Diksha Mohanty, MD

CASE

Dr. Peter D is a mid-career family physician in a group practice that recently adopted an electronic health record system. Although he realizes he is now competent at computerized medicine, he has far less of the one-on-one patient contact that he once found so gratifying about the field of medicine.

Others in the practice have similar concerns, but they suggest that everyone ought to “go along to get along.” To manage the increasing demands of his case load and the required documentation, Dr. D has begun staying late to finish charting, which is negatively impacting his family life.

Dr. D finds himself burdened by record keeping that is increasingly complicated and insurance company demands that are onerous. Pharmaceutical prior authorizations that previously had been mildly bothersome are now a full-on burden. More often than not, he finds himself becoming irritable over extra requests and administrative demands, impatient with some patients and staff, and extremely fatigued at the end of workdays. Simply put, he finds that practicing medicine is far less enjoyable than it once was. He takes the Maslach Burnout Inventory, and his score indicates that he has moderate burnout.

©Joe Gorman/Shutterstock

Physician burnout has been a growing concern in recent decades.¹ Characterized by varying degrees of job dissatisfaction, cynicism, emotional exhaustion, clinical inefficiency, and depression, physician burnout can impede effective patient care, cause significant health issues among physicians, diminish professional gratification and feelings of accomplishment, and financially burden society as a whole. Here we present the information you need to recognize burnout in yourself and colleagues and address the problem on personal, organizational, and legislative levels.

A problem that affects physicians of all ages

Physician burnout has been recognized to present anywhere on a spectrum, manifesting as ineffectiveness, overextension, disengagement, and/or an inability to practice.² Such features may lead to feelings of professional inadequacy among even the highest functioning physicians.

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.

Burnout occurs in all stages of medical life—as students, residents, and practicing physicians.^3-6 Due to pressures in excess of coping capacity, some physicians will suffer from alcohol or other drug abuse, depression, and/or suicidal thinking.⁷ Stress and burnout can also result in musculoskeletal disorders, immune system dysfunction, cardiac pathology, and a shorter lifespan.⁸

Not only do individual practitioners suffer consequences from burnout, but it also compromises health care delivery. In 2018, the Medscape National Physician Burnout and Depression Report surveyed 15,000 physicians from 29 specialties; 33% of the respondents said that they were more easily frustrated by patients, and 32% reported less personal engagement.⁹ Burnout adversely impacts care, patient satisfaction, productivity, physician retention, retirement, and income, as well.⁶ Safety during clinical practice deteriorates because of an increase in medical error rates.¹⁰ Resultant emotional distress for physicians creates a vicious cycle.¹⁰

[polldaddy:10427848]

Continue to: These issues negatively impact...

These issues negatively impact practice enthusiasm and may engender self-doubt.¹¹ They may lead to absenteeism or, worse, to abandoning the profession, further contributing to physician shortages.¹² The financial impact of physician burnout in lost revenue in 2018 was about $17 billion, according to the National Taskforce for Humanity in ­Medicine.¹³

How prevalent is physician burnout?

Between October 2012 and March 2013, the American Society of Clinical Oncology surveyed US oncologists and found that 45% had evidence of burnout.¹⁴ In another survey of US physicians from all specialties conducted in 2011, at least 1 symptom of burnout was documented in nearly 46% of respondents.¹⁵ By 2014, this percentage increased to 54%.¹⁶

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.⁹ About 48% of female practitioners reported burnout vs 38% of male peers.⁹ Work-related distress varies between specialties, with internists, family physicians, intensivists, neurologists, and gynecologists more affected than those from other specialties.⁹

Causes and contributing factors

Job stress generally increases with changes in the workplace. This can be heightened in the health care workplace, which demands perfection and leaves little room for emotional issues. Loss of autonomy, time constraints associated with clinical care, electronic health record (EHR) documentation, and disorganized workflow tend to contribute to provider dissatisfaction and stress, as do ethical disagreements about patient care between physicians and leadership.^10,17 Fear of reprisal for speaking up about such issues can further exacerbate the problem. Some older physicians may have difficulty with technology and computerized record keeping. Reduced patient contact due to increasing reliance on computers can diminish physicians’ job satisfaction. And managing recurrent or difficult-to-treat ailments can result in compassion fatigue, diminished empathy, and emotional disengagement.

Burnout in the health care workplace is inconsistently addressed, despite negative professional and personal ramifications. The reasons include denial, uncertainty about monetary implications, and lack of corrective programs by decision-making organizations and/or employers.⁶ American medicine has lacked the political and financial will to implement strategies to mitigate burnout. Improvement requires changes on the part of government, physician groups, and the population at large.

The answer?

A multipronged approach

Identifying burnout is the first step in management. The 22-item Maslach Burnout Inventory (MBI) is a self-reporting questionnaire, reliable at detecting and assessing burnout severity.¹⁸ It screens 3 main domains: emotional exhaustion, depersonalization, and diminished feelings of accomplishment. The American Medical Association recommends the 10-item Zero Burnout Program—the “Mini Z Survey”—as being quicker and more convenient.¹⁹

Once the problem is recognized, experts suggest adopting a multipronged approach to prevention and intervention by using personal, organizational, and legislative strategies.²⁰

Continue to: On a personal level...

