What is provider burnout?
Burnout is a long‑term stress reaction characterized by depersonalization, including cynical or negative attitudes toward patients, emotional exhaustion, a feeling of decreased personal achievement and a lack of empathy for patients. By measuring and responding to burnout you will be able to:
- Reduce sources of stress
- Intervene with programs and policies that support professional well‑being
- Prevent burnout
Burnout makes it nearly impossible for individuals to provide compassionate care for their patients.
Seven steps to prevent burnout
- Establish wellness as a quality indicator for your practice
- Start a wellness committee and/or choose a wellness champion
- Distribute an annual wellness survey
- Meet regularly with leaders and/or staff to discuss data and interventions to promote wellness
- Initiate selected interventions
- Repeat the survey within the year to re‑evaluate wellness
- Seek answers within the data, refine the interventions and continue to make improvements
Establish wellness as a quality indicator for your practice
Encourage your clinic or organization to recognize the impact of burnout on providers as well as patients, the quality of care delivered and finances (e.g., through turnover). Establish provider wellness, which is the inverse of burnout, as a quality indicator that is regularly measured in your practice. Consider using annual burnout scores on the “mini Z” (see step 3) as a sign of the health of the provider workforce within your organization; if scores should slide, use the interventions described in step 5 to turn things around.
What factors can contribute to burnout?
The “big 4” factors known to contribute to stress and burnout include1:
- Lack of control over work conditions
- Time pressure
- Chaotic workplaces
- Lack of alignment of values (around mission, purpose and compensation) between providers and their leaders
Why should my practice measure provider stress and burnout?
Recent studies show a national burnout rate of 46 percent among physicians in practice,2 including private practice, academic medical centers and the Department of Veteran's Affairs (VA). With almost half of US doctors showing signs of burnout, and numerous adverse outcomes for physicians linked to burnout, it is an important issue for practices to address. Reducing burnout can have a positive impact on your practice, including higher retention rates, improved devotion to patients, better morale in the office and improved recruitment.
Why does control over the work environment matter and how does it contribute to burnout?
Providers who are unable to control their work are not able to balance the competing demands of the practice with their personal commitments. This results in increased stress and eventual burnout.
When work demands are balanced by work control (e.g., ability to control one's schedule), burnout is less. When demands are heavy, workers (in this case, providers) use work control to mitigate stress and avoid burnout. For example, providers who are also parents often need to adjust end‑of‑day and start‑of‑day schedules to allow for dropping off or picking children up at child care. Having control over their workday reduces the likelihood of burnout.
Why does burnout matter?
Stressful work conditions and burnout can lead to the following practice issues1:
- Increased clinician errors
- Reduced empathy for patients
- Reduced patient satisfaction
- Decreased patient adherence to treatment recommendations
- Increased physician intent to leave the practice
Start a wellness committee and/or choose a wellness champion
The wellness committee should be made up of providers (MDs, NPs and PAs) from various disciplines and administrators (finance, management) that can work with your practice or organizational leaders to periodically measure burnout. Members can then present data to providers and brainstorm solutions to challenges. The committee should plan to meet for about one hour a month to review current projects, plan new initiatives, discuss survey data and respond to new opportunities or stresses.
If you have a solo or small practice, a wellness champion may be a better option. Wellness champions are individuals within an organization that promote the use of wellness resources, model positive behaviors such as leaving work on time and encourage employees to complete the annual wellness survey.
Who should be on the wellness committee in my practice?
All relevant practice stakeholders should be involved in wellness initiatives. This approach can work for many types of providers, including hospital‑based physicians, surgeons, non‑office‑based physicians and advanced practice providers (NPs and PAs). Depending on the size of the practice or organization, representatives can be drawn from different functional areas. Practice professionals will learn from each other and be able to spread findings and news throughout the organization.
Distribute an annual wellness survey
The 10‑item Zero Burnout Program survey,3 also referred to as the “mini Z,” is short and easy to use. Distribute this survey annually to all providers in your practice. The mini Z can be completed individually online below or with paper copies. Solo or small practices can also take the mini Z and use the data to improve the practice environment.
Meet regularly with leaders and/or staff to discuss data and interventions to promote wellness
Share mini Z data with practice/departmental leaders or office staff. Meet regularly to discuss the data. An easy way to share the results of the mini Z survey is to create a document with summary data for all respondents. After reviewing the data, identify the areas of greatest concern, either practice‑ or organization‑wide or by department. Based on the problem area(s), select appropriate interventions to address them. More information can be found in the article, "10 Bold Steps to Prevent Burnout In General Internal Medicine."
Should data be shared across the practice or organization?
