Burnout occurs almost twice as often in healthcare practitioners as it does in the general population. What role should healthcare administrators play in combating this rampant issue?
The healthcare industry’s primary mission is to improve the wellbeing of patients, yet one of its biggest challenges today is an epidemic that strikes providers themselves: burnout. Of course, burnout does not only affect healthcare providers. It can affect individuals in nearly any profession or trade, especially those that involve long hours with substantial amounts of supportive, secondary, or administrative tasks beyond a profession’s primary functions. Notably, however, burnout occurs almost twice as often in healthcare practitioners as it does in the general population. What role should healthcare administrators play in combating this rampant issue?
In surveys conducted by burnout researchers Shanafelt et al., 28.4% of respondents from the general population suspected they were experiencing symptoms of burnout, but that number skyrocketed to 54.4% of physicians.1,2 Evidence suggests that burnout also is wreaking havoc among other types of care providers as well, including over 40% of nurses, who reported struggling with the type of emotional exhaustion frequently experienced as part and parcel of professional burnout.3
As a sign of how prevalent and damaging burnout has become, the World Health Organization added burnout to its International Classification of Diseases in May 2019 as an “occupational phenomenon.”4 Statistics like these paint a grim picture of the reality for healthcare practitioners in modern society. Yet the negative impacts of burnout do not stop at the individual level. In fact, some of the most severe consequences affect these practitioners’ employing organizations. Increasingly, healthcare organizations expect their physicians and other providers to put in a full workday caring for patients, then spend substantial amounts of time processing emails, voicemails, and electronic health record (EHR) messages. Moreover, the organization expects these “shadow work” tasks to be performed in a high-pressure environment constrained by high performance metrics, increasing levels of bureaucratization, and a constantly changing regulatory framework.
THE SCOPE OF THE BURNOUT CHALLENGE FACING HEALTHCARE ADMINISTRATORS
Until fairly recently, the prevailing model for an organizational response to provider burnout has been to focus on individuals struggling with the condition. Unfortunately, one of the primary factors driving the escalating rates and intensity of burnout in the healthcare field is the systemic and organizational framework in which medicine is practiced. Increased record keeping and digitalization of tasks mean there is even less time for performing the tasks that arguably drew most providers into the professions in the first place: treating and caring for patients. In addition, added layers of bureaucracy and increased isolation from peers further complicate the workplace culture in today’s healthcare organizations, exacerbating the very conditions that lead to burnout in the first place.5
The complex realities of today’s healthcare industry further frustrate an organizational response in identifying and addressing practitioner burnout. Organizations already struggle with declining reimbursement rates triggered by increased price-based competition, increasingly restrictive insurance policies and networks, and a skyrocketing percentage of patients who struggle to meet higher out-of-pocket provisions.6 Consequently, administrators often are forced to protect a shrinking bottom line by requiring practitioners to stretch limited resources to meet expanding needs.
Burnout can and does inflict staggering levels of financial damage to healthcare organizations. A 2017 Stanford report estimated that physician burnout costs the U.S. healthcare profession anywhere between $2.9 and $5 billion on an annual basis.7 One of the biggest costs is the expense of recruiting, training, and compensating new physicians and practitioners to replace those who have left their jobs early or exited the field entirely. Compounding this issue, administrators then also struggle to fill those empty positions, thanks to national shortages in both the nursing and M.D. professions.8 Additionally, when practitioners experience symptoms of burnout, they often struggle to meet minimum standards of patient care.9 Over time, the combination of these factors can lead to decreased revenues and, in the worst of all possible cases, cause harm to patients.
As if these challenges didn’t present enough of an obstacle, healthcare organizations are further hampered by the very nature of the people they may seek to help. Individuals drawn to the practice of medicine and nursing often are highly driven, intrinsically motivated to surpass their own past performance levels, and less than forthcoming about their own struggles. Healthcare practitioners often tend to “suffer in silence,” and since they are already known for stoic professionalism, this failure to reach out for help when it is needed means that quite often the problem goes undetected or undiagnosed until an explosive change occurs. That change may be behavioral in nature, or it may take the form of a seemingly sudden resignation, leaving administration officials stunned and short-staffed.
MICRO VERSUS MACRO: THE DUAL FRONTS OF THE BURNOUT WAR
Burnout affects both the individual practitioner and the organization that employs that practitioner. Until recently, however, organizational resources provided to combat burnout tended to focus solely on the individual while ignoring the part the organization itself played in creating a burnout-conducive work culture. Lunchtime seminars about mindfulness and stress reduction certainly may help by giving practitioners a few additional tools to use to manage their wellness. However, burnout is not the same as generic work stress, and cannot be effectively resolved with enhanced self-care tactics. Beating burnout on the individual level requires significant time, energy, and resources devoted to increasing resilience, reducing isolation, examining destructive thought patterns, and dismantling specific behavioral patterns, among other actions. Even if successfully addressed, these factors represent only one part of the problematic equation.
