Burnout - It's the Workplace, Stupid!
It's the economy, stupid! In 1992 Bill Clinton was a relatively unknown governor or Arkansas running for president against Republican George H. W. Bush and third party candidate Ross Perot. The Clinton campaign identified a key issue, and used the phrase, "It's the economy, stupid" to keep themselves focused on this key issue. Bush had rescinded on his promise made during his first campaign, raising taxes after his infamous statement, "Read my lips, no new taxes." Bush had no choice to change course as the economy was struggling. Clinton's advisors knew that by focusing on this root cause problem, they could win. Physician burnout is similar. It's not a problem of a lack of resilience, it's the workplace that's the root cause. Resilience and Burnout This past week Drs. Colin West , Lotte Dyrbye, Tait Shanafelt, and Chris Sinsky, four leaders in the crusade to eliminate physician burnout, published a key new paper in the JAMA Network, Resilience and Burnout Among Physicians and the General US Working Population, that demonstrates that physicians are more resilient than the general population, yet have higher rates of burnout. This was accompanied by an invited commentary by Dr. Allan Goroll titled, "Addressing Burnout—Focus on Systems, Not Resilience". I highly recommend you read both of these articles. They provide the evidence that supports what many of us have been saying for years, that physician burnout isn't a problem of inadequate resilience, it's a problem of a dysfunctional workplace in which even highly resilient professionals struggle with emotional exhaustion, cynicism, and as sense of inefficacy. Fixing the Workplace - Two Guidebooks They also call for changes to the workplace as described in the 2019 National Academy of Medicine Collaborative Report, Taking Action Against Clinician Burnout. Dr. Goroll specifically recommends focusing on actions to reform physician payment, improve electronic medical records, and reduce threats to professionalism. I was particularly gratified to see these papers, as they confirm the message of the book Dr. Diane Shannon and I published 3 and a half years ago and recently republished, Preventing Physician Burnout: Curing the Chaos and Returning Joy to the Practice of Medicine. With a forward by Dr. Christina Maslach, and endorsed by the likes of Drs. Bob Wachter, John Toussaint, and Paul Grundy, the book describes burnout's manifestations, how patient care became rife with the drivers of burnout, and specific actions that healthcare leaders can take to improve the clinical workplace and promote professional fulfillment. A Handbook for Healthcare Leaders While one might think this book is written for physicians deeply engaged in, and burned out by, patient care, in fact it's written for healthcare leaders. Leaders often struggle with how to deal with burnout. They know it's a serious issue, but they are concerned about the potential downside of the solutions for healthcare organizations that were struggling financially pre-COVID-19, and are now buckling under the financial blow of the pandemic. The common misconception regarding burnout is that it basically manifests as exhaustion due to work overload. Therefore, the common solutions seem to be reducing patient volumes, i.e. lowering productivity which lowers revenues, and/or providing resilience training and support, which adds expenses. Reducing revenues and increasing expenses puts healthcare organizations at risk. They need a healthy bottom line to be resilient as an organization. Building Organizational Resilience It is true that work overload drives emotional exhaustion. It's not true that the best way to address this is to reduce the number of patients seen. When we remove data entry and administrivia from physicians' workflows, doctors can see the same number or more patients and not end up exhausted. This is the point of improving practice efficiency. The second manifestation of burnout, cynicism, is driven by the other five drivers of burnout - lack of control, insufficient reward, breakdown of community, absence of fairness, and conflicting values. These are addressed by changing the management system and culture, moving from a top-down command and control approach to one that aligns and empowers physicians. This is the focus of developing a culture of wellness. Prevention is the Best Medicine for Burnout It's no surprise that all the physicians I've mentioned in this post are primary care physicians. While we train to treat a broad swath of people and diseases, by nature we prioritize preventing problems as much as possible. The benefits of fixing the workplace outweigh the benefits of making already resilient physicians even more so. These are the lessons of the publications by Drs. West, Sinsky, and Goroll. Using the analogy of the canary in the coalmine, our focus should be on reducing the toxicity of the air in the coalmine, not strengthening the canaries to withstand the fumes. I am committed to helping leaders transform their organizations to reduce burnout and improve organizational performance, as well as helping physicians cope with burnout. If you'd like to learn more, I welcome the opportunity to connect. You can email me here, or schedule a time to talk here.