On a personal level, it’s important to identify stressors and employ stress-reduction and coping skills, such as mindfulness and/or reflection.²¹ Mindfulness programs may help to minimize exhaustion, increase compassion, and improve understanding of other people’s feelings.²² Such programs are widely available and may be accessed through the Internet, mental health centers, or by contacting psychiatric or psychological services.

Other self-care methods include ensuring adequate sleep, nutrition, exercise, and enjoyable activities. If a physician who is suffering from burnout is taking any prescription or over-the-counter drugs or supplements, it is important to be self-aware of the potential for misuse of medications. Of course, one should never self-prescribe controlled drugs, such as opiates and sedatives. Consumption of alcohol must be well-controlled, without excesses, and drinking near bedtime is ill-advised. The use of illegal substances should be avoided.

Pursuing aspects of health care that are meaningful and that increase patient contact time can boost enthusiasm, as can focusing on the positives aspects of one’s career.²³ Continuing medical education can enhance self-esteem and promote a sense of purpose.²⁴

Peer support. Practice partners may assist their colleagues by alerting them to signs of burnout, offering timely intervention suggestions, and monitoring the effectiveness of strategies. Physicians should discuss stress and burnout with their peers; camaraderie within a practice group is helpful.

Professional coaches or counselors may be engaged to mitigate workplace distress. Coaching is best instituted collegially with pre-identified goals in order to minimize stigmatization.

Continue to: Professional societies and medical boards

Professional societies and medical boards. Reporting requirements by medical boards tend to stigmatize those seeking professional assistance. But that could change if all of us—through our participation in these organizations—pursue change.

Specifically, organizations and related societies could assist with better guidance and policy adjustment (see “Resources”). State medical boards could, for example, increase education of, and outreach to, physicians about mental health issues, while maintaining confidentiality.²⁵ Medical organizations could regularly survey their membership to identify burnout early and identify personal, social, and institutional shortcomings that contribute to physician burnout. In addition, hospital quality improvement committees that monitor health care delivery appropriateness could take steps toward change as well.

The American Medical Association (AMA) just recently announced that they are launching a new effort to fight the causes of physician burnout. The AMA’s Practice Transformation Inititative²⁶ seeks to fill the knowledge gaps regarding effective interventions to reduce burnout. AMA’s leadership indicates that the initiative will focus on “improving joy in medicine by using validated assessment tools to measure burnout; field-testing interventions that are designed to improve workflows, applying practice science research methodology to evaluate impact, and sharing best practices within an AMA-facilitated learning community.”²⁶

Stanford’s example. Stanford University instituted a ‘time bank’ program, to help their academic medical faculty balance work and life and reduce stress. They essentially offer services, such as home food delivery and house cleaning, in return for hours spent in the clinic.²⁷

Reorganizing and reprioritizing. Prioritizing physician wellness as a quality indicator and instituting a committee to advocate for wellness can help attenuate burnout.^28,29 Specific measures include minimizing rushed, overloaded scheduling and allowing more clinical contact time with patients. Using nursing and office staff to streamline workflow is also helpful.²⁹ The University of Colorado’s “Ambulatory Process Excellence Model” strives to assist doctors by increasing the medical assistant-to-clinician ratio, yielding better productivity.²³ Medical assistants are increasingly handling tasks such as data entry, medication reconciliation, and preventive care, to allow physicians more time to focus on medical decision-making.²³

Continue to: The role of the EHR

The role of the EHR. One important way to boost professional morale is to simplify and shorten the EHR. The complexity of and reduced patient contact caused by today’s record-keeping systems is the source of great frustration among many physicians. In addition, many patients dislike the disproportionate attention paid by physicians to the computer during office visits, further compromising physician-patient relationships. Improving documentation methodology and/or employing medical assistant scribes can be helpful.^30,31 (See “Advanced team-based care: How we made it work” at http://bit.ly/2lNaB5Q.)

Legislation with physician input can mandate policies for more appropriate work environments. A good way to initiate improvement and reform strategies is to contact local medical societies and political representatives. Federal and state collaboration to reduce physician shortages in selected specialties or geographic regions can improve work-related stress. This might be attained by expanding residency programs, using telemedicine in underserved regions, and employing more physician assistants.³²

Health insurance. Enhancing universal access to affordable medical care, including pharmaceutical coverage, would alleviate stress for physicians and patients alike.³³ Health insurance regulation to decrease paperwork and simplify coverage would decrease physician workload. Standardized policy requirements, fewer exclusionary rules, and simplified prescribing guidelines (including having less cumbersome prescription pre-authorizations and greater standardization of drug formularies by different payer sources or insurance plans) would facilitate better clinical management.

CASE

Dr. D begins by discussing his concerns with his colleagues in the group practice and finds he is not alone. Many of the concerns of the group center around brief, rushed appointments that diminish relationships with patients, a lack of autonomy, and the fear of medical malpractice. Several older physicians acknowledge that they just want to retire.

Stanford University instituted a "time bank" program that offers home food delivery and house cleaning in return for hours spent in the clinic.