By addressing only half of the picture, we provide only half-measures that can, at best, half succeed. Instead, a two-pronged approach will help organizations effectively meet and address the issue of practitioner burnout. In addition to providing these individually targeted resources aimed at empowering practitioners to create a more balanced and resilient sense of self in the workplace, successful organizations also simultaneously work to change their own often-ingrained cultures to reduce isolation and administrative or secondary task expectations, simplify workflows and record keeping processes, and foster a stronger sense of community and teamwork among its practitioners and specialties.
HOW HEALTHCARE’S ORGANIZATIONAL SYSTEMS CONTRIBUTE TO BURNOUT
Many aspects of the modern-day practice of medicine and medical caregiving help contribute to and exacerbate the practitioner’s experience of burnout, and a significant portion of them are created or controlled by the organization itself, including:
- Excessively long workdays (10 to 12 hours for three or more days in a row; working on weekends; hours that interfere with other obligations or downtime);
- Failure to communicate clear and concrete expectations
- about the practitioner’s role or job duties; and
- Evolution of the work environment into a more intense or acute culture.
In addition, an ever-increasing workload of “shadow work” adds to the overwhelming pressure that, unchecked, often develops into full-blown burnout. This added burden began as a well-intentioned movement to integrate technology into healthcare record keeping, particularly via EHRs, which have been strongly touted as a positive development (and, ultimately, a requirement) to simplify and expedite access to health data.
Certainly the use of EHRs carries clear benefits for patients, practitioners, and organizations alike. However, EHRs and the larger context of digitalization as a whole pose serious risks as well. Chief among those risks is the concomitant explosion in practitioner frustration. For the nurses and physicians who are tasked with creating and maintaining EHRs, technology and digitalization are leading causes behind today’s burnout epidemic.
Other technological factors also may add to the burnout epidemic, although at present the research data only establish a correlation. For example, each practitioner must contend with a fresh learning curve when their organization implements a new charting methodology or requires an additional EHR workflow. These shadow tasks are undoubtedly important, but the way they are currently being added to practitioners’ already burdened workdays seems to be exacerbating the burnout problem. The administrative challenge for healthcare organizations is to consider these tasks as a whole—any one of these responsibilities likely seems reasonable on its own, yet the cumulative impact often is overlooked.
Each practitioner in an organizational staff has a breaking point or a “last straw” that, when breached, creates a critical inflection point. To help reduce burnout and its myriad associated costs and impacts, organizational administrators must begin to address these unreasonable burdens before the proverbial camel’s back is weakened beyond the point of no return.
IMPROVING ORGANIZATIONAL RESILIENCE
To address burnout effectively and create a more supportive work environment that fosters practitioner wellness, healthcare organizations must commit to making strategic changes in a top-down fashion in addition to helping practitioners improve their own resilience and coping mechanisms. This approach will require administrators and organizational leaders to develop heightened leadership and professional fulfillment skills. Working within the framework of research conducted by the Mayo Clinic, I have developed a six-point strategy to help administrators shore up organizational resilience in the fight against practitioner burnout.
1. Recognize that burnout is a systemic issue that includes personal, organizational, and policy factors.
It is important to address the problem on both the micro (individual) and macro (organizational) level, while recognizing that it is primarily the work environment that drives burnout.
2. Promote a culture of efficient leadership through additional training and support.
Strong supervisory leadership helps decrease the likelihood of physician burnout and increase practitioner well- ness. Effective leaders create far-reaching positive impacts throughout the staff and extending to patients as well. Start by selecting leaders with innate listening and empathy skills; then train them for their new roles. In addition, include any employee who is directly affected by the leader’s performance in evaluating that individual’s performance.
3. Measure organizational progress with appropriate metrics.
Unless we track our progress toward goals with appropriate and relevant metrics, we will never know whether the changes we’re making are having the right impact. That is true of individuals and equally true of organizations. Many healthcare institutions, including the American Medical Association, the Mayo Clinic, and Stanford University, are working to develop new metrics that can more accurately reflect and measure “soft” factors such as resilience, professional contentment, well-being, and more.
4. Implement targeted solutions.
Organizations should only take action when they can do so in a targeted, specific way, given that inefficiencies in work systems are a leading cause of professional frustration. Untargeted solutions waste both time and resources, and they simply add to the level of aggravation and burnout perceived by practitioners. Those in healthcare leadership roles can evaluate proposed changes through the following three questions:
- Will the proposed change ease our healthcare providers’ work burden?