That is a choice the wellness committee or wellness champion will have to make. Some leaders may feel they are being attacked if their results are poor. Others may want to see where they rank compared to others. Sharing the data across practices provides an opportunity to introduce thoughtful and consistent programs throughout the organization to strengthen team culture.
What about naysayers who believe burnout doesn't matter?
- Appeal to what they care about, including their experiences as a busy health care provider, administrator or patient. “Would you like yourself or your family members to receive care from a frustrated, cynical or angry provider?”
- Emphasize the relationship between work conditions that lead to burnout, turnover and recruitment challenges. Replacing a single physician is estimated to cost over $250,0004
- Provide evidence of the relationships between burnout improvement and beneficial effects on quality and safety in your practice
- As burnout decreases, assess changes and present findings in key metrics, such as the patient experience, cost of care and staff productivity
Initiate selected interventions
Prioritize and select interventions to address burnout where it exists. Interventions may take one of three forms:
- Workflow redesign
- Better communication between providers in your practice
- Quality improvement (QI) projects targeted to clinician concerns
Workflow redesigns to reduce burnout may include: pairing nurses or medical assistants (MAs) with physicians in stable relationships, improving preparation and organization and pre‑visit planning with pre‑visit labs, sharing tasks with non‑physician staff, including having MAs enter patient data into the EHR and altering workflow between MAs and appointment coordinators. You may also consider if the time allotted for daily visits, procedures or bedside inpatient care in your practice is insufficient or if it is causing time pressure for your providers. Please see other STEPS Forward™ modules for suggestions to improve workflow in your practice.
Communication intervention projects could include: co‑location of key team members (e.g., nurses/medical assistants and providers), daily huddles to discuss complex patients and care coordination and scheduling monthly provider meetings focused on either work‑life issues and personal challenges or difficult patient care management issues. Please see other STEPS Forward™ modules for assistance with improving communication in your practice.
Targeted QI projects could include: a streamlined prescription renewal process, screening patients for depression, employing clerks instead of clinicians to track forms and send faxes, presenting mini Z data in an open forum to prompt discussions of issues within the practice and hypertension or pre‑diabetes management programs. Please see STEPS Forward™ modules on hypertension and pre-diabetes for guidance on QI recommendations in these areas. Table 1 summarizes interventions performed as part of the Healthy Work Place (HWP) study conducted by Mark Linzer, MD, and colleagues.3 Many of these interventions are the foundation for the recommendations in this and other STEPS Forward™ modules.
|Workflow||Communications||Targeted Quality Improvement (QI)||Other|
|Shift to MA entering data into EHR instead of physician. Covered in team documentation||Improved interpersonal communication and teamwork. Discussed in team meetings||Implementing a hypertension management program||Implementing panel management|
|Better patient flow through the clinic enabled by pre-visit planning including pre-visit laboratory testing||Improved opportunities for informal communication among providers, such as a shared lounge or periodic shared meals. Reviewed in team culture||Establish quality improvement projects for issues of importance to providers||Dashboard of patient population measures for clinicians|
|Sharing information to make the clinic more efficient||Monthly formal discussions on patient care for clinicians to improve collegiality||Freeing time for nurses and physicians by implementing synchronized prescription renewal||Presentation of wellness data to prompt discussions on changing the clinic environment|
|Assess workflow between MAs and nurses to identify opportunities for change. Discussed in expanded rooming and discharge protocols||Informal survey of clinicians for a ‘wish list’ of issues to be corrected||Implementing a pre-diabetes management program|
|More time for nursing/MA staff to complete tasks||Sharing organizational updates with monthly email or meeting with leaders||Implementing processes to improve medication adherence|
|Pairing one MA with each attending physician. Described in expanded rooming and discharge protocols||Clinicians meeting individually with leadership to review operations and identify concerns||PDSA program for patient portals. Discussed in Lean management|
|EHR=Electronic Health Record; MA=Medical assistant; PDSA=Plan, Do, Study, Act quality improvement program|
*Adapted with permission from: Linzer M, Poplau S, Grossman E, et al. A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) Study. J Gen Intern Med. 2015 Feb 28 [epub ahead of print].
Your practice may also consider developing a resource list detailing how individual practitioners can reduce burnout through time management, delegation, exercise, sleep and mindfulness. Please see the resiliency module.
Should self‑care interventions be included to reduce burnout?
Yes, self‑care is an important tool that providers in your practice can use to reduce their individual stress levels and prevent burnout. Some self‑care interventions include meditation, getting enough sleep, a regular exercise routine, engaging in other hobbies or taking mini‑breaks throughout the day in a quiet space to decompress. Please see the resiliency module for more details.
What are the benefits of addressing burnout?