To address the patient contact and documentation issues, the group decides to hire scribes. They also decide to bring their concerns to the next county medical society meeting. The end result: They petitioned their state medical association to host presentations about mitigating burnout, to hold roundtable discussions, and to establish panels focused on remedying the situation.

Continue to: With this accomplished...

With this accomplished, Dr. D’s anxieties lessened. He surveyed relevant literature and shared tips for improving professional time management with his partners. In a hopeful mood, he volunteered to address burnout prevention at the next statewide medical meeting. He felt it was a good start.

CORRESPONDENCE
Steven Lippmann, MD, 401 E. Chestnut Street, Suite 610, Louisville, KY 40202; steven.lippmann@louisville.edu.

CASE

Dr. Peter D is a mid-career family physician in a group practice that recently adopted an electronic health record system. Although he realizes he is now competent at computerized medicine, he has far less of the one-on-one patient contact that he once found so gratifying about the field of medicine.

Others in the practice have similar concerns, but they suggest that everyone ought to “go along to get along.” To manage the increasing demands of his case load and the required documentation, Dr. D has begun staying late to finish charting, which is negatively impacting his family life.

Dr. D finds himself burdened by record keeping that is increasingly complicated and insurance company demands that are onerous. Pharmaceutical prior authorizations that previously had been mildly bothersome are now a full-on burden. More often than not, he finds himself becoming irritable over extra requests and administrative demands, impatient with some patients and staff, and extremely fatigued at the end of workdays. Simply put, he finds that practicing medicine is far less enjoyable than it once was. He takes the Maslach Burnout Inventory, and his score indicates that he has moderate burnout.

©Joe Gorman/Shutterstock

Physician burnout has been a growing concern in recent decades.¹ Characterized by varying degrees of job dissatisfaction, cynicism, emotional exhaustion, clinical inefficiency, and depression, physician burnout can impede effective patient care, cause significant health issues among physicians, diminish professional gratification and feelings of accomplishment, and financially burden society as a whole. Here we present the information you need to recognize burnout in yourself and colleagues and address the problem on personal, organizational, and legislative levels.

A problem that affects physicians of all ages

Physician burnout has been recognized to present anywhere on a spectrum, manifesting as ineffectiveness, overextension, disengagement, and/or an inability to practice.² Such features may lead to feelings of professional inadequacy among even the highest functioning physicians.

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.

Burnout occurs in all stages of medical life—as students, residents, and practicing physicians.^3-6 Due to pressures in excess of coping capacity, some physicians will suffer from alcohol or other drug abuse, depression, and/or suicidal thinking.⁷ Stress and burnout can also result in musculoskeletal disorders, immune system dysfunction, cardiac pathology, and a shorter lifespan.⁸

Not only do individual practitioners suffer consequences from burnout, but it also compromises health care delivery. In 2018, the Medscape National Physician Burnout and Depression Report surveyed 15,000 physicians from 29 specialties; 33% of the respondents said that they were more easily frustrated by patients, and 32% reported less personal engagement.⁹ Burnout adversely impacts care, patient satisfaction, productivity, physician retention, retirement, and income, as well.⁶ Safety during clinical practice deteriorates because of an increase in medical error rates.¹⁰ Resultant emotional distress for physicians creates a vicious cycle.¹⁰

[polldaddy:10427848]

Continue to: These issues negatively impact...

These issues negatively impact practice enthusiasm and may engender self-doubt.¹¹ They may lead to absenteeism or, worse, to abandoning the profession, further contributing to physician shortages.¹² The financial impact of physician burnout in lost revenue in 2018 was about $17 billion, according to the National Taskforce for Humanity in ­Medicine.¹³

How prevalent is physician burnout?

Between October 2012 and March 2013, the American Society of Clinical Oncology surveyed US oncologists and found that 45% had evidence of burnout.¹⁴ In another survey of US physicians from all specialties conducted in 2011, at least 1 symptom of burnout was documented in nearly 46% of respondents.¹⁵ By 2014, this percentage increased to 54%.¹⁶

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.⁹ About 48% of female practitioners reported burnout vs 38% of male peers.⁹ Work-related distress varies between specialties, with internists, family physicians, intensivists, neurologists, and gynecologists more affected than those from other specialties.⁹

Causes and contributing factors

Job stress generally increases with changes in the workplace. This can be heightened in the health care workplace, which demands perfection and leaves little room for emotional issues. Loss of autonomy, time constraints associated with clinical care, electronic health record (EHR) documentation, and disorganized workflow tend to contribute to provider dissatisfaction and stress, as do ethical disagreements about patient care between physicians and leadership.^10,17 Fear of reprisal for speaking up about such issues can further exacerbate the problem. Some older physicians may have difficulty with technology and computerized record keeping. Reduced patient contact due to increasing reliance on computers can diminish physicians’ job satisfaction. And managing recurrent or difficult-to-treat ailments can result in compassion fatigue, diminished empathy, and emotional disengagement.

