Medicine is recognizing that physician well-being affects both practitioners and their patients.
By Kate Ledger
Macaran Baird, M.D., remembers a time early in his career when it seemed his professional life was getting the better of him. Only a few years into his first job as a family physician in the late 1970s, Baird was working as a clinician and chief of staff at a practice in Wabasha, Minnesota. With additional training as a family therapist, he also was writing a book on involving families in health care, and he occasionally took trips away from his own young family to teach. “I was tired, and, like most physicians, busy. But I thought I was doing OK,” he says.
So it took him by surprise when one of the nurses he worked with asked whether he might be overextended. She’d noticed he’d grown “grumpy” at the hospital. In fact, she told him, nurses had begun trading shifts in order to avoid working the nights he was on call. The feedback hit home. Baird realized at once that what he knew intellectually about the importance of taking care of himself wasn’t playing out in his day-to-day routine. Having already seen some overworked colleagues grow depressed and others get in trouble with alcohol and other addictions, he knew he had to make some changes.
Ultimately, Baird took steps to fit more down time and family activities into each day. Today, as chair of family medicine and community health at the University of Minnesota, he pays attention to his daily stress level and takes breaks from work when he finds stress getting out of hand. As important, he continues to be concerned about the well-being of the physicians he’s working with and training.
Baird is not alone. A growing body of evidence is pointing out high levels of stress, frustration, depression, and fatigue among doctors in all disciplines and at all stages of their careers. In particular, physician burnout, long recognized as a potential landmine in a medical career, is now seen as a threat to the workforce and to the quality of patient care. The good news, however, is that physicians—and the institutions they work for—have begun talking about the problem more openly than ever before. Many are beginning to address the issue of physician well-being. “What we may be seeing now is the beginning of a cultural shift in medicine,” says Mayo Clinic internist Liselotte Dyrbye, M.D., who has studied the deleterious effects of stress on doctors. “There’s an enormous amount of interest in this issue. People are seeing that, yes, this matters.”
A High-Stakes Problem
The issue of physician burnout began cropping up in medical journals 20 years ago, with some studies reporting burnout in up to 60 percent of physicians. Recent investigations have shown that the number of those afflicted is still high (some say 37 percent to 47 percent among academic faculty and 55 percent to 67 percent among private practitioners). Research also now shows that burnout isn’t just a late-career phenomenon, which many had once presumed. Says Dyrbye, who serves as associate director of Mayo’s Program on Physician Well-Being, a recently created research entity to study the topic: “All the studies we’ve conducted across the continuum of [medical careers] have found a high prevalence of distress.”
The stakes are high, notes an article in the April 15, 2003, American Journal of Medicine. Burnout takes a toll on doctors and their families in the form of “depression, anxiety, substance abuse, divorce, broken relationships, and disillusionment.” Significantly, doctors have a higher suicide rate than other professions, according to a 2004 study in the American Journal of Psychiatry—that rate being as much as 3.8 times higher among male physicians and as much as 4.5 times higher among female physicians.
Although these and other studies have underscored the pervasiveness of physician distress, new work over the last decade has focused on another aspect of the issue: how physician distress may lead to lower-quality medical care. A study funded by the federal Agency for Healthcare Research and Quality (AHRQ) published in the Annals of Internal Medicine in 2009 found that today’s work environment makes physicians feel stressed more than it used to and postulated that physicians might become less effective at controlling patients’ blood pressure and diabetes, and more likely to omit preventive screenings and to commit medical errors. In another Annals study from 2002, residents who experienced burnout were asked whether they thought they’d provided “suboptimal care” at least once a month. Fifty-three percent acknowledged they had.
