Welcome to PREVENTING CLINICIAN BURNOUT:

PERSONAL AND PROFESSIONAL ISSUES AND PLANS

Presented by: Mark Linzer, MD, FACPThe presentation will begin shortly

This webinar will be recorded and used for future presentations.

Funds for this webinar were provided by the U.S. Department of Health and Human Services (HHS), Health Resources and Services

Administration (HRSA) with the American Recovery and Reinvestment Act (ARRA) funding for the Retention and Evaluation Activities (REA)

Initiative.

This webinar is being offered by the California Statewide AHEC program in partnership with the Office of Statewide Health Planning and Development

(OSHPD), designated as the California Primary Care Office (PCO).Center for Patient and Provider Experience at

Preventing Clinician Burnout: Personal and Professional Issues

and PlansMark Linzer MD

General Internal Medicine Center for Patient and Provider Experience

Hennepin County Medical Center

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Research supported by Federal Agency for Healthcare Research and Quality (AHRQ)

No conflicts of interest

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1. Identify features of a healthy work environment and how to create one.

2. Discuss ideas of self-care to protect against burnout.

3. Process collaborative approaches to develop and maintain a healthy workplace.

Objectives

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Burnout is in the news…

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New York Times, 6-17-08“It will take real structural change in the work environment for physician satisfaction to improve. Fortunately, the data show physicians are willing to put up with a lot before giving up.”

Mark Linzer, Madison, WI

Physician Worklife Study Funded by Robert Wood Johnson Foundation

1996-98: national survey of >5000 MDs Findings:

◦ Satisfaction promoted by long term relationships with patients

◦ Time pressure diminished satisfaction◦ Stress related to lack of work control◦ Burnout predicted by work-home interference

Linzer. J Gen Intern Med. 2000;15(7):441-50.

Research Base

Burnout model

SexAgeChildrenSolo practiceAcademic practiceWork hours

Stress Satisfaction

Work control Work-home interferenceHome support

Background variables

Mediating variables

Variableoutcomes

Burnout

From Linzer M. Am J Med 2001; 111:170-75.

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Funded by AHRQ; 2002-2006 119 PC clinics; 422 MDs; 1785 patients. To determine relationships between work

conditions, physician reactions (stress and burnout) and patient care (quality and errors).

Linzer M, et al. Ann Intern Med 2009;151:28-36.

MEMO study: aligning physician and patient

outcomes

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MEMO Study conceptual model

StructureCultureWorkflowPolicies, processesPatient demands

SatisfactionTrustQuality of careMedical errors

SatisfactionStressBurnout Intent to leave

WorkplaceCharacteristic

s

Physician Reactions

PatientOutcomes

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Measuring QualityUp to 6 patients per primary care physician with diabetes and/or HTN

Assess: Patient satisfaction Quality of life

Disease management

Patient Survey

Chart review

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Confidential chart reviews for errors in processes of care (e.g., wrong medications, missed preventive activities)

Determining Errors

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50% need more time for visits 27% burning out or burned out 30% moderately likely to leave job in 2 years Strong relationships between work conditions

(time pressure, work control, chaos, organizational culture) and physician satisfaction, stress, burnout, intent to leave

Many patient care outcomes linked to work conditions

MEMO results: physician outcomes

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MEMO Results: patient care

Variable Outcome p-value

Moderate to high work control

Higher diabetes care quality

<0.05

Time pressure Lower overall qualityPoorer care for HTN patients

<0.05<0.05

Linzer et al. Ann Intern Med 2009Center for Patient and Provider Experience at

MEMO Results: patient care

Variable Outcome p-valueInformation and communication emphasis

Higher overall qualityBetter HTN quality care

<0.05 <0.01

Values alignment

Better diabetes care qualityFewer prevention errors

<0.001 <0.01

Linzer et al. Ann Intern Med 2009

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Mock OWL (problematic setting), taken from Linzer et al. Ann Intern Med. 2009;151:28-36.