By addressing burnout clinics are more likely to achieve other organizational goals, such as better recruitment, higher retention, better quality of care and improved patient safety. A model of burnout prevention is highlighted below:
Adapted with permission from Linzer M, Levine R, Meltzer D, et al. 10 bold steps to prevent burnout in general internal medicine. J Gen Intern Med. 2014;29(1):18‑20.
Will these interventions cost money?
Yes, some interventions do have costs associated with them. But burnout is likely to be even more costly to your organization or practice. Each provider who leaves the practice costs money and adds stress to remaining providers. This finding suggests that investing money now to reduce physician stress and burnout could provide significant return on investment down the road.
Are the interventions all expensive?
No, many are very inexpensive. Re‑engineering schedules for provider‑parents and making team meetings more productive are examples of inexpensive interventions. However, some needed interventions to reduce chaos, such as additional exam rooms for more efficient use of provider time, require resource investment.
Another low cost intervention is discussing clinic or departmental values. Lack of values alignment with leaders is a known contributor to stress and burnout, and by making time to discuss and agree on shared values, you can alleviate this source of stress.
For example, begin staff meetings with an interesting case and allow time for group discussion. Providers chose this profession for the medicine! Discussing rare or interesting cases can re‑energize your providers and help them reconnect with the joy of practicing medicine. Another free option is to create a list of values that your practice deems important. This exercise can be valuable even in a solo practice. Consider starting with a short menu to expand upon, such as:
- Quality over productivity
- Work‑home balance
I've heard people talk about “meetings with meaning.” What are they and how can I use them as an intervention?
Clinicians have limited time to meet. Research indicates that restructuring meetings to address clinical cases or challenging patients and issues of concern to them, rather than administrative issues, is a successful way to reduce clinician stress. These restructured meetings are called “meetings with meaning.”
What is “career fit” and how can that help providers?
Shanafelt et al. define career fit as the extent to which an individual is able to focus their effort on the aspect of work that they find most meaningful.5 Physicians often have a particular passion they wish to pursue (e.g., education, research, QI). Researchers at Mayo Clinic have shown that when the amount of time a physician has to pursue what they are passionate about falls below 10 to 20 percent, burnout rises dramatically from 29.9 percent to 53.8 percent.5 Physicians may decide to devote part of their work week to what interests them most, be it workflow improvement or improving communication in the office.
Can burnout be helped by community service?
Providers who are burning out may benefit from leading community service programs outside of the clinic, such as providing health education for children or adults. Studies have shown that community service can substantially reduce burnout, as it brings people closer to their true values and mission in medicine.
What kind of interventions work for providers with very high burnout?
Add a comment box on the survey for those respondents that have the highest burnout score (5 on the 5‑point scale, “I am so burned out I cannot go on…”) so that they can provide more information about reasons they are burned out. List a telephone number directly on the survey for the person to call for help, for example, the “Employee Assistance Program,” human resources or a member of the wellness committee. Alternatively, if you do not survey anonymously, you can let individuals know that you will be contacting those that indicate very high burnout.
Repeat the survey within the year to re‑evaluate wellness
Compare stress and burnout scores from before and after intervention. Use a simple spreadsheet or graph to show changes in stress levels, burnout, satisfaction, control over work, chaos and alignment of values (if applicable) over time. Develop an understanding of what worked and celebrate those successes. Examine factors that saw no change or a rise after intervention and seek remediable explanations.
Seek answers within data, refine the interventions and continue the improvements
Determine which interventions are working; refocus on those interventions and reinvigorate staff to carry them out. In areas where burnout is increasing or observed improvements are not sustained, analyze the mini Z results to guide new or modified interventions. The commitment of the wellness committee or wellness champion to the wellness interventions will help convince providers that your practice is dedicated to staying on a path to reduce burnout.
What's the long‑term goal of this type of “measure, intervene, re‑measure” program? What are the short‑term goals?
The overarching goal is zero provider burnout. Since burnout is a long‑term stress reaction, surveying for high stress levels and intervening may help prevent most cases of burnout.
A short‑term goal could include bringing clinical and administrative leadership on board with wellness initiatives. Knowing your own data, addressing it and providing stability, if not improvement, in the work environment is another short‑term goal.
When do we stop measuring the impact of our wellness interventions? Can we stop if they appear to be working and sustained?
Medicine is a high‑stress profession. Even if burnout in your practice is driven down to zero, stress may still exist and the need to monitor it will not be eliminated. Keep on measuring and keep supporting successful programs.
Wellness interventions work
Improving workflows within the practice is the most powerful antidote to burnout. This approach increases the odds of reducing burnout six‑fold.6 Targeted quality improvement projects addressing clinician concerns increase the odds of reducing burnout five‑fold.6 Improving communication between team members can improve the odds of professional satisfaction up to three‑fold.6 Please see other STEPS Forward™ modules for guidance on practice redesign to improve workflow, communication and practice culture.
