Are we still talking about burnout?
What is it with burnout? There’s so much talk about it, particularly as it relates to healthcare professionals – in academic articles, social media posts and comments, private conversations, – that it’s easy to gloss over. I wasn’t even sure how to write another post on burnout that would contribute, but in writing it I realize again why it’s just too important to let go.
One of the pioneer researchers of burnout defined it as “a syndrome characterized by depersonalization, emotional exhaustion, and a sense of low personal accomplishment,” not what we want to see in any of our doctors or people we love(1). And yet in a 2019 Medscape survey of over 15,000 healthcare providers 42% reported they were burned out (note: this was actually a decrease from a previous Medscape survey 5 years prior which reported 46%)(2).
Studies from the Mayo Clinic from 2011-2017 showed burnout among physicians improving slightly, and yet physicians still had a significantly increased risk of burnout and lower rates of satisfaction with work-life integration than the general population(3). The effects are not just felt personally, but in the healthcare system at large. Studies have estimated that physician burnout may contribute as much as $4.6 billion in healthcare costs each year in the U.S. due to increased turnover and reduction in working hours(4). And these numbers were published in June 2019, prior to the COVID-19 pandemic which has already demonstrated a worsening of the situation(5).
I pivoted to a non-clinical career before falling victim to burnout (or maybe, some would argue, I just burnt out really early?), but I’m still fascinated by the subject. I want to help my fellow physicians and friends who are on the front lines. I want desperately for us to have a healthcare system where they do not have to struggle under the weight of burnout but can be fulfilled practitioners taking care of their patients. Having worked in healthcare technology for the past seven years, I believe tech can help us even though, ironically, it was actually tech that made the problem worse.
Today’s conversations on burnout
The conversation around burnout in the medical community is ongoing. On Facebook alone I found posts within the past two years related to burnout on every medical page I searched – Harvard Medical School, Cleveland Clinic, and many more, including Johns Hopkins, home of William Stewart Halstead. Dr. Halstead who, as father of the modern medical residency model, suffered from addiction throughout his life and famously advocated for his trainees to “forgo many pleasures in life” in order to pursue their career(6).
Here are just a few posts:
Burnout, long work hours, growing administrative tasks, managing the heartbreak of complicated patient cases, overwhelming student debt, sacrifice of personal time with family and friends – with all of this in mind, what keeps doctors going? Sept 12, 2019
You can only push yourself so far before your ability to function at a high level becomes impaired. Using the example of traveling and its stresses, a Mayo Clinic oncologist talks about whether you’re just feeling pressured or you’re at the brink and how to prevent burnout… Jan 25, 2020
New England Journal of Medicine:
The burnout problem won’t be solved without addressing the issues of autonomy, competence, and relatedness. During the COVID-19 pandemic, a sense of altruism and urgency has catalyzed restoration of these pillars of intrinsic motivation. Can these changes be sustained? May 1, 2020
And just this week, a good friend who isn’t in the healthcare industry (and did not know I was writing this article) referred to an episode of Brene Brown’s podcast, Unlocking Us. Guess what subject it tackled? Yes, that’s right. The guests were the authors of the new book Burnout, Amelia Nagoski and Emily Nagoski. The authors point out that the term burnout was first used by psychologist Herbert Freudenberger in the 1970s to describe the effects of stress in the “helping professions”(7).
Healthcare providers are critical “helpers” – we’ve never seen it more clearly than in 2020 during the COVID-19 pandemic. And anyone who has ever been in the presence of a truly empathetic hospice attendant, a skilled brain surgeon, a rockstar labor and delivery nurse, and so many more, knows these helpers first hand. It’s hard to imagine that the best of them get burned out.
What causes burnout?
Burnout is multi-faceted, and these causes among healthcare professionals summarized are illustrative:
1) Loss of autonomy
2) Treating the data, not the patient
3) A world of rules
4) Asymmetric rewards
5) Sense of powerlessness
6) Electronic health record woes
For the last category – electronic health record woes – the authors cite this explanation: “Instead of being a mere replacement for paper records, EHRs have evolved into data-collection devices for HIPAA and other government regulations. Consequently, they focus more on processes than on outcomes, adding to the physician's workload while not improving patient care”(8).
