The health care workforce burnout epidemic is a national crisis. The time to act like it is now.
Despite the promise of delivery system reform, especially following passage of the Affordable Care Act (ACA), the risk of burnout among physicians (and other health care professionals) represents a significant threat to system-wide achievement of Triple Aim goals: better patient experience of care, improved population health, and lower costs.
In the rush to implement various initiatives, including additional reporting requirements and adoption of new technology such as electronic health records (EHR), and coupled with increasing pressure to increase throughput and reduce costs, most physicians are being asked to provide high-quality, compassionate care with less time and resources to effectively engage patients.
This “work compression,” wherein clinicians have to do the same amount of work in less time, occurs on a backdrop of steadily increasing medical complexity in the forms of multimorbidity and increased prevalence of chronic disease and often physically and psychologically challenging work environments. In response, over half (54 percent) of surveyed physicians in the U.S. now reported at least one symptom of burnout in 2014 — a 9 percent increase from three years prior.
The response from the physician community has been passionate and pervasive in the pages of both academic medical journals and in lay media. Yet, despite the growing chorus of concern over the burnout epidemic, some still characterize this problem simply as clinicians unwilling to adapt to the priorities of quality improvement and lowering costs. Such characterizations not only implicitly underestimate the increasing stress placed upon practicing physicians, but they compound the problem by adding castigation and motivational misattribution to the equation.
In reality, physicians are caught in a quagmire between the demands of the health care system and their deeply held desire for a meaningful relationship with their patients based on compassion, trust, and mutual respect. The stark dichotomy between the kind of care clinicians want to provide and what they are able to provide, is leading to burnout. Consequently, the inability to deliver on the promise of patient-centered care has become the breeding ground for disillusionment with the health care system and their professional calling.
Clinician Wellbeing Drives The Triple Aim
In a seminal 2014 Annals of Family Medicine article, Tom Bodenheimer and Christine Sinksy noted the threat that clinician burnout poses for achieving the Triple Aim of enhancing patient experience, improving population health, and reducing costs, all of which have been demonstrated to be impacted by clinician wellbeing. In characterizing the triple aim as a “compass to optimize health system performance,” the authors noted that a fourth aim, improving the work life of health care providers, was necessary to achieve successful system transformation.
At its core, the recommendation to expand the triple aim to the “Quadruple Aim” recognized that wellbeing is not simply an issue for clinicians; the consequences of burnout extend to patients in measurable ways. For example, physicians experiencing burnout are more prone to diagnostic and patient safety errors and less likely to engage patients and colleagues alike.
Similarly, burnout has been demonstrated to be negatively associated with empathy. Accordingly, and not surprisingly, physicians and nurses suffering from burnout find it more difficult to deliver compassionate care. Compassion is a universal expression of human connection and caring in response to distress and suffering and underlies the very purpose of medicine. In short, if we are to expect caregivers to engage patients (and each other) characterized by effective communication, mutual trust and respect, and adequate emotional support, then it is essential that we begin supporting the wellbeing of the people charged with delivering care.
Burnout of our health care workforce also has broad implications for our health care system as a whole. Lost productivity for physicians, nurses, and other members of the health care team contribute to additional costs, and associated attrition leads to loss of continuity across the care team and care settings. In one recent study in a long-term care setting, nurses who felt supported by a compassionate, collaborative culture had significantly fewer missed days of work, higher patient satisfaction, and fewer of their patients had trips to the emergency department, as compared with colleagues that did not experience the same level of organizational support.
Without a clear focus on the wellbeing of the clinicians delivering patient care, the limits of changing payment models to drive Triple Aim outcomes will become evident and ultimately moderate delivery system efforts.
Set A Target And Timeframe To Reduce Burnout
Following passage of the ACA, the first major federal initiative launched under the auspices of delivery system reform was the public-private patient safety initiative, Partnership for Patients, which set specific goals of decreasing preventable hospital-acquired conditions (HAC) and hospital readmissions by 40 percent and 20 percent respectively within three years. The Partnership for Patients campaign was launched, in part, to accelerate best practices around quality improvement, despite financial incentives/penalties and mandatory reporting requirements for HACs and readmissions.