Try not to embarrass or blame people with negative findings. Be supportive and encourage improvement. Congratulate leaders on successful steps they have taken and provide additional concrete actions they can take. Be creative with them in seeking ways to improve their department, unit or practice. Function as a liaison with clinic administration to find best practices and advocate for bigger organizational or practice changes when they are needed to make a difference for individual departments or units.
Change is slow and steady
Don't try to move the needle too far too fast. Patience is needed to make sustained work‑life improvements. Small improvements can make a difference in the day‑to‑day work lives of physicians, so do not be discouraged if you cannot make big changes right away.
The unsolvable can be solved
Don't be intimidated or discouraged by your challenges. Ask your colleagues for possible solutions. You may find that the problem has been discussed and solutions have been identified but not shared across the practice. Be creative when looking for partners. Don't forget you could have allies in departments/units such as Finance and Billing, Environmental Services or Quality Improvement. Every unit/person will see the problem from a different perspective so seek to understand what they see and how they'd fix it.
Don't be afraid to create new work schedules
Consider alternative clinical structures, such as “7 days on, 7 days off,” even for predominantly ambulatory providers. At Hennepin County Medical Center (HCMC) in Minneapolis, MN, graduating residents suggested a 7‑on, 7‑off model to encourage careers in ambulatory medicine. HCMC took their advice and developed a model program for new faculty hires. They've since hired two physicians and three nurse practitioners to join the two full time clinicians with the 7‑on, 7‑off work schedules. The work schedule includes atypical work hours, but the providers have a week off in‑between. They are leading the organization in certain aspects of innovation, such as measuring the impact of scribes and problem‑oriented charting on quality of care, provider satisfaction and clinic finances.
The creation of a Provider Wellness Program at HCMC demonstrates that we recognize that the well‑being of providers is critical to the health and wellness of our patients. Small changes that come from the suggestions of providers can be hugely impactful and strengthen the unity of the care teams, thereby improving the quality of care and satisfaction of patients, families and providers.
If you standardize, customize
Remember to adjust standard work for complex lives. Most busy provider schedules don't fit comfortably in four‑hour boxes (8 a.m. to noon, 1 to 5 p.m.). Allow for flexibility, especially around the beginning and end of work shifts.
Provider stress and burnout can have a significant impact on organizational productivity, morale, costs and the quality of care being delivered. This module will help you take corrective action early by identifying sources of stress and developing interventional approaches that will help your organization reduce burnout and promote wellness.
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- Linzer M, Manwell LB, Williams ES, et al. Working conditions in primary care: physician reactions and care quality. Ann Intern Med. 2009;151(1):28‑36, W6‑W9.
- Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work‑life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377‑1385.
- Shimotsu S, Poplau S, Linzer M. Validation of a brief clinician survey to reduce clinician burnout. Manuscript submitted for publication. 2015.
- Buchbinder SB, Wilson M, Melick CF, Powe NR. Estimates of costs of primary care physician turnover. Am J Manag Care. 1999;5(11):1431‑1438.
- Shanafelt TD, West CP, Sloan JA, et al. Career fit and burnout among academic faculty. Arch Intern Med. 2009;169(10):990‑995.
- Linzer M, Poplau S, Grossman E, et al. A Cluster Randomized Trial of Interventions to Improve Work Conditions and Clinician Burnout in Primary Care: Results from the Healthy Work Place (HWP) Study. J Gen Intern Med. 2015.
- Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573‑576.
- Daskivich TJ, Jardine DA, Tseng J, et al. Promotion of wellness and mental health awareness among physicians in training: perspective of a national, multispecialty panel of residents and fellows. J Grad Med Educ. 2015;7(1):143‑147.
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- Linzer M, Gerrity M, Douglas JA, McMurray JE, Williams ES, Konrad TR. Physician stress: results from the physician worklife study. Stress Health. 2002;18(1):37‑42.
- Linzer M, Levine R, Meltzer D, Poplau S, Warde C, West CP. 10 bold steps to prevent burnout in general internal medicine. J Gen Intern Med. 2014;29(1):18‑20.
- Schwartz T, Gomes J, McCarthy C. The Way We're Working Isn't Working: The Four Forgotten Needs That Energize Great Performance. New York, NY: Free Press; 2010.
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STEPS in practice
How's it working in Boston?
The Boston Medical Center (BMC) Wellness Committee was created to combat burnout and reduce physician stress with seed money from a malpractice insurance program in 2012. The committee is composed of 15 members from different departments. Its project from 2012 to 2013 was to develop a broad wellness website that brought together resources from around campus on work, personal and health topics. The Wellness Committee also organized seminars on resiliency training and narrative writing.