Lately, the topic of physician well-being has drawn new attention. The emphasis is just in time, many physicians note, as health care reform will add upwards of 40 million previously uninsured people to the patient population, increasing physicians’ workload and, undoubtedly, their stress. A number of organizations are starting to address the issue. For example, the meeting of the American Medical Association (AMA) last October included a gathering of the International Alliance for Physician Health, a group of practitioners and organizations working to promote the health and well-being of physicians. Researchers from the United States, Canada, and the United Kingdom presented talks and posters on modes of assessing physician stress and understanding its consequences. Other presentations focused on ways to increase positive communication within busy medical practices, how to enhance the personal health habits of physicians, as well as reviews of physician wellness and counseling programs at medical institutions. In addition, the AMA has created “AMA Healthier Life Steps—A Physician’s Guide to Personal Health,” a toolkit to help physicians support their own efforts to lead healthier lives.
In Minnesota, several physicians have been pushing to make physician health a better-studied, more talked-about topic. Fergus Falls family physician Patricia Lindholm, M.D., who became president of the Minnesota Medical Association (MMA) last September, has spoken about the issue to physician groups and shared her own experience with needing to bring more balance to her own life. She also blogs about physician health for the MMA (http://mmapresident.blogspot.com) and continues to provide resources to anyone interested in health (one she recommends is ephysicianhealth.com from the Canadian Medical Association). One of her hopes is that physician well-being will become a priority issue for the MMA. “The time is right,” she says. “If there’s something we can do that will support people in their day-to-day practice and enrich their life as a physician, that’s the goal.”
At Mayo Clinic, Greg Poland, M.D., decided the topic of wellness was one for the entire community. Five years ago, he became acutely aware of the stress and lack of balance in his own life. He was working long hours, coming home so tired he wanted only to fall asleep on the couch. His children were growing up, and he felt he was missing out. “It’s a dangerous temptress,” he says of his work. “I love what I do. It’s easy to get drawn in further and further and neglect important parts of life.” But it was the suicide of a colleague, and the suggestion that burnout and work pressure had played a destructive role in that colleague’s life, that was Poland’s wake-up call. He began reading up on the topic of wellness, particularly the idea of work-life balance, and found inspiration in the book Just Enough. The authors, Harvard business professors Howard Stevenson and Laura Nash, espoused greater intentionality: determining goals in an array of spheres—work, exercise, family, spirituality, and connection to religion—and consciously attending to them.
Poland developed a lecture based on those ideas, which he advertised to Mayo staff. He knew his message about striving for work-life balance would resonate with some colleagues, but he was surprised when more than 800 people showed up for his presentation. He included in his talk a film segment showing a physician-father engrossed with his Blackberry at his child’s baseball game. As Poland looked out at the audience, he knew he had touched a nerve. He could see physicians weeping. Immediately after the lecture, he remembers, “We received hundreds of responses, some with comments from people who agreed that the problem existed and others offering suggestions, ‘Here’s what I do,’ ‘Here’s how I find balance.’”
In order to increase understanding of the issues that influence and promote physician well-being, the head of the department of medicine at Mayo, Nicholas LaRusso, M.D., formed the Program on Physician Well-Being. Directed by Tait Shanafelt, M.D., who has studied wide-ranging manifestations of physician stress since 2001, the program serves as a research base and a resource for Mayo leaders as well as for those at other health care institutions seeking to implement programs to enhance the health of the workforce. Important studies of physician experience have already emerged from the program. One identified the negative effects of “work-home interference,” in which the demands of one realm of life impinge on another. “Physicians who experience conflict are more likely to have distress, especially if a work-home conflict results in favor of work,” Dyrbye says. Another showed that residents who had a greater sense of personal well-being were capable of being more empathetic to patients than others. Mayo researchers are pleased to note that some of their studies, in conjunction with others being done around the country, have already led to change. Recent investigations of medical student distress, for example, prompted the Liaison Committee for Medical Education, the accrediting authority for U.S. and Canadian medical schools, to require that every school have a well-being program in place for its trainees.
