Picture of John Choi, MD

John Choi, MD

Stanford Resident & CANS Fellow

Socioeconomic Journal Club

Since its lexical popularization in 1974 by psychologist Herbert Freudenberger, the term “burnout” has collated numerous explorations in healthcare settings ranging from studies of provider wellness, descriptions of moral injury, and systemic policy change. At our hospital, we have intermittent wellness events hosted by the GME—our last one was this past Lunar New Year—and it was almost surreal to see eight administrators lined up in front of a table spread of food smiling and shaking our hands with a photographer while the residents wordlessly sat down to try and wolf down egg fried rice at 7:30am post-rounds. I remember seeing the photographer look out of place trying to capture planned joviality in such a heavy atmosphere. Personally, I found the whole situation hilarious—an image resonant with recent social media memes that equate wellness with free pizza.

Clearly burnout is much more multifactorial than wellness paraded under intermittent meals and celebrations. But even beyond that, understanding wellness alone is insufficient to address burnout. A recent JAMA article this past July by Aiken et al at the University of Pennsylvania used a cross-sectional multicenter survey of 15738 nurses in 60 Magnet-designated hospitals and 5312 physicians in 53 of the same hospitals to examine factors associated with burnout. While certainly not the first study to examine burnout, this article does explore multiple aspects of burnout beyond addressing aspects of physician wellness (e.g. depression, work-life balance, health, anxiety) and delves into issues of patient safety and hospital resources for patient care. The survey results can broadly be summarized as follows:

  • 32% of physicians and 47% of nurses reported high burnout as described by the Maslach Burnout Inventory, which has been associated with patient outcomes in previous studies such as those by Welp et al from 2015 in Front Psychol
  • 12% of physicians and 26% of nurses rated their hospitals unfavorably on patient safety
  • 28% of physicians and 54% of nurses said there were too few nurses
  • 42% of physicians and 46% of nurses had dissatisfaction with management and endorsed that they felt their concerns related to patient safety were not being heard
  • Both physicians and nurses endorsed addressing issues of patient safety as more important to their mental health than traditional interventions directed at improving their wellness
  • The highest ranked intervention was improving nurse staffing (45% of physicians and 87% of nurses)

While it should be noted that the author list is entirely composed of nurses or researchers without an MD/DO, the metrics described were standard scales that have been used for both clinician and nursing studies on burnout. Moreover, this study was conducted during the height of the COVID-19 pandemic where staffing issues were in extremis and the authors caution extrapolating causality given its cross-sectional nature. 

With that being said, the most pertinent finding to highlight is that the greatest contributor to health care providers wanting to leave their occupation revolved around issues with patient safety.  Some of this was contributed to poor hospital management, with >40% of physicians and nurses saying they lacked confidence that administration would listen to or respond to clinical concerns. >50% of physicians and nurses across all hospitals raised issues with their hospitals’ culture of patient safety, stating that they were not confident their patients could manage their care after discharge.

Speaking for myself, I came into this profession as a call to serve my patients. I would assume that there are very few neurosurgeons in our specialty who are afraid of working hard. As a resident, I expected long hours and chaotic schedules—at some level these are intrinsic to the training process. Yet when there is juxtaposition between duty and observed impact, when we feel we are part of a system that is doing harm despite good intentions, we question why we are working so hard for a system that is failing the people we chose to serve.

I am extremely fortunate to be part of a residency program at an institution where patient safety comes first and extraordinary measures are taken to make sure that we keep that mission at the forefront. Contrasting our hospital’s recent Lunar New Year celebration, our department invited Dr. Wendy Dean, founder of Moral Injury of Healthcare group, LLC, to our grand rounds last Friday to address how clinician distress often revolves around issues with moral injury rather than simply burnout. Following grand rounds, the residents had a teaching session with Dr. Dean in discussing how systemic change is needed; in an ideal environment, the administration needs to mitigate distractors and all other barriers to care so that physicians can focus on what they have spent their whole lives training to do: be doctors. In full disclosure, it helps that our department also takes wellness seriously and we are quite possible the best fed residents in the hospital, but really the patient safety aspect is what makes us feel proud to come to work every day.  