Dr. Freudenberger could have never predicted in the 70s the way that HIT (Health Information Technology), and specifically the EHR (Electronic Health Record) would add to the burnout picture and to providers’ plates. The advent of the EHR promised fluidity and efficiency, but for the providers who have to use them, these systems can seem more like “death by 1,000 clicks,” the title of a scathing article about the disconnect between the goal of EHRs and the reality of their use(9).
A 2019 study of over 4,000 Rhode Island physicians reported 70% prevalence of HIT-related stress among the group. And the presence of any three specific HIT-related stress factors was associated with greater amounts of burnout (even when adjusting for age, gender, use of a medical scribe, practice size and more). Those factors were 1) agreement that EHR use adds to “daily frustration” 2) reporting “insufficient time” to complete patient documentation during the day, and 3)reporting increased EHR time at home. Interestingly, aside from these specific HIT-related stress indices, female gender was an independent risk factor for burnout symptoms in this study(10). (I’ll refer you back to Brené’s podcast episode to hear more on why that may be).
There is a lot to unpack with each of the HIT-related stress factors, as the authors point out. Take the third, for instance – insufficient time to document clinical encounters:
Insufficient documentation time might contribute to burnout because this time pressure poses a direct challenge to connecting with patients, one of the more sustaining aspects of primary care practice. Additionally, documentation time is generally not reimbursed, which may contribute to physicians’ frustration, particularly if, as our study shows, a majority of physicians feel that EHRs do not improve patient care. In other words, physicians may feel that they are spending a large portion of their time on complex and time-consuming work that does not benefit their patients(10).
Regardless of the mechanisms by which EHRs contribute to clinician burnout, the problem is devastating individuals, their families and their livelihoods. It’s something that must first be faced with vulnerability and humanity, but we cannot forget that we also have tools that can help us. Yes, bad tools can make things harder, but good tools have saved us before.
Unfortunately EHRs (and I reluctantly admit they do fall under the category of technology) have been part of the problem, but there is technology available that can redeem the current situation and give providers their time back. What if smarter technology is actually part of the answer to burnout, just as, arguably, clunky technology has brought us to its height?
Even though it’s only one of the factors associated with burnout, what if we could predict HIT-related stress (based on time spent on EHR, clicks, wrong clicks and redos, time spent outside of the hospital on EHRs, etc.) early on and intervene before HIT stress induced burnout?
But even better, what if we could predict things about the actual patient-provider interaction to make the provider’s work easier and more efficient, not replacing their important hands-on presence, but enhancing it. Many have talked about smarter EHRs – moving to “plan-centric” and “intelligence-oriented” EHRs, from EHRs that are merely “transaction oriented”(11). EHRs, however, have been historically slow to adapt, and other technologies may be necessary to push things forward. For example, I’m excited to have started working with a company called PredictionHealth that is making technology that runs in the background of the clinic room on the clinician’s laptop, listening, understanding, and seamlessly integrating with existing EHRs - completing clinicians' documentation for them so they can focus on the patient in front of them.
However we tackle it, we know where we need to go. I still believe in a future that isn’t marred by burnout, and I have faith that technology can be one of the helpers, not hindrances, in getting us there.
Imagine a system that fills out the EHR, making it easy for you to glide through your day and frees you up to deliver better patient care? Get in touch to learn more about PredictionHealth!
2. National Physician Burnout and Suicide Report, 2020 | Medscape
3. Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2017 | Mayo Clinic Proceedings
4. Estimating the attributable cost of physician burnout in the United States | Annals of Internal Medicine
5. Physician income drops, burnout spikes globally in pandemic | Medscape
6. Mental pathologies at the root of modern medical training: Lessons from the Life of Professor William Stewart Halstead | clinicalcorrelations.org
9. “Death by 1,000 Clicks: Where Electronic Health Records Went Wrong” | KHN.org
10. Physician stress and burnout: the impact of health information technology | Journal of the American Medical Informatics Association
11. It’s Time for a New Kind of Electronic Health Record | Harvard Business Review
Kate Celauro, MD