Randomized trial of QI interventions to improve work conditions and care quality

34 clinics in Rural WI; Chicago; NYC Use OWL to measure work environment and

patient outcomes at baseline and after 6-12 months in intervention and control sites

Current AHRQ grant: Creating Healthy

Workplaces

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Clinics shown their OWL data and comparison clinics data

Data spurred meaningful conversations and movement towards solutions

The power of the data

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Harvard Business School: stocks rose 147% when employee satisfaction rose

In 7900 businesses: productivity and income tied to employee satisfaction

Sears: when employee satisfaction rose 4%, sales increased by $200 million, with a rise in customer satisfaction

Job satisfaction: business case

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(Brown & Gunderman. Acad Med 2006;81:577-82)

Outcomes of dissatisfaction

Burnout Linzer et al. Am J Med 2001;111:170-75.

Turnover: $250,000/departing physician Buchbinder et al. Am J Manag Care 1999;5:1431-8

Instability (larger patient load for remaining providers)

Brown & Gunderman. Acad Med 2006;81:577-82

Reduced patient: 1) access to care, 2) satisfaction, 3) medication adherence

Linn et al. Med Care 1985; 23:1171-78; DiMatteo. Health Psychol 1993;12: 93-102

Increased patient disenrollment Brown & Gunderman. Acad Med 2006;81:577-82

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Prevalent (20-40%) in practicing physicians (Linzer. Am J Med. 2001;111:170-75), higher in medical students (Dyrbe L. Ann Intern Med 2008;149:334-41).

Associated with perceived errors by medical housestaff (West C. JAMA. 2009;296:1071-78)

1.6 x higher in women physicians than men Mediated by home support, work control, and

work-home balance (Linzer et al. Am J Med 2001;111:170-5) Present in 46% of US MDs (Shanafelt T. Arch Intern Med

2012)

Burnout: long-term stress reaction

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Demands balanced by control Stress increases if demands rise or

control diminishes Support can facilitate impact of control:

more support, less stress Bottom line… support and work control

prevent stress

Demand-control model of job stress

(Karasek et al. Am J Public Health 1981;71:694-705)

Demands Control Support

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US vs Netherlands: Less gender difference in burnout in Netherlands due to a) fewer work hours and b) better work control in women vs men MDs

(Linzer et al. J Am Med Women’s Assoc 2002;57:191-3) More burnout in US women MDs due to

gendered expectations for listening US women MDs describe faster pace, less

values alignment with leadership (Horner-Ibler et al. J Gen Intern Med 2005; 20(s1):194)

Gender differences in burnout

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Burnout in Surgeons Common - 32-40% Predictors:

- lack of control- lack of work-family balance- dual career family- nights, work hours- comp based on billing

(Shanafelt T. Ann Surg. 2009;250:463-71. Balch C. Arch Surg. 2009; 144:371-76)

MEMO study looked at relationship between EMR functionality and stress.

Two findings:◦ Stress increased (3 to 3.5 on 1-5 scale) as EMR

functions increased; stress decreased as EMR fully functional (3.2) – but not to original level.

◦ In fully functional EMRs, shorter visits associated with more stress, burnout and intent to leave.

(Babbott. JGIM, abstract, 2011)

Stress and EMR

Career fit: If % time clinicians are able to do what they

are most passionate about falls below 10%, burnout rises dramatically (>50%).

Thus, be sure clinicians have time (at least 10%) to devote to what they care most about (“career fit”)

(Shanafelt T. Arch Intern Med. 2009;169(10):990-995.)

One more burnout predictor

Flexible/part-time work (Linzer. Acad Med 2009;84:1395-1400)

Leaders model work-home balance; value well-being (Saleh. Clin Orthop Relat Res 2009;467:558-65; Dunn. J Gen Intern Med 2007;22:1544-52)

Promote work control; limit EMR time outside office; provide sufficient time to use it inside

Alter our “culture of endurance” (Viviers. Can J Ophthalmol 2008;43:535-46)

How can we prevent burnout?