The committee also developed various in-person programs, including a monthly clinical case discussion group within the GIM clinical practice started by Jane M. Liebschutz, MD, MPH, Associate Chief of General Internal Medicine in 2013. This discussion group, which continues to this day, was modeled after Balint groups, which are groups of clinicians who meet and talk through clinical cases to better understand their relationships with patients. At this monthly meeting, one clinician presents a difficult case to groups of eight to 12 colleagues. It is an opportunity to overcome the isolation inherent in clinical practice and feel supported by colleagues, which decreases personal and professional stress. This program was endorsed by over 80 percent of participants. As one participant said, “The group has reminded me that relationships and communication are very important—often more important than the technical aspects of care.”
Having a wellness program helps buffer some of the challenges presented with clinical practice in today's evolving health care environment. The BMC wellness programs have reinvigorated clinicians with joy and passion in practice and have been enthusiastically received at BMC.
How's it working in Redwood City, CA?
The wellness programs at Kaiser Permanente of North California in Redwood City were started to improve physician satisfaction and retention. At first, our program consisted solely of an annual physician recognition dinner. As we learned more about what wellness means, we started designing programs supporting physical health, collegiality, community and practice management.
"Wellness is personal" at Permanente, so we try to promote programs with a variety of information and services that meet the needs of all physicians. Some successful programs we've implemented include:
- Mentoring. Experienced physicians are paired up with new physicians. There is also a "speed dating" lunch program where primary care doctors sit on one side of the table and specialists on the other side. The specialists rotate every five minutes. This approach not only introduces staff who might not otherwise meet, but also promotes collegiality.
- Health festivals. Tables are set up with different services where physicians rotate through and learn about various aspects of their own health. Examples include a blood pressure check, dermatology check for skin cancers and dietary evaluations. Physicians also have an opportunity to sign up for their own preventive health screenings, such as Pap smears and blood tests.
- Movie day. Wellness committee staff rent a movie for the physicians and their families and organize a lunchtime viewing party. This promotes community and a sense of pride in the workplace for the physicians.
- Wellness Thursday lunches. Every Thursday at noon, lunch is provided to staff and various topics are covered including travel, financial management, how to save for college, real estate and home remodeling.
- Birthday letter. In their birthday month, physicians receive a letter reminding them to see their own provider. Leaders help them block the time in their schedule for that appointment to promote their own health.
How's it Working in Palo Alto, CA?
At Stanford University Medical Center, the guiding principle of the Stanford Medical Staff Committee for Professional Satisfaction and Support (SCPSS) is that the professional fulfillment of clinicians is inextricably linked to quality, safety and patient‑centeredness. The committee focuses on implementing programs that target these six areas that impact professional fulfillment: personal health, peer support, community building, work‑life integration, personal resilience and professional fulfillment and organizational/personal values alignment.
The Educators‑4‑Care (E4C) program pairs five to six medical students annually with a faculty member, who serves as teacher, mentor and colleague for the duration of the student's time at the school of medicine. A resident peer program supports housestaff after they experience an adverse patient outcome and when they need general support. Chief residents, trained as peer supporters, guide their colleagues through the coping and self‑care process. For medical staff, there is also a peer support program with trained physician peer supporters who are available following critical incidents.
A medicine and literature dinner discussions series is a six‑month program with facilitated discussions of stories, poems, plays, personal narratives and films. Participants engage in deep conversations about circumstances that brought patients into their care and about patients' and providers' diverse experiences of healthcare, illness, trauma and recovery. There is also a mindfulness sub‑group to create awareness of mindfulness‑based stress reduction and its benefits for physicians and patients.
The committee has a WellMD website and monthly newsletter with links to self‑assessment tests and contact information for groups, classes and volunteering opportunities regarding exercise and fitness, stress and burnout, depression, mindfulness, resilience and work‑life balance.
A pilot faculty flexibility program provided career development coaching, with a focus on increasing work‑life integration and addressing work‑work conflict (defined as the competing demands faced by faculty as they meet multiple institutional missions). This program had two parts: career customization and a support mechanism with a banking system. Preliminary results demonstrated improved work‑life fit, more frequent use of vacation time, more cross‑coverage for colleagues in need, more time to discuss science with colleagues, more support by Stanford for career development of women faculty and more grants submitted by program participants. The program has continued in some departments post‑pilot and the integration of key elements of the pilot into career development strategies is being evaluated.
How's it working at Adventist Health System?
Over the past decade, Adventist Health System (AHS), comprised of more than forty hospitals in ten states, has pursued a program designed to support the personal and professional well-being of physicians. AHS created four major initiatives, including Physician Support Services, Finding Meaning in Medicine, Schwartz Rounds, and The Coalition for Physician Well-being. While challenging to quantify with accuracy, we are convinced that these initiatives have contributed significantly to this goal and are being increasingly adopted by hospitals and physicians across the system.