Overall, while this survey is limited by its cross-sectional nature and does not shed groundbreaking new findings, it highlights an important aspect of clinician burnout and fatigue that we could all remind ourselves and our hospital management—that in the end, we do this work for patients and it is critical to first and foremost support us so we can do this job in the safe and intended manner that all of our patients deserve. And if a pizza party or two accompanies these systemic changes, I would be the first to line up and take a photo with a big smile on my face. 

Anthony DiGiorgio, DO, MHA

This month’s article discussed the omnipresent “burnout,” something on which I’ve written extensively.  Dr. Choi’s analysis is stellar, leaving me lacking much to add.

It is notable that the numbers for burnout in this study are so low.  Only a third of physicians and half the nurses were burned out, while other estimates have those numbers much higher.  On average, 23% of doctors wanting to leave their job is an alarming figure, though.  Despite this, the turnover rate is only 6%, meaning most physicians feel trapped in their jobs.  The EHR came up for both groups as a driver of burnout.  This isn’t groundbreaking.

What is most revealing is the outliers.  Some hospitals had 40% of doctors wanting to leave, with 25% of them stating their hospital was unsafe.   These outliers warrant further investigation by regulators.  When an aggressive burdensome quality metric regime was unleashed upon physicians, it was really meant to target the outliers of clinical care: the truly unsafe physicians.  A multi-billion-dollar metric industrial complex was created to improve “quality” by essentially targeting the tails of the normal distribution.  Instead, these hospital systems, these outliers, should be the true target of quality metrics.

As I’ve argued before, the frontline clinicians should not be the target of quality metrics.  Metrics should help identify these hospitals where physicians want to leave or feel their workplace is unsafe.  There is otherwise little incentive for these places to change their behavior, as large consolidated systems have monopsony purchasing power over physician labor.  CMS should scrap their metrics, instead encouraging payors and watchdog groups to retool their metrics.  Let the hospital star ratings directly reflect the number of frontline clinicians who are burned out, wanting to leave, and identifying their hospital as unsafe. 

Highly competitive private industries would never tolerate workforce metrics such as this.  Why it’s tolerated in healthcare is a long tale that shall not be retold here.  Until hospitals feel the pressure, be it from metrics or from a direct competitor siphoning off its best clinicians, there is no impetus to change.  Dr. Choi hits the nail on the head when asking for systemic changes to go along with the pizza parties. 

Picture of Anthony DiGiorgio, DO, MHA

Anthony DiGiorgio, DO, MHA

 

This month’s article discussed the omnipresent “burnout,” something on which I’ve written extensively.  Dr. Choi’s analysis is stellar, leaving me lacking much to add.

It is notable that the numbers for burnout in this study are so low.  Only a third of physicians and half the nurses were burned out, while other estimates have those numbers much higher.  On average, 23% of doctors wanting to leave their job is an alarming figure, though.  Despite this, the turnover rate is only 6%, meaning most physicians feel trapped in their jobs.  The EHR came up for both groups as a driver of burnout.  This isn’t groundbreaking.

What is most revealing is the outliers.  Some hospitals had 40% of doctors wanting to leave, with 25% of them stating their hospital was unsafe.   These outliers warrant further investigation by regulators.  When an aggressive burdensome quality metric regime was unleashed upon physicians, it was really meant to target the outliers of clinical care: the truly unsafe physicians.  A multi-billion-dollar metric industrial complex was created to improve “quality” by essentially targeting the tails of the normal distribution.  Instead, these hospital systems, these outliers, should be the true target of quality metrics.

As I’ve argued before, the frontline clinicians should not be the target of quality metrics.  Metrics should help identify these hospitals where physicians want to leave or feel their workplace is unsafe.  There is otherwise little incentive for these places to change their behavior, as large consolidated systems have monopsony purchasing power over physician labor.  CMS should scrap their metrics, instead encouraging payors and watchdog groups to retool their metrics.  Let the hospital star ratings directly reflect the number of frontline clinicians who are burned out, wanting to leave, and identifying their hospital as unsafe. 

Highly competitive private industries would never tolerate workforce metrics such as this.  Why it’s tolerated in healthcare is a long tale that shall not be retold here.  Until hospitals feel the pressure, be it from metrics or from a direct competitor siphoning off its best clinicians, there is no impetus to change.  Dr. Choi hits the nail on the head when asking for systemic changes to go along with the pizza parties.