Burnout in the health care workplace is inconsistently addressed, despite negative professional and personal ramifications. The reasons include denial, uncertainty about monetary implications, and lack of corrective programs by decision-making organizations and/or employers.⁶ American medicine has lacked the political and financial will to implement strategies to mitigate burnout. Improvement requires changes on the part of government, physician groups, and the population at large.

The answer?

A multipronged approach

Identifying burnout is the first step in management. The 22-item Maslach Burnout Inventory (MBI) is a self-reporting questionnaire, reliable at detecting and assessing burnout severity.¹⁸ It screens 3 main domains: emotional exhaustion, depersonalization, and diminished feelings of accomplishment. The American Medical Association recommends the 10-item Zero Burnout Program—the “Mini Z Survey”—as being quicker and more convenient.¹⁹

Once the problem is recognized, experts suggest adopting a multipronged approach to prevention and intervention by using personal, organizational, and legislative strategies.²⁰

Continue to: On a personal level...

On a personal level, it’s important to identify stressors and employ stress-reduction and coping skills, such as mindfulness and/or reflection.²¹ Mindfulness programs may help to minimize exhaustion, increase compassion, and improve understanding of other people’s feelings.²² Such programs are widely available and may be accessed through the Internet, mental health centers, or by contacting psychiatric or psychological services.

Other self-care methods include ensuring adequate sleep, nutrition, exercise, and enjoyable activities. If a physician who is suffering from burnout is taking any prescription or over-the-counter drugs or supplements, it is important to be self-aware of the potential for misuse of medications. Of course, one should never self-prescribe controlled drugs, such as opiates and sedatives. Consumption of alcohol must be well-controlled, without excesses, and drinking near bedtime is ill-advised. The use of illegal substances should be avoided.

Pursuing aspects of health care that are meaningful and that increase patient contact time can boost enthusiasm, as can focusing on the positives aspects of one’s career.²³ Continuing medical education can enhance self-esteem and promote a sense of purpose.²⁴

Peer support. Practice partners may assist their colleagues by alerting them to signs of burnout, offering timely intervention suggestions, and monitoring the effectiveness of strategies. Physicians should discuss stress and burnout with their peers; camaraderie within a practice group is helpful.

Professional coaches or counselors may be engaged to mitigate workplace distress. Coaching is best instituted collegially with pre-identified goals in order to minimize stigmatization.

Continue to: Professional societies and medical boards

Professional societies and medical boards. Reporting requirements by medical boards tend to stigmatize those seeking professional assistance. But that could change if all of us—through our participation in these organizations—pursue change.

Specifically, organizations and related societies could assist with better guidance and policy adjustment (see “Resources”). State medical boards could, for example, increase education of, and outreach to, physicians about mental health issues, while maintaining confidentiality.²⁵ Medical organizations could regularly survey their membership to identify burnout early and identify personal, social, and institutional shortcomings that contribute to physician burnout. In addition, hospital quality improvement committees that monitor health care delivery appropriateness could take steps toward change as well.

The American Medical Association (AMA) just recently announced that they are launching a new effort to fight the causes of physician burnout. The AMA’s Practice Transformation Inititative²⁶ seeks to fill the knowledge gaps regarding effective interventions to reduce burnout. AMA’s leadership indicates that the initiative will focus on “improving joy in medicine by using validated assessment tools to measure burnout; field-testing interventions that are designed to improve workflows, applying practice science research methodology to evaluate impact, and sharing best practices within an AMA-facilitated learning community.”²⁶

Stanford’s example. Stanford University instituted a ‘time bank’ program, to help their academic medical faculty balance work and life and reduce stress. They essentially offer services, such as home food delivery and house cleaning, in return for hours spent in the clinic.²⁷

Reorganizing and reprioritizing. Prioritizing physician wellness as a quality indicator and instituting a committee to advocate for wellness can help attenuate burnout.^28,29 Specific measures include minimizing rushed, overloaded scheduling and allowing more clinical contact time with patients. Using nursing and office staff to streamline workflow is also helpful.²⁹ The University of Colorado’s “Ambulatory Process Excellence Model” strives to assist doctors by increasing the medical assistant-to-clinician ratio, yielding better productivity.²³ Medical assistants are increasingly handling tasks such as data entry, medication reconciliation, and preventive care, to allow physicians more time to focus on medical decision-making.²³

Continue to: The role of the EHR

The role of the EHR. One important way to boost professional morale is to simplify and shorten the EHR. The complexity of and reduced patient contact caused by today’s record-keeping systems is the source of great frustration among many physicians. In addition, many patients dislike the disproportionate attention paid by physicians to the computer during office visits, further compromising physician-patient relationships. Improving documentation methodology and/or employing medical assistant scribes can be helpful.^30,31 (See “Advanced team-based care: How we made it work” at http://bit.ly/2lNaB5Q.)

Legislation with physician input can mandate policies for more appropriate work environments. A good way to initiate improvement and reform strategies is to contact local medical societies and political representatives. Federal and state collaboration to reduce physician shortages in selected specialties or geographic regions can improve work-related stress. This might be attained by expanding residency programs, using telemedicine in underserved regions, and employing more physician assistants.³²

Health insurance. Enhancing universal access to affordable medical care, including pharmaceutical coverage, would alleviate stress for physicians and patients alike.³³ Health insurance regulation to decrease paperwork and simplify coverage would decrease physician workload. Standardized policy requirements, fewer exclusionary rules, and simplified prescribing guidelines (including having less cumbersome prescription pre-authorizations and greater standardization of drug formularies by different payer sources or insurance plans) would facilitate better clinical management.

