Mitigating Burnout Through Physician Engagement and Empowerment
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Inspired by the recent article “Faculty Development Committee: Evolution through engagement and empowerment”, which was recently published in the Academy of Emergency Medicine, Education and Training.
This review continues our Physician Career Solution Institute (PCSI) series of reviews of evidence-based studies on physician burnout. This study comes from the Journal of the Academy of Emergency Medicine: Education and Training. The article is titled “Faculty Development Committee: Evolution through Engagement and Empowerment. The authors are Alexa Sabedra, MD, Caroline Freiermuth, MD, MS, FACEP, Sally Santen, MD, PhD, and Elizabeth Leenellett, MD, FACEP. The authors represent Emergency Medicine from the University of Cincinnati College of Medicine (Cincinnati, OH). Alexa Sabedra is the corresponding author.
This study provides a platform for me to advocate for investing in our physicians’ well-being and including them in meaningful leadership positions.
I’ve noticed a general trend. From the early 2000s, many academic healthcare organizations cultivated physicians into health system leadership. By the time we entered the 2010s, physician leaders were in vogue, and you could roughly divide health systems into two camps.
The first camp embraced physician leadership, placed physicians in meaningful positions, and openly listened to physician leaders, respecting physician insights earned through years of patient care, education, and research. This camp appreciated that when their physician leader disagreed with the traditional administrative ‘book’, the intent of their physician was almost always pro-patient. The resultant conversation was conducted transparently, curiously so that all parties could understand the downstream consequences of whatever actions were being considered.
The second camp saw physician leadership as an inconvenience and a necessary evil. They tended to place their physician leaders in well-titled yet relatively powerless positions. These physicians were paid well and expected to go along to get along. A significant portion of this camp started in the first camp and found that physician leaders wouldn’t quietly follow the administrative ‘book’. Subsequently, it was easier to minimize the physician’s voice than to conduct the hard conversations. They subsequently converted to the second camp.
In fairness to these systems, some of our physician brethren played along. Many physicians accepted extra pay and title when selling their name and degree. Some thought of leadership as a mechanism to get fewer clinical hours and a bigger office with a window. Some may have initially tried to put up a good fight. Still, when they found the battle uncomfortable, they hid behind their clinical duties and returned their responsibilities to non-physicians despite maintaining a title. My concern with the latter is that these physicians returned their duties to those with less background and knowledge about patient care and how to position their colleague physicians for success.
Positioning your colleague physician for success, which is defined as providing the highest value of care possible now and in the future (which requires education and research), takes investment in physician leadership. Advocating for investment takes effort and often comes with risk, particularly in tough economic times. The individuals best positioned to advocate for physician leadership are physician leaders, which leads us to this piece of fine scholarship, despite my roundabout dance on the soap box.
So now to our article.
This fine scholarly work describes how physicians were placed in a position to advocate for solutions to physician burnout and met with meaningful success. A component not discussed by the authors is how the department’s culture facilitated many of the implemented solutions. Some solutions placed greater burdens on colleagues or required more FTE, but the article is unclear on who shouldered the burden: the physician or the administration. In fairness, this latter issue is not the focus of the study. Regardless, the ability to implement the solution with either accommodation is a credit to the department’s leadership. I am suitably impressed.
GENERAL BACKGROUND
Physician burnout continues to be a significant occupational syndrome characterized by a prolonged reaction to chronic interpersonal stressors on the job. The American Medical Association (AMA) define it through three primary dimensions: emotional exhaustion, where physician feel emotionally drained and depleted by their work; depersonalization, which involves developing cynical or detached attitudes towards patients and caregiving; and a diminished sense of personal achievement, where physicians feel ineffective and their work lacks meaning.
Physician burnout is recognized globally as an “occupational phenomenon” and is highly prevalent. Recent national surveys show that the burnout rate is approximately 45% in U.S. physicians, and some front-line subspecialties have burnout rates as high as 60%. For physicians, burnout is linked to deteriorating mental and physical health, including risks of anxiety, sleep disturbances, depression, substance abuse, erosion of personal relationships, and suicidal ideation. From a patient care perspective, burnout adversely affects the quality and Safety of care, contributing to increased medical errors, lower patient satisfaction, and a higher likelihood of malpractice claims. From a healthcare system perspective, the impacts are just as damaging, including increased physician turnover, heightened litigation risk, poor morale, compromised financial well-being, reduced workflow efficiency, and significant challenges in recruitment and retention.
The AMA has identified the following as the “Big 4” factors significantly contributing to physician stress and burnout.
Time Pressure: The extensive documentation requirements from electronic health records have exacerbated this over the last twenty years.
Lack of Control over the Work Environment: This has been exacerbated by the transition in hospital systems from medical administrators to non-medical administrators in managerial positions, making decisions that directly affect healthcare. Often, this is seen through a lack of alignment of values between clinicians and administration.
Chaotic, Face-Paced Workplaces: This is exacerbated by the high unpredictