges.
Physicians who seek help dealing with burnout may feel stigmatized for doing so, and although the profession has tried to make it easier over the past few years, it can still be challenging(afsp.org) for physicians to get the help they need.
The authors recommended that physician organizations and other agencies take steps to make it easier for physicians to get the treatment and support they need without hindering their ability to practice. They noted recent efforts by the Federation of State Medical Boards to have member boards modify questions on licensing and renewal application that ask physicians about mental health, addiction or substance use, which could preclude physicians from seeking care for these conditions. The authors also acknowledged the role of state physician health programs, which could be a useful resource for residents and medical students.
2. Improve EHR standards with strong focus on usability and open application programming interfaces.
The authors wrote that EHRs "impose a frustrating and nonintuitive workflow" on many physicians, which reduces the time that could be spent with patients and creates a series of administrative chores "that do little, if anything, to advance the goals of patient care."
Part of that frustration is with the federal government -- specifically, the Office of the National Coordinator for Health IT (ONC), which last issued EHR certification standards in 2015. Although the ONC issued a draft document(www.hhs.gov) on reducing administrative burden related to EHRs last November, the final strategy document won't be published until the end of 2019.
New standards that address physicians' concerns about EHRs "are long overdue," the authors wrote, adding that the ONC's failure to issue new standards and address longstanding concerns over usability and workflow "has thus contributed to the significant challenges and obstacles physicians experience in using EHRs to effectively and efficiently achieve the goals of patient care."
To help solve this problem, the authors recommended that the ONC allow software companies to develop applications that can operate with most, if not all, certified EHR systems, and that these applications allow third parties to develop apps that can work with any EHR. This would give physicians and hospitals the ability to substitute one preferred app for another and to customize workflow and improve usability, while still collecting all necessary patient information.
3. Appoint executive-level chief wellness officers (CWOs) at every major health care organization.
These officers, according to the authors, would be senior part-time or full-time executives with the authority to work across departments and teams. Among other things, a CWO would be responsible for studying the scope and severity of burnout, exploring options that reduce administrative burden, and reporting on and sharing findings with other professionals.
The authors described several scenarios in which a CWO could be useful. At teaching hospitals, for example, CWOs could focus on the experiences of medical students and residents and use interventions that provide trainees with the necessary support. In other organizations, CWOs could lead efforts to survey health care professionals for burnout, identify barriers to success and develop appropriate solutions.
Advice From FP Co-author
Chaoui, who co-authored the report, told AAFP News that the burnout crisis is real and that it affects physicians regardless of specialty.
"We know that if the problem is not addressed, there will be repercussions for our patients and the health care system as a whole, as burnout drives compassionate and qualified clinicians away from practice," Chaoui said.
Turning his attention to family medicine, Chaoui cited statistics from the 2018 Medscape National Physician Burnout & Depression Report,(www.medscape.com) in which 47 percent of family physicians surveyed reported feelings of burnout. Chaoui called this number "troubling, but also not beyond the point of repair."
Chaoui attributed some of those feelings of burnout to the nature of family medicine itself, which emphasizes the ability to connect with patients and establish a bond -- something that's becoming less and less possible in the current health care system.
"Family physicians believe it is imperative to have strong relationships with the patients we care so deeply for, and burnout caused by systemic influences slices into face-to-face time with patients, and that puts in jeopardy the sacred patient-physician relationship," he said.
Chaoui advised family physicians to not take burnout lightly and not be afraid to seek assistance if necessary.
"First of all, if for any one reason the joy you take in practicing medicine begins to erode, take it seriously and don't chalk it up to a bad day or convince yourself that it's a result of your own lack of resilience," he said. "Do not hesitate to seek and get support."
Chaoui also took the opportunity to speak directly to family physicians.
"I would encourage you to urge your leaders to read our report as an additional way to make clear the magnitude of this crisis," he said. "If you can pinpoint some of the outside influences that are contributing to burnout, such as inefficient EHR or other administrative burdens, engage decision-makers and alert them to the issues and make a strong push to begin corrective measures."
Finally, Chaoui stressed the importance of physicians working together to advocate for change.
"The bottom line is all physicians should know that they are not alone, and that we are in this together," he said. "The only way to truly effect any meaningful change is through advocacy efforts and by continuing to stress that burnout is a threat to clinicians, the health care infrastructure and economy and, most importantly, patient care and outcomes."
AAFP's Continued Fight Against Burnout
The AAFP has made a concerted effort to listen to members' concerns and take steps to address both the causes and consequences of burnout. In July 2017, the Academy joined the Action Collaborative on Physician Well-Being and Resilience, a group of several dozen medical organizations working together to improve physician wellness. In September 2017, the Academy introduced the Physician Health First initiative at the Family Medicine Experience in San Antonio.
The Academy expanded those efforts in 2018. In April, the AAFP added a Well-being Planner to the Physician Health First portal to help family physicians plot a course to improved personal wellness and professional fulfillment. Also in April, the Academy held its first-ever Family Physician Health and Well-being Conference in Naples, Fla. Feedback from that conference was overwhelmingly positive.
In particular, the AAFP has made it a strategic priority to address administrative burden, which it sees as a root cause of stress for family physicians. In January 2018, the AAFP Board of Directors adopted the Academy's own Principles for Administrative Simplification, which cover issues such as prior authorization, quality measure harmonization, certification and documentation of medical services and supplies, and medical record documentation. In April, the AAFP launched the Transformation in Practice Series (TIPS) to simplify practice changes for family physicians. A new TIPS module added in October that is free to AAFP members covers team documentation, which could reduce burnout by freeing up time FPs may spend documenting patient encounters.
The Academy will continue working to fix the systemic causes of burnout while providing resources to assist family physicians in 2019. Among other things, registration is underway for the 2019 Family Physician Health and Well-being Conference in Phoenix this June. The AAFP also is in the process of adding an additional well-being evaluation tool and a performance improvement module to the Physician Health First portal. The Academy also has established an advisory and speaker panel called the Physician Health First panel, whose members have begun delivering presentations on physician well-being to AAFP chapters.
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