CASE

Dr. D begins by discussing his concerns with his colleagues in the group practice and finds he is not alone. Many of the concerns of the group center around brief, rushed appointments that diminish relationships with patients, a lack of autonomy, and the fear of medical malpractice. Several older physicians acknowledge that they just want to retire.

Stanford University instituted a "time bank" program that offers home food delivery and house cleaning in return for hours spent in the clinic.

To address the patient contact and documentation issues, the group decides to hire scribes. They also decide to bring their concerns to the next county medical society meeting. The end result: They petitioned their state medical association to host presentations about mitigating burnout, to hold roundtable discussions, and to establish panels focused on remedying the situation.

Continue to: With this accomplished...

With this accomplished, Dr. D’s anxieties lessened. He surveyed relevant literature and shared tips for improving professional time management with his partners. In a hopeful mood, he volunteered to address burnout prevention at the next statewide medical meeting. He felt it was a good start.

CORRESPONDENCE
Steven Lippmann, MD, 401 E. Chestnut Street, Suite 610, Louisville, KY 40202; steven.lippmann@louisville.edu.

CASE

Dr. Peter D is a mid-career family physician in a group practice that recently adopted an electronic health record system. Although he realizes he is now competent at computerized medicine, he has far less of the one-on-one patient contact that he once found so gratifying about the field of medicine.

Others in the practice have similar concerns, but they suggest that everyone ought to “go along to get along.” To manage the increasing demands of his case load and the required documentation, Dr. D has begun staying late to finish charting, which is negatively impacting his family life.

Dr. D finds himself burdened by record keeping that is increasingly complicated and insurance company demands that are onerous. Pharmaceutical prior authorizations that previously had been mildly bothersome are now a full-on burden. More often than not, he finds himself becoming irritable over extra requests and administrative demands, impatient with some patients and staff, and extremely fatigued at the end of workdays. Simply put, he finds that practicing medicine is far less enjoyable than it once was. He takes the Maslach Burnout Inventory, and his score indicates that he has moderate burnout.

©Joe Gorman/Shutterstock

Physician burnout has been a growing concern in recent decades.¹ Characterized by varying degrees of job dissatisfaction, cynicism, emotional exhaustion, clinical inefficiency, and depression, physician burnout can impede effective patient care, cause significant health issues among physicians, diminish professional gratification and feelings of accomplishment, and financially burden society as a whole. Here we present the information you need to recognize burnout in yourself and colleagues and address the problem on personal, organizational, and legislative levels.

A problem that affects physicians of all ages

Physician burnout has been recognized to present anywhere on a spectrum, manifesting as ineffectiveness, overextension, disengagement, and/or an inability to practice.² Such features may lead to feelings of professional inadequacy among even the highest functioning physicians.

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.

Burnout occurs in all stages of medical life—as students, residents, and practicing physicians.^3-6 Due to pressures in excess of coping capacity, some physicians will suffer from alcohol or other drug abuse, depression, and/or suicidal thinking.⁷ Stress and burnout can also result in musculoskeletal disorders, immune system dysfunction, cardiac pathology, and a shorter lifespan.⁸

Not only do individual practitioners suffer consequences from burnout, but it also compromises health care delivery. In 2018, the Medscape National Physician Burnout and Depression Report surveyed 15,000 physicians from 29 specialties; 33% of the respondents said that they were more easily frustrated by patients, and 32% reported less personal engagement.⁹ Burnout adversely impacts care, patient satisfaction, productivity, physician retention, retirement, and income, as well.⁶ Safety during clinical practice deteriorates because of an increase in medical error rates.¹⁰ Resultant emotional distress for physicians creates a vicious cycle.¹⁰

[polldaddy:10427848]

Continue to: These issues negatively impact...

These issues negatively impact practice enthusiasm and may engender self-doubt.¹¹ They may lead to absenteeism or, worse, to abandoning the profession, further contributing to physician shortages.¹² The financial impact of physician burnout in lost revenue in 2018 was about $17 billion, according to the National Taskforce for Humanity in ­Medicine.¹³

How prevalent is physician burnout?

Between October 2012 and March 2013, the American Society of Clinical Oncology surveyed US oncologists and found that 45% had evidence of burnout.¹⁴ In another survey of US physicians from all specialties conducted in 2011, at least 1 symptom of burnout was documented in nearly 46% of respondents.¹⁵ By 2014, this percentage increased to 54%.¹⁶

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.⁹ About 48% of female practitioners reported burnout vs 38% of male peers.⁹ Work-related distress varies between specialties, with internists, family physicians, intensivists, neurologists, and gynecologists more affected than those from other specialties.⁹

Causes and contributing factors

Job stress generally increases with changes in the workplace. This can be heightened in the health care workplace, which demands perfection and leaves little room for emotional issues. Loss of autonomy, time constraints associated with clinical care, electronic health record (EHR) documentation, and disorganized workflow tend to contribute to provider dissatisfaction and stress, as do ethical disagreements about patient care between physicians and leadership.^10,17 Fear of reprisal for speaking up about such issues can further exacerbate the problem. Some older physicians may have difficulty with technology and computerized record keeping. Reduced patient contact due to increasing reliance on computers can diminish physicians’ job satisfaction. And managing recurrent or difficult-to-treat ailments can result in compassion fatigue, diminished empathy, and emotional disengagement.