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Less time pressure, more control Extend appt times, or offload non-clinician work “Desk top” slots during sessions Time to catch up (2 hrs?) after vacation/leave

More order, less chaos Maximally utilize space Pilot unique schedules: “7 on, 7 off”

Support for work-home balance Support part-time practice and practice styles

supportive of parents of young children

A healthy work environment

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Creating healthy work environments

Build forms work into practice

flow

Don’t wait

until the end of the day

Respect the

lifecycle

Hire float

clinicians to

cover parental

/sick leaves

Build workplace

teams

Address work flow

and quality

measures

MDs, APPs,

MAs, RNs, Pharm Ds

Supportive Culture

Be sure values

are aligned (betwee

n clinician

s and leaders)

Take time to listen

Action often not

needed

Kenny C. Transforming Health Care: Virginia Mason Medical Center's Pursuit of the Perfect Patient Experience,  CRC Press; 1 edition (November 8, 2010).Linzer M, Respecting the lifecycle: rational workforce planning in a section of general internal medicine. Am J Med. 2002;113: 443-48.

Time to:◦ Reflect together on challenging cases◦ Exercise 3-4 x per wk◦ Eat all meals◦ Complete work at work◦ See a patient, listen, provide empathy, attend to quality

measures, and use the EMR◦ Huddle with your team (who can help with all of the above)◦ Meet with leaders and discuss values, direction and

purpose

Wellness in work life

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Hard workers; usually at more than their FTE

Loyal, connected, good morale Patient satisfaction is high They may become full-time one day when

you wish to go part-time (e.g. for children, end of career)!

Mechaber H et al. J Gen Intern Med. 2008;23(3):300-3.

Remember part-time physicians are key:

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1. Visible site for clinician wellness2. Wellness Champions in each setting3. Periodic, brief surveys of stress, burnout

and remediable predictors4. Focused action plans to promote wellness

One way to get there – Create an Office of Professional Worklife and Wellness

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1. Overall, I am satisfied with my current job:Strongly disagree Disagree Neither agree nor disagree Agree Agree strongly 2. I feel a great deal of stress because of my job Strongly disagree Disagree Neither agree nor disagree Agree Agree strongly 3. Using your own definition of “burnout”, please circle one of the answers below: 1. I enjoy my work. I have no symptoms of burnout.2. I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out.3. I am definitely burning out and have one or more symptoms of burnout, ex. emotional exhaustion. 4. The symptoms of burnout that I’m experiencing won’t go away. I think about frustrations at work a lot. 5. I feel completely burned out and often wonder if I can go on. I am at the point where I may need to seek help.  4. My control over my workload is:1 – Poor 2 – Marginal 3 – Satisfactory 4 – Good 5 – Optimal 5. Sufficiency of time for documentation is:1 – Poor 2 – Marginal 3 – Satisfactory 4 – Good 5 – Optimal 6. Which number best describes the atmosphere in your primary work area?Calm Busy, but reasonable Hectic, chaotic 1 2 3 4 5 7. My professional values are well aligned with those of my department leaders:Strongly disagree Disagree Neither agree nor disagree Agree Agree strongly 8. My professional values are well aligned with those of our organizational leaders:Strongly disagree Disagree Neither agree nor disagree Agree Agree strongly 

*This survey was developed by Dr. Mark Linzer (Division Director, General Internal Medicine) and his team at Hennepin County Medical Center in Minneapolis MN as part of his ongoing research in Clinician Worklife and Satisfaction. Disclaimer-this is adapted from the OWL (Office and Work Life™ measure); more detailed surveys are often needed for second stage work.  

Mini-OWL

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Been a privilege to share our research with you. Thank you for listening and

participating!

mark.linzer@hcmed.org

Thank you

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