- Will it create measurable progress toward quality or convenience for our patients?
- Can we identify a sufficient revenue stream and enough personnel to support and implement this change?
Further, healthcare executives and administrators may consider contracting with an experienced consultant who specializes in enhancing workplace efficiency or in reducing employee burnout to help fine-tune and implement winning solutions.
5. Cultivate a stronger sense of community.
One of the leading aggravating factors behind practitioner burnout is a looming, pervasive sense of isolation and loneliness. This lack of community and peer support is particularly challenging in the healthcare environment, where long work hours and extremely intense situations (some of them literally life-and-death) can make it almost impossible for individuals to reach out and connect with colleagues.
It is, however, undoubtedly a crucial step in addressing burnout. A 2012 randomized trial conducted by the Mayo Clinic found that physicians who were guaranteed as little as one hour every two weeks to gather with colleagues and openly discuss their work experiences reported reduced burnout and improved engagement at work.10 The community helps protect the individual.
6. Provide flexibility and work–life integration.
Healthcare providers who are already struggling with burnout need to know that they can ask for more flexible schedules or have access to other benefits to help address burnout without fear of repercussions from administrative leaders. Cutting back hours, creating a staggered shift or later start time, easier access to childcare, or other flex-time practices are some examples of meaningful changes that can facilitate a more holistic integration of work and personal life. Administrators must be willing to work with staff to implement these changes where appropriate.
TRANSFORMING YOUR ORGANIZATION IS GOOD BUSINESS
Taking concrete steps to address practitioner burnout across your organization not only improves the wellbeing of employees, but also impacts a healthcare system’s employee retention, financial health, and patient satisfaction. Taking a holistic systemic approach to combating burnout is the best way to help your workplace culture evolve into a healthier, more balanced environment. That, in turn, will help defuse burnout throughout your staff, improve patient care (and, possibly, patient outcomes as a result), and improve your organizational reputation for excellence. That’s an investment worth making.
- Reith T. Burnout in United States healthcare professionals: a narrative review. Cureus. 2018. doi:10.7759/cureus.3681
- Shanafelt T, West C, Sinsky C et al. Changes in burnout and sat- isfaction with work-life integration in physicians and the generalUS working population between 2011 and 2017. Mayo Clin Proc. 2019;94:1681-1694. doi:10.1016/j.mayocp.2018.10.023
- Mudallal R, Othman W, Al Hassan N. Nurses’ burnout: the influence of leader empowering behaviors, work conditions, and demo- graphic traits. Inquiry. 54, 46958017724944 Jan 1 2017; doi:10.1177/ 0046958017724944.
- World Health Organization. Burn-out an “occupational phenome- non”: International Classification of Diseases. May 28, 2019. www. who.int/mental_health/evidence/burn-out/en/. Accessed Septem- ber 28, 2019.
- Kaufman S. Why your passion for work could ruin your career. Har- vard Business Review. https://hbr.org/2011/08/why-your-passion- for-work-coul. Published 2011. Accessed November 3, 2019.
- Bannow T. Low reimbursement, high expenses contribute to poor 2018 not-for-profit healthcare outlook. Modern Healthcare. www.modern healthcare.com/article/20171204/NEWS/171209962/low-reimburse ment-high-expenses-contribute-to-poor-2018-not-for-profit-health care-outlook. Published 2017. Accessed November 5, 2019.
- Goh J, Han S, Shanafelt TD, et al. An economic evaluation of the cost of physician burnout in the United States. http://wellmd.stanford. edu/content/dam/sm/wellmd/documents/2017-ACPH-Goh.pdf. Accessed November 3, 2019.
- Association of American Medical Colleges. New findings confirm pre- dictions on physician shortage. April 23, 2019. www.aamc.org/news- insights/press-releases/new-findings-confirm-predictions-physician- shortage. Accessed November 3, 2019.
- Dewa CS, Loong D, Bonato S, Trojanowski L. The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: a systematic review. BMJ Open. 2017;7(6). doi:10.1136/bmjopen-2016-015141
- West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote phy- sician well-being, job satisfaction, and professionalism: a random- ized clinical trial. JAMA Intern Med. 2014;174:527-33. doi: 10.1001/ jamainternmed.2013.14387.
Physician at St. Elizabeth Healthcare in Northern Kentucky, Author of Burnout in Healthcare: A Guide to Addressing the Epidemic (independently published, 2019), Physician: How Science Transformed the Art of Medicine (River Grove Books, 2018), and Unbound Intelligence: A Personal Guide to Self Discovery (Pranova, 2014)
This article appeared in The Journal of Medical Practice Management, March/April, 2020