Burnout in the health care workplace is inconsistently addressed, despite negative professional and personal ramifications. The reasons include denial, uncertainty about monetary implications, and lack of corrective programs by decision-making organizations and/or employers.⁶ American medicine has lacked the political and financial will to implement strategies to mitigate burnout. Improvement requires changes on the part of government, physician groups, and the population at large.

The answer?

A multipronged approach

Identifying burnout is the first step in management. The 22-item Maslach Burnout Inventory (MBI) is a self-reporting questionnaire, reliable at detecting and assessing burnout severity.¹⁸ It screens 3 main domains: emotional exhaustion, depersonalization, and diminished feelings of accomplishment. The American Medical Association recommends the 10-item Zero Burnout Program—the “Mini Z Survey”—as being quicker and more convenient.¹⁹

Once the problem is recognized, experts suggest adopting a multipronged approach to prevention and intervention by using personal, organizational, and legislative strategies.²⁰

Continue to: On a personal level...

On a personal level, it’s important to identify stressors and employ stress-reduction and coping skills, such as mindfulness and/or reflection.²¹ Mindfulness programs may help to minimize exhaustion, increase compassion, and improve understanding of other people’s feelings.²² Such programs are widely available and may be accessed through the Internet, mental health centers, or by contacting psychiatric or psychological services.

Other self-care methods include ensuring adequate sleep, nutrition, exercise, and enjoyable activities. If a physician who is suffering from burnout is taking any prescription or over-the-counter drugs or supplements, it is important to be self-aware of the potential for misuse of medications. Of course, one should never self-prescribe controlled drugs, such as opiates and sedatives. Consumption of alcohol must be well-controlled, without excesses, and drinking near bedtime is ill-advised. The use of illegal substances should be avoided.

Pursuing aspects of health care that are meaningful and that increase patient contact time can boost enthusiasm, as can focusing on the positives aspects of one’s career.²³ Continuing medical education can enhance self-esteem and promote a sense of purpose.²⁴

Peer support. Practice partners may assist their colleagues by alerting them to signs of burnout, offering timely intervention suggestions, and monitoring the effectiveness of strategies. Physicians should discuss stress and burnout with their peers; camaraderie within a practice group is helpful.

Professional coaches or counselors may be engaged to mitigate workplace distress. Coaching is best instituted collegially with pre-identified goals in order to minimize stigmatization.

Continue to: Professional societies and medical boards

Professional societies and medical boards. Reporting requirements by medical boards tend to stigmatize those seeking professional assistance. But that could change if all of us—through our participation in these organizations—pursue change.

Specifically, organizations and related societies could assist with better guidance and policy adjustment (see “Resources”). State medical boards could, for example, increase education of, and outreach to, physicians about mental health issues, while maintaining confidentiality.²⁵ Medical organizations could regularly survey their membership to identify burnout early and identify personal, social, and institutional shortcomings that contribute to physician burnout. In addition, hospital quality improvement committees that monitor health care delivery appropriateness could take steps toward change as well.

The American Medical Association (AMA) just recently announced that they are launching a new effort to fight the causes of physician burnout. The AMA’s Practice Transformation Inititative²⁶ seeks to fill the knowledge gaps regarding effective interventions to reduce burnout. AMA’s leadership indicates that the initiative will focus on “improving joy in medicine by using validated assessment tools to measure burnout; field-testing interventions that are designed to improve workflows, applying practice science research methodology to evaluate impact, and sharing best practices within an AMA-facilitated learning community.”²⁶

Stanford’s example. Stanford University instituted a ‘time bank’ program, to help their academic medical faculty balance work and life and reduce stress. They essentially offer services, such as home food delivery and house cleaning, in return for hours spent in the clinic.²⁷

Reorganizing and reprioritizing. Prioritizing physician wellness as a quality indicator and instituting a committee to advocate for wellness can help attenuate burnout.^28,29 Specific measures include minimizing rushed, overloaded scheduling and allowing more clinical contact time with patients. Using nursing and office staff to streamline workflow is also helpful.²⁹ The University of Colorado’s “Ambulatory Process Excellence Model” strives to assist doctors by increasing the medical assistant-to-clinician ratio, yielding better productivity.²³ Medical assistants are increasingly handling tasks such as data entry, medication reconciliation, and preventive care, to allow physicians more time to focus on medical decision-making.²³

Continue to: The role of the EHR

The role of the EHR. One important way to boost professional morale is to simplify and shorten the EHR. The complexity of and reduced patient contact caused by today’s record-keeping systems is the source of great frustration among many physicians. In addition, many patients dislike the disproportionate attention paid by physicians to the computer during office visits, further compromising physician-patient relationships. Improving documentation methodology and/or employing medical assistant scribes can be helpful.^30,31 (See “Advanced team-based care: How we made it work” at http://bit.ly/2lNaB5Q.)