Physician Support Services (PSS) provides individual counseling and coaching services, along with seminars and retreats. These programs are designed to promote personal growth and enrich relationships. In order to maintain professional dignity and ensure privacy, counseling services are confidential and are not reported to the medical staff office or hospital administration. To date, over one thousand physicians and/or their families across AHS locations have accessed the services of PSS, which translates to more than 10,000 total contacts.
Finding Meaning in Medicine (FMM), conceived and developed by Dr. Rachel Naomi Remen, is described as “self-directed, on-going, values and meaning study groups.” In Dr. Remen's words, these groups help doctors “remember the heart of medicine.” Typically, FMM is initiated by a physician champion who opens their home to invite colleagues over for a casual evening meal and conversation. Alternate venues might include a comfortable conference room or private restaurant. Small groups of five to 15 physician colleagues gather for a shared storytelling experience centered on a predetermined theme. Example themes might include Gratitude, Humility, Teamwork, Loyalty, Surprise or Service, among many others. These groups are scheduled regularly, either on a bi-monthly or quarterly basis.
Physician evaluations after a recent weekend conference that included a Finding Meaning in Medicine group session contained the following feedback:
- “Best event of the weekend. I will be taking this home and implementing at our hospital.”
- “Powerful community building.”
- “Very meaningful to build empathy with each other.”
- “This could singularly change the culture of our medical staff for the better.”
For more information, visit http://www.rishiprograms.org/programs/all-healthcare-professionals/.
Schwartz Rounds are sponsored by the Schwartz Center for Compassionate Healthcare which was created in memory of health care attorney Ken Schwartz. Schwartz Rounds are designed to promote compassionate care by bringing together health professionals across disciplines to address and bring attention to the personal, emotional and social aspects of patient care. A small panel of caregivers uses a case presentation approach to provide a brief orientation to a pre-selected case, including sufficient clinical background to frame the topic, followed by facilitated discussion involving the assembled interdisciplinary audience. Issues of privacy and confidentiality are respected. The focus is as much, or more, on caregiver experiences, attitudes and feelings as it is on the patient case. Sample case stories drawn from the local institution might include:
- Death of a young person by overdose
- A patient with frequent readmissions that can be attributed to family and social issues
- A patient with acute onset of progressive dementia
- A patient with traumatic brain injury resulting from a vehicular accident
Now widely adopted in hospitals across the country, Schwartz Rounds has been described as a “culture-changing conversation” that contributes to empathy, professional collaboration and teamwork within a practice. Physician comments following a recent Schwartz Rounds event included the words, “powerful,” “amazing,” “moving” and “engaging.”
For more information, visit www.theschwartzcenter.org.
The Coalition for Physician Well-Being is a 501(c)6 tax-exempt association of hospitals and related health care entities that are committed to promoting physician wholeness and resiliency. Through mutual learning, networking, facilitating and consulting, the Coalition seeks to help physicians achieve balanced lives, purposeful practices and meaningful relationships. The ultimate goal is to enhance healthcare culture, thereby improving the safety, quality and humanity of patient care. The Coalition sponsors monthly educational webinars, which are archived for continued access. At its fifth annual meeting in April, 2015, the Coalition introduced the new Medicus Integra designation that was created to recognize hospitals for exemplary dedication to promoting physician well-being.
For more information about the Coalition for Physician Well-Being or the Medicus Integra designation, visit www.forphysicianwellbeing.org.
How's it working in Minneapolis, MN?
At Hennepin County Medical Center in Minneapolis, physician‑parents were often unable to leave on time because their last complex patient was scheduled at 4:30 p.m. In many instances, this patient would not be ready for the provider to see until 4:45, making it extremely challenging for the provider to leave on time to pick up a child from daycare by 5:30. This was creating high stress for these providers. To address this challenge, the end‑of‑day schedule was re‑engineered so the last complex patient was scheduled at 4:00 p.m. instead of 4:30 p.m. The appointment slot at 4:30 p.m. was changed to routine care instead of complex. This simple change helped parents leave work on time.
The general internal medicine department also took steps to improve the physical environment by investing in new carpeting and asking staff to contribute ideas for locally sourced art. The result was transformation in which everyone was invested. Satisfaction in the department increased from 65 percent in 2013 to 83 percent in 2014, while burnout decreased from 39 percent to 17 percent over the same time period.
How’s it working in Minneapolis, MN?
