Thwarting physician burnout – today and tomorrow

Physician burnout is not new news. Recent studies show 51% of physicians have experienced some degree of burnout1, and the impact is profound – for physicians, patients, and the public.

To date, burnout has been addressed as a chronic stress problem,2 and interventions have fallen short of the mark. Approaching burnout instead as a brain health problem may help truly address both the symptoms and the underlying culture contributing to burnout.

Brain health is usually noticed only in its absence, when caused by disease, injury or psychological issues. Burnout demonstrates all the markers of reduced brain health, as the neural and cognitive effects of chronic stress associated with it are well documented. These include a hyperactive amygdala, reduced neuronal activity in the frontal lobe (critical for problem-solving and decision making), and cell death in the hippocampus, which controls new learning and memory.3

Individual intervention is needed for each physician to mitigate brain health decline. Studies on interventions have been biased toward meditation and mindfulness, communication, education and cognitive behavioral therapy. We recommend a holistic approach to include these along with sleep management, exercise, and cognitive training focused on executive functions such as goal setting, decision making, emotional regulation and problem solving. A number of studies show the neural, cognitive and psychological benefits of these interventions, although more is needed to specifically measure the impact among medical practitioners.

Successful execution of individual interventions remains a major challenge. Impacted physicians (as well as their organization’s board and executives) may resist, since interventions often have a financial impact. However, data suggests the quantitative and qualitative costs of inertia are even higher. Losing a physician to early retirement or other career opportunities could cost between $500,000 and $1 million in recruitment, training, and lost revenue.4 Further, the qualitative consequences of burnout include diminished clinical judgment, increasing medical errors and adversely impacting outcomes and patient experience.

Changing the complexion of the workforce is one solution. More training for nurse practitioners or physician’s assistants takes the pressure off physicians as the predominant providers of health care. This emerging model enables a brain healthy work pace, and could improve patient care and reduce labor costs.

Organizations could also eliminate or reduce tasks that divert physicians from patient care. How physicians spend their time is an important factor in burnout, as indicated by one study showing time spent on meaningful work and burnout risk have a strong inverse relationship.5 One major detractor is the time required for electronic health record keeping. Atrius Health, Massachusetts' largest independent physicians group, has diverted unnecessary email traffic away from doctors to other staffers and simplified medical records, aiming to cut 1.5 million mouse "clicks" per year.6

However, individual interventions and organizational changes will have limited impact if implemented in a toxic work culture. Integral to a sustained solution is to redefine how physicians are expected to work, starting with how medical students are taught. Medical school and residency training are synonymous with inordinate workloads and sleep deprivation, accepted as the ethos of being a physician – even though the detriments of sleep deprivation to neural health and cognitive functioning are significant and uncontroversial.7 Changing medical school culture would help ensure the next generation of physicians has a healthier environment. This requires agreement from medical educators and a shift in the underpinning financial structure that promotes a constrained residency workforce, as funding for residencies comes from Medicare.

Addressing physician burnout starts with acknowledging three things: a) this is a brain health issue, 2) meaningful work matters, and 3) current practices negatively impact the physician’s most critical asset – clinical judgment. However, if we stop here, this critical public health issue will not go away. To address this urgent and life threatening public health problem we must change the health care culture and ecosystem itself.

Yele Aluko, MD, MBA, Chief Medical Officer, EY Americas, Health Advisory.
Dr. Leanne Young, PhD, Executive Director of the Brain Performance Institute at UT-Dallas

1 Medscape Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout Carol Peckham | January 11, 2017
2 Lacy, BE, Chan, JL. Physician Burnout: The Hidden Health Care Crisis. Clinical Gastroenterology and Hepatology. 2017;S1542-3565(17)30790-5. Doi: 10.1016/j.cgh.2017.06043.
3 Chetty, S., et al., Stress and glucocorticoids promote oligodendrogenesis in the adult hippocampus. Molecular Psychiatry, 2014. 19: p. 1275.
4 Health Affairs - Physician Burnout Is A Public Health Crisis: A Message To Our Fellow Health Care CEOs
5 Shanafelt TD, West CP, Sloan JA, et al. Career fit and burnout among academic faculty. Archives of Internal Medicine. 2009;169(10):990-995.
7 Killgore, WDS. Effectsof sleep deprivation on cognition. Progress in Brain Research, Vol. 185. Elsevier BV: 2010, pp 105-129. DOI: 10.1016/B978-0-444-53702-7.00007-5.

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