Legislation with physician input can mandate policies for more appropriate work environments. A good way to initiate improvement and reform strategies is to contact local medical societies and political representatives. Federal and state collaboration to reduce physician shortages in selected specialties or geographic regions can improve work-related stress. This might be attained by expanding residency programs, using telemedicine in underserved regions, and employing more physician assistants.³²

Health insurance. Enhancing universal access to affordable medical care, including pharmaceutical coverage, would alleviate stress for physicians and patients alike.³³ Health insurance regulation to decrease paperwork and simplify coverage would decrease physician workload. Standardized policy requirements, fewer exclusionary rules, and simplified prescribing guidelines (including having less cumbersome prescription pre-authorizations and greater standardization of drug formularies by different payer sources or insurance plans) would facilitate better clinical management.

CASE

Dr. D begins by discussing his concerns with his colleagues in the group practice and finds he is not alone. Many of the concerns of the group center around brief, rushed appointments that diminish relationships with patients, a lack of autonomy, and the fear of medical malpractice. Several older physicians acknowledge that they just want to retire.

Stanford University instituted a "time bank" program that offers home food delivery and house cleaning in return for hours spent in the clinic.

To address the patient contact and documentation issues, the group decides to hire scribes. They also decide to bring their concerns to the next county medical society meeting. The end result: They petitioned their state medical association to host presentations about mitigating burnout, to hold roundtable discussions, and to establish panels focused on remedying the situation.

Continue to: With this accomplished...

With this accomplished, Dr. D’s anxieties lessened. He surveyed relevant literature and shared tips for improving professional time management with his partners. In a hopeful mood, he volunteered to address burnout prevention at the next statewide medical meeting. He felt it was a good start.

CORRESPONDENCE
Steven Lippmann, MD, 401 E. Chestnut Street, Suite 610, Louisville, KY 40202; steven.lippmann@louisville.edu.

Tobacco companies are marketing a new version of cigarettes dubbed heat-not-burn (HNB) cigarettes.^1,2 Offered as a “modified-risk tobacco product,” HNB cigarettes utilize a lithium battery-powered heating element and are available all over the world.^1,2 Like conventional smokes, they contain tobacco, but deliver nicotine by heating leaves at 350° C rather than burning them at 600° C.^1-3 Heating the tobacco produces an inhalable aerosol with tobacco flavor and nicotine, without smoke. These HNB cigarettes are also different from e-cigarettes that aerosolize a liquid.

Heat-not-burn aerosols deliver many of the same dangerous compounds as traditional cigarettes, including carbon monoxide, tar, and aromatic hydrocarbons.

Tobacco companies contend that HNB cigarettes are safer than smoking tobacco.¹ Consumers inhale a heated tobacco aerosol that reportedly contains less nicotine and fewer toxicities; yet, HNB are not independently substantiated as being healthier, nor proven safe.^1-5 Thermal decomposition, rather than combustion, may afford a less dangerous nicotine consumption; however, HNB aerosols deliver many of the same dangerous compounds as traditional cigarettes, including carbon monoxide, tar, and aromatic hydrocarbons.^2-6 Despite possible harm reduction in the short-run, long-term safety remains unconfirmed.

Safety in passive environmental inhalations is not established.² HNB cigarettes are contraindicated during pregnancy and/or lactation. Nicotine is provided in addictive quantities, enough to foster continued dependence. Exposure to HNB products can promote longer-term usage or lead to smoking traditional tobacco cigarettes. There is also an increased risk to non-smokers of exposure to HNB aerosols. Additionally, lithium batteries have been known to burn or explode. HNB devices may even lead to privacy concerns due micro-controller chips contained within that harvest information. These chips could inform manufacturers about device usage.⁷

Tobacco is a global health hazard and smoking is the number one preventable cause of disease.^1,5,8 Global smoking prevalence is nearing 19%.⁹ There are concerns about dual use, rather than HNB cigarettes alone as a substitute for conventional smoking. The ultimate hope is to abstain from all tobacco and nicotine. Although HNB inhalations contain fewer toxic chemicals than by smoking, evidence regarding mitigation of tobacco-related diseases is inconclusive.¹⁰

Physicians have an obligation to minimize tobacco and nicotine-related hazards.

Physicians have an obligation to minimize tobacco and nicotine-related hazards. Ongoing research and clinical exposure might better document the health impact of HNB cigarettes. Until the risks and benefits of HNB cigarettes are confirmed, health care professionals would be wise to counsel against their use.

Diksha Mohanty, MD; Steven Lippmann, MD
Louisville, Ky

Tobacco companies are marketing a new version of cigarettes dubbed heat-not-burn (HNB) cigarettes.^1,2 Offered as a “modified-risk tobacco product,” HNB cigarettes utilize a lithium battery-powered heating element and are available all over the world.^1,2 Like conventional smokes, they contain tobacco, but deliver nicotine by heating leaves at 350° C rather than burning them at 600° C.^1-3 Heating the tobacco produces an inhalable aerosol with tobacco flavor and nicotine, without smoke. These HNB cigarettes are also different from e-cigarettes that aerosolize a liquid.