At Hennepin County Medical Center (HCMC) in downtown Minneapolis, MN, a conversation between the chief of the Department of Internal Medicine, a resident training in internal medicine, and an administrator triggered the launch of a pilot program to try an innovative scheduling model. The question they were discussing was: "Why can't we get more internists to practice primary care?" The resident responded that the schedule of a primary care physician appeared far less appealing than that of non-primary care specialists. In addition, there was a sense that the work of primary care physicians carried over past the end of a work day to a greater degree than that of hospitalists. The chief pitched an idea to two internists who had been hospital-based for a decade: switch to a primary care clinic outside the hospital with a schedule that is more responsive to your preferences and responsibilities.
Peter Sandgren, MD, and Veeti Tandon, MD, a married couple who both trained at HCMC, were invited to set up a primary care clinic at the medical center with a schedule tailored to their needs. Sandgren and Tandon were comfortable with the seven days on/seven days off schedule used by many hospitalists. Their initial plan was to use a similar schedule for the clinic, with each physician working alternating 7-day periods. The on-week would include 10 four-hour sessions: mornings, afternoons, and evenings on weekdays (except Wednesday morning), plus Saturday mornings. Both Sandgren and Tandon opted for part-time work; full-time requires 12 sessions per week.
To start, the clinic included Sandgren and Tandon, three nurse practitioners, and two embedded clinical psychologists. "We've chosen a week on/week off schedule, but it's not about seven on/seven off—it's about having flexibility, so that the schedule goes along with your life. Physicians with younger children may want to work more Saturday mornings and have fewer evening sessions. Others may want more evenings and fewer Saturdays."
Wednesday mornings are dedicated to a care coordination meeting. The session is attended by both physicians, as well as nurses, medical assistants, a pharmacist, and the two clinical psychologists. The session is considered direct patient care time. During the meeting, the multidisciplinary group discusses care plans, consults and medication management. They consider each provider’s patient panel and daily census with a focus on chronic disease management (e.g., diabetes management and preventive care, colon cancer screening, depression screening). The meeting is also an opportunity to check that diagnoses and complexity scores are correct, and to streamline and optimize billing.
The largest obstacle Sandgren and Tandon have encountered in launching the clinic has been keeping up with the electronic health record inbox during their off weeks. They have chosen to work one session during their off week to spend time on inbox messages.
Sandgren and Tandon say the keys to success for the schedule and the clinic overall have been the coordination meeting, the presence of nurse practitioners with whom to collaborate, the small size of the clinic, and the group’s intentionally supportive culture. "We have a clear identity as a group. We understand that the schedule matters and that physicians won’t last or will be unhappy if the schedule doesn’t work. It helps that we are a group of five clinicians; it makes it easier to reconcile different interests related to the schedule," says Sandgren.
It’s too soon to say whether the new model will help attract or retain primary care physicians; however, Sandgren and Tandon are pleased with the schedule and their ability to transition to primary care, as both physicians were ready for a career shift. The system has also expanded access for patients, providing more evening hours than many of the other clinics. The small size of the group has allowed for piloting of new care processes, such as the use of scribes to decrease the burden of data entry.
The group is creating a second pod within the clinic, with positions for another two physicians. The first physician has signed on for a flexible schedule that is not seven days on/seven days off. A second physician will be recruited soon to craft a coordinated schedule for the second pod.
According to Tandon, the ability to influence their schedules is important for the long term. "We can't think only of the patient. We need to create something that is sustainable for the physician. We need to balance access for patients with flexibility for us."
How’s it working in Minneapolis, MN?
Hennepin County Medical Center (HCMC) is a safety net hospital and Level 1 Trauma Center that serves the Minneapolis area. Mark Linzer, MD, an internal medicine doctor and Director of the Division of General Medicine at HCMC, is a nationally recognized expert on physician burnout. In 2013, he noticed how hard everyone was working and wanted to create a support network within HCMC to help retain and recruit top quality providers. While HCMC providers face similar levels of stress and burnout as providers across the county, Dr. Linzer felt that HCMC could help its providers sustain their busy workload by applying the findings from the national Work Life Study.1 Following Dr. Linzer’s suggestion, HCMC established a Provider Wellness Committee (PWC) composed of physicians and advanced practice providers (APPs) from 12 of HCMC’s 16 departments.2 The PWC's objective is to support and sustain provider wellness. The PWC reports to executive leadership and is tasked with identifying provider stressors and executing solutions. Within one year of implementing the PWC, reports of provider burnout decreased from 33 percent to 27 percent.
The PWC meets monthly for 40 minutes during the lunch hour and offers attendees a healthy lunch option. While these features may seem trivial, the short meeting time and lunch are greatly appreciated by the busy PWC members. During initial meetings, the PWC developed a charter to improve efficiency and make it easier to disseminate wellness initiatives throughout the HCMC system. Importantly, this charter opens a direct line of communication to HCMC leadership so they can stay informed about the impact that PWC-initiated policies are having on providers. This line of communication also gives providers a better understanding of why specific policies are in place.