While some have questioned the causal relationship between Partnership for Patients and significant improvements in HAC and readmission reductions, the fact remains that the initiative has activated thousands of hospitals to collaborate and prioritize a specific set of goals. Similarly, in January 2015, the Department of Health and Human Services (HHS) set specific targets and a timeline for shifting Medicare reimbursements to alternative payment models (APMs), setting a goal of 30 percent and 50 percent of Medicare payments by the end of 2016 and 2018 respectively. Due in part to a flurry of models developed by CMS and also private sector initiatives, on March 3, 2016, CMS announced they had reached their first stated goal of 30 percent, well ahead of schedule.
The burnout epidemic presents a similar need for collaboration across the health care sector and the need to measure improvement in a defined period of time. The case for linking clinician burnout to ongoing national priorities now, relates to the ideas that 1) simply engaging on-the-ground clinicians – the very people suffering from burnout – is unlikely to be successful as a sole strategy, and that 2) significant systemic and structural changes to the current health care delivery system are likely to be necessary, given the broad, multifactorial nature of physician burnout, ranging from work compression to reporting requirements, all while attempting to deliver (and simultaneously measure) high-quality care.
Additionally, the tools to measure burnout already exist. The Maslach Burnout Inventory, a 22-item questionnaire, is the most commonly used tool. The General Health Questionnaire and Nursing Stress Inventory are other validated measures. In other countries like the United Kingdom, leading medical associations offer simple online surveys to measure burnout among clinicians.
We believe that finding ways to reduce and consolidate public reporting requirements will be a key component of the solutions to address burnout. In a recent study published in Health Affairs, Lawrence Casalino and colleagues were able to quantify the burden on physician practices in four common specialties, finding they spent an average of 785 hours per physician and more than $15.4 billion dealing with the reporting of quality measures. Physician practices now face a multitude of non-direct care tasks such as: understanding quality measure requirements, recording and reporting measures in new information systems, and understanding performance reports from payers and provider systems alike.
CMS recently concluded the comment period for their Draft Measure Development Plan that would set the framework for future quality measures under the new Medicare Merit-based Incentive Payment System (MIPS) and certain Medicare APMs. The draft plan sets out a general effort to reduce provider data collection requirements by creating core sets of measure across public and private payers and integrating new measures into existing workflow. The forthcoming plan expected by May 2016 and other recommendations from measure consolidation/alignment initiatives, such as the public-private Core Quality Measures Collaborative Workgroup, should be a good indicator of how CMS is prioritizing the burden issue.
Combatting Burnout On Every Level
Addressing the other contributors to physician burnout, including the pressure to manage increasingly medically complex patients in less time for less money with better outcomes, will be more difficult, and will require larger system modifications. Potential remedies at the disposal of a hospital, much less an individual primary care practice, are lacking. Payment models that value patient counseling and care coordination/team-based approaches to care as much as procedures and traditionally measured relative value units, will help, as will use of physician extenders, such as nurse practitioners and physician assistants as part of the realization of the medical home.
At the organizational level, leadership is instrumental in creating a culture that sustains resilience and supports employee wellbeing. Some organizations prioritize recognition programs for compassionate caregivers. There is also evidence that forums for interdisciplinary teams to come together to discuss the psychosocial and emotional aspects of patient care can improve collaboration and foster empathy.
Further, as new EHR systems are adopted, hospital leaders should integrate clinicians into the front-end of purchasing, implementation, and training decisions. The same should apply to major regulatory proposals and other system modifications, where involvement of front-line clinicians is imperative to assuring that such changes always foster, rather than impede, the delivery of compassionate care that is both physician and patient-centered.
In the end, however, a comprehensive strategy to address burnout at the individual, organizational, and system levels will ultimately require a national movement led by stakeholders across the public and private sectors.
We propose that before the end of the year, the Obama Administration convene a multi-stakeholder task force to set specific targets to reduce clinician burnout in a timeframe that aligns with other national health care goals. It seems only fitting now, as we get closer than ever before to scaling Triple Aim innovation across the health care sector, that we similarly emphasize the wellbeing of our health care workforce as an essential factor in achieving a sustainable and truly patient-centered health system.