Heat-not-burn aerosols deliver many of the same dangerous compounds as traditional cigarettes, including carbon monoxide, tar, and aromatic hydrocarbons.

Tobacco companies contend that HNB cigarettes are safer than smoking tobacco.¹ Consumers inhale a heated tobacco aerosol that reportedly contains less nicotine and fewer toxicities; yet, HNB are not independently substantiated as being healthier, nor proven safe.^1-5 Thermal decomposition, rather than combustion, may afford a less dangerous nicotine consumption; however, HNB aerosols deliver many of the same dangerous compounds as traditional cigarettes, including carbon monoxide, tar, and aromatic hydrocarbons.^2-6 Despite possible harm reduction in the short-run, long-term safety remains unconfirmed.

Safety in passive environmental inhalations is not established.² HNB cigarettes are contraindicated during pregnancy and/or lactation. Nicotine is provided in addictive quantities, enough to foster continued dependence. Exposure to HNB products can promote longer-term usage or lead to smoking traditional tobacco cigarettes. There is also an increased risk to non-smokers of exposure to HNB aerosols. Additionally, lithium batteries have been known to burn or explode. HNB devices may even lead to privacy concerns due micro-controller chips contained within that harvest information. These chips could inform manufacturers about device usage.⁷

Tobacco is a global health hazard and smoking is the number one preventable cause of disease.^1,5,8 Global smoking prevalence is nearing 19%.⁹ There are concerns about dual use, rather than HNB cigarettes alone as a substitute for conventional smoking. The ultimate hope is to abstain from all tobacco and nicotine. Although HNB inhalations contain fewer toxic chemicals than by smoking, evidence regarding mitigation of tobacco-related diseases is inconclusive.¹⁰

Physicians have an obligation to minimize tobacco and nicotine-related hazards.

Physicians have an obligation to minimize tobacco and nicotine-related hazards. Ongoing research and clinical exposure might better document the health impact of HNB cigarettes. Until the risks and benefits of HNB cigarettes are confirmed, health care professionals would be wise to counsel against their use.

Diksha Mohanty, MD; Steven Lippmann, MD
Louisville, Ky

Tobacco companies are marketing a new version of cigarettes dubbed heat-not-burn (HNB) cigarettes.^1,2 Offered as a “modified-risk tobacco product,” HNB cigarettes utilize a lithium battery-powered heating element and are available all over the world.^1,2 Like conventional smokes, they contain tobacco, but deliver nicotine by heating leaves at 350° C rather than burning them at 600° C.^1-3 Heating the tobacco produces an inhalable aerosol with tobacco flavor and nicotine, without smoke. These HNB cigarettes are also different from e-cigarettes that aerosolize a liquid.

Heat-not-burn aerosols deliver many of the same dangerous compounds as traditional cigarettes, including carbon monoxide, tar, and aromatic hydrocarbons.

Tobacco companies contend that HNB cigarettes are safer than smoking tobacco.¹ Consumers inhale a heated tobacco aerosol that reportedly contains less nicotine and fewer toxicities; yet, HNB are not independently substantiated as being healthier, nor proven safe.^1-5 Thermal decomposition, rather than combustion, may afford a less dangerous nicotine consumption; however, HNB aerosols deliver many of the same dangerous compounds as traditional cigarettes, including carbon monoxide, tar, and aromatic hydrocarbons.^2-6 Despite possible harm reduction in the short-run, long-term safety remains unconfirmed.

Safety in passive environmental inhalations is not established.² HNB cigarettes are contraindicated during pregnancy and/or lactation. Nicotine is provided in addictive quantities, enough to foster continued dependence. Exposure to HNB products can promote longer-term usage or lead to smoking traditional tobacco cigarettes. There is also an increased risk to non-smokers of exposure to HNB aerosols. Additionally, lithium batteries have been known to burn or explode. HNB devices may even lead to privacy concerns due micro-controller chips contained within that harvest information. These chips could inform manufacturers about device usage.⁷

Tobacco is a global health hazard and smoking is the number one preventable cause of disease.^1,5,8 Global smoking prevalence is nearing 19%.⁹ There are concerns about dual use, rather than HNB cigarettes alone as a substitute for conventional smoking. The ultimate hope is to abstain from all tobacco and nicotine. Although HNB inhalations contain fewer toxic chemicals than by smoking, evidence regarding mitigation of tobacco-related diseases is inconclusive.¹⁰

Physicians have an obligation to minimize tobacco and nicotine-related hazards.

Physicians have an obligation to minimize tobacco and nicotine-related hazards. Ongoing research and clinical exposure might better document the health impact of HNB cigarettes. Until the risks and benefits of HNB cigarettes are confirmed, health care professionals would be wise to counsel against their use.

Diksha Mohanty, MD; Steven Lippmann, MD
Louisville, Ky