All 16 departments at HCMC have a Wellness Champion (WC) who acts as the "face of wellness" for their department and who can be approached with complaints and suggestions. A WC can be any provider—a physician, dentist, psychologist, nurse practitioner or physician assistant—as long as they are invested in making wellness happen at HCMC. WCs often serve on the PWC and they also work directly with department chairs to implement PWC improvement tactics. This relationship helps ensure a more evenly distributed workload and supports rapid uptake of changes in the department. The WC infrastructure is a key component of wellness promotion at HCMC.
One of the PWC's first major initiatives was the transformation of selected physical spaces. The former Doctors' Dining Room was renamed the Provider Dining and Wellness Center after it was transformed into a multi-purpose area open to all physicians, nurse practitioners, physician assistants, psychologists and dentists. Private philanthropy made it possible to give the area a complete facelift. Space was carved out for exercise equipment, lockers, a shower and dressing room to accommodate providers who exercise during the day or bike into work. The space also hosts weekly Reflection Rounds with residents, where they can talk about the challenges of practicing medicine in a safe and supportive environment. A new Reset Room was also created for providers who want to have a few quiet moments away from colleagues and residents, a place they can go if they need to regroup after a traumatic encounter with a patient or a place to take a private phone call.3 The Reset Room is a serene environment modeled after a spa relaxation room. Revamping a formerly underutilized dining area and creating a new sanctuary are just two of the tangible ways HCMC has shown its commitment to provider wellness.
The other major task of the PWC is running the annual wellness survey. This mini Z survey comprises 10 questions along with one optional open-ended question. About half of the respondents take the time to write in sources of stress and possible solutions. The survey results are shared in small meetings with the chairs of each department. WCs also attend these meetings, which is incredibly valuable since they are often able to bring insights gathered firsthand from colleagues. Immediate assistance is provided to departments that exhibit a great deal of stress and burnout. Departments with low burnout rates are also targeted to learn what makes them function so well. The survey findings are not shared outside of departments or used to compare one department to another. There is also no benchmarking to other organizations or departments across the country. The survey is only used to assess each department’s progress year to year.
PWC members and WCs are given time away from clinical practice to participate in the annual wellness retreat. The time away is paid for by the institution and does not count as vacation or personal time away from the office. The retreat is an opportunity for all PWC members and supporters to:
- share findings of new provider burnout research
- discuss wellness initiatives
- connect with others within the institution who care about provider wellness
- share ideas across departments
- participate in personal wellness initiatives
- discuss survey data
- brainstorm new interventions
Everyone leaves the annual retreat with a tangible plan for discussing the proceedings of the retreat with their department chair and a clear understanding of the resources available to assist with departmental challenges.
In addition to establishing the PWC and selecting WCs, HCMC has further demonstrated its commitment to provider wellness by establishing the Office of Professional Worklife (OPW). OPW plays an advocacy and support role, working between hospital executive leadership and departments experiencing work-life stresses. The OPW is a place providers can go when they need assistance, have suggestions, or need conflict resolution assistance. The OPW also introduces wellness programs at HCMC during new provider orientations.
HCMC is very fortunate to have all of these programs focused on provider wellness. None of this work would be possible without support from leaders and champions that span all offices and levels within the organization. They understand that being a provider is challenging and have taken action to make it less demanding, with the goal of making HCMC one of the best places to practice medicine!
- Linzer M, Poplau S, Grossman E, et al. A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) Study. J Gen Intern Med. 2015;30(8):1105-1111. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4510236/.
- Hennepin County Medical Center News. Healthy work/life balance is essential for caregivers: Office for Professional Worklife is the first of its kind to address physician stress. https://hcmcnews.org/2016/01/14/healthy-worklife-balance-is-essential-for-caregivers/. Published January 14, 2016. Accessed September 27, 2016.
- AMA Wire. Physicians take to "reset room" to battle burnout. http://www.ama-assn.org/ama/ama-wire/post/physicians-reset-room-battle-burnout. Published June 8, 2016. Accessed September 27, 2016.
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Preventing physician burnout module
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Mini Z Survey
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Talking points for leaders
These tips will help you encourage leadership to support provider wellness efforts.
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Tactics to reduce burnout
Use these tactics to reduce burnout in your practice.
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Zero burnout program survey for clinicians
This in-depth survey will identify sources of stress and burnout for clinicians.
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AMA Wire - Physician Burnout
Article adapted from the AMA Wire® that summarizes the STEPS Forward module on Physician Burnout.
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