One question that researchers continue to grapple with is what’s at the root of burnout. Internist Mark Linzer, M.D., has long been interested in finding the answer. In the mid 1990s, when he was on the faculty at the University of Wisconsin, Madison, Linzer led a Robert Wood Johnson Foundation-sponsored investigation of physician satisfaction. Surveying nearly 3,000 physicians, the researchers explored 10 domains of physicians’ day-to-day experiences to pinpoint where satisfaction fell off. The team found that physicians who were under time pressure, and who had little control over their environments, were the most distressed. “A lot of [the problem] was the work environment itself, and this was across the board, primary care doctors and specialists,” says Linzer, who now directs the division of general internal medicine at Hennepin County Medical Center.
Linzer has looked closely at how the work environment contributes to physician stress and found some of the factors contributing to burnout may not be altogether different from the pressures that exist in other careers. He found that women physicians are 60 percent more likely to experience burnout than men and that the discrepancy may be the result of their lacking control over their time. He notes that although their work hours may not differ from those of men, they often have responsibilities outside the office such as caring for family members. However, there are also nuances in the exam room that may contribute to burnout among women physicians. “One of the factors [leading to greater stress] seems to be a gendered expectation for listening,” he explains. “Female patients often choose female providers, and many male patients choose a female provider because they expect women doctors will take great care of their medical problems, but then spend time listening and counseling and empathizing, and all those things are very hard to do in a 15-minute visit.”
The tenor of a medical practice—and the mechanics of it—can play a significant role not only in the well-being of physicians but also in the quality of care they provide. Linzer and his group defined four parameters that affect both physician well-being and patient outcomes: time pressure during visits, physicians’ lack of control over their work environment and schedule, fast-paced or chaotic environments, and lack of alignment of values between leaders and practitioners. “The way a practice is organized can really affect us,” Linzer explains. To assess that, he and his research team developed the Office and Work Life (OWL) measure, which provides, in Linzer’s words, “a snapshot of a practice.” After gathering data from doctors, patients, office managers, and staff, researchers then observe how the medical practice functions. In a new AHRQ-funded study, the Healthy Workplace Study, Linzer’s group will use the OWL measure to evaluate a randomized array of medical practices. Clinics will use their OWL data to incorporate changes designed to smooth out operations and reduce stress among physicians. “We’ll see if we can improve the quality of care by changing the work environment,” Linzer says.
Addressing the Issue
Researchers agree that there is no single strategy for relieving physician distress. What’s hopeful is that many institutions are now offering new programs to address physician well-being. According to the Joint Commission, hospitals must have a process in place to promote physician wellness. At Mayo, for example, a workout center makes it easier for physicians to take an exercise break, and nutrition counseling helps them plan a balanced diet. University of Minnesota medical students now learn about the concept of work-life balance and attend small-group meetings where they can reflect on their experiences with patients. For residents, the university established new support programs based on requirements of accrediting programs to address stress proactively. With the support of chaplain Bradley Skogen, Lindholm helped bring a physician support group to Lake Region Healthcare in Fergus Falls, where she practices (See “Healing Each Other, p. 26”).
Health care leaders are also beginning to address the importance of “career fit” among physicians. Dyrbye describes “fit” as an alignment of the tasks a physician enjoys doing—teaching, for instance—with what he or she does during a day. In academic settings, for instance, department heads leading annual faculty evaluations can ask physicians about career fit in order to incorporate roles and tasks a physician finds fulfilling into their work.
Some workplace pressures may be harder to address, researchers acknowledge. One frequently cited frustration is implementing an electronic medical record, which can involve a learning curve for doctors that can be burdensome. Moreover, some systemwide changes aiming to address one source of distress may lead to new ones. The national restriction on residents’ weekly work hours is one example. The change has reduced fatigue among residents, which is important, according to Dyrbye. But studies have shown that the limits have not lessened residents’ stress levels, as they find themselves having to do more work in a shorter amount of time.
Over time, institutions may be pressed to come up with new strategies for giving physicians more control over their schedules, more autonomy, and more flexibility in their daily responsibilities. Linzer, for one, notes that such changes will slowly change the work environment for physicians. “I do hope people will begin to acknowledge that a more supportive environment for work-family balance, and more attention to time pressure and chaos and values can really change the landscape in how we practice medicine and the kind of care we deliver,” he says. He’s encouraged to hear that topics such as physician satisfaction and work control are now being discussed at department meetings and by clinic directors. Linzer says changing the work environment to make it less stressful for physicians may take time, but recognizing the magnitude of the problem of burnout is a critical first step. “It’s not just an individual’s responsibility to face up to the stress of the job,” he says. “It’s each organization’s responsibility to take it on and make it better.” MM
Kate Ledger is a St. Paul freelance writer and a frequent contributor to Minnesota Medicine.
Healing Each Other
Family physician Patricia Lindholm, M.D., was well-read on the topic of physician stress, but she became aware of the loneliness and isolation that existed among her colleagues in a way she hadn’t anticipated. Giving a presentation about preventing burnout for the Minnesota Academy of Family Physicians two years ago, Lindholm took a chance and divulged her personal experience with depression and her struggle to “get more balance back in my life.” The response to her candor was overwhelming. “People came up to me during and after the conference, they called me and emailed me, sharing their own experiences. It was clear that there was a huge need for physicians to reach out to each other,” she says.
She talked with Rev. Bradley Skogen, a chaplain at Lake Region Healthcare Clinic Services in Fergus Falls where she practices, and the two began to formulate a plan to address physician isolation. They developed a format for a discussion group, a hospital-based gathering in which physicians could talk freely with each other about the stresses, expectations, frustrations, and hardships of their lives. The group, they decided, would have a limited number of members. They would meet periodically in a hospital conference room, at an hour that wouldn’t interfere with work. No one in the administration would know who belonged to the group. Any information discussed would remain strictly confidential.
The Lake Region administration offered instant and unquestioning support, providing space and the breakfast for each gathering. The initial “scary moment,” Lindholm acknowledges, was inviting physicians to join. “Even though we may work together in the same building, we’re really all quite isolated and live in our own silos,” she says. “We can tell that others around us may be having some distress, but it doesn’t feel comfortable to broach the subject in a day-to-day conversation.” She scheduled individual meetings with physicians from a variety of disciplines whom she thought might benefit and sat down with each one in private to describe the group that she and Skogen wanted to start. As she extended an invitation to join, she remembers, “every one of them said yes.”
The group, which has been meeting twice a month for the last 18 months, consists of six male and two female physicians from different specialties who are at various stages of their careers. “It’s not just crisis management and talking about problems, but also a chance to be proactive about well-being,” says Skogen, who leads the meetings. Sometimes we watch a media presentation or discuss a book, and we talk about whatever people want to talk about.” (One book they discussed was national bestseller Kitchen Table Wisdom, by pediatrician Rachel Naomi Remen, M.D.) Skogen’s training in clinical pastoral education helps him set the tone: “The idea is to provide a nonjudgmental place where it’s safe to talk. None of us are trying to solve or fix what’s going on. The idea is to ask a question or respond in a way that may help another person express themselves or reflect on what they’re going through.”
What Lindholm found in the group was that the sense of isolation melted away at once. “There was all this pent-up hurt, and people shared it very frankly. And immediately people thought they could meet every couple of weeks. Over time, we’ve seen some [people’s personal issues] resolve and get better, and we’re still meeting, still talking. Just sharing with each other,” she says, “has diffused a lot of stress and tension, and we’ve forged a bond we didn’t have before.”
In fact, interest in the group is spreading. Lindholm and Skogen described the meeting format they developed at the American Medical Association’s meeting in Chicago last year. And enough physicians at Lake Region Healthcare are asking about it that they plan to start a second group in the near future. “It’s apparent if we can break down the isolation and be a little closer in terms of camaraderie and collegiality, and not be so stuck on appearing perfect to each other, we can do a lot of good,” Lindholm says. “We can actually be healing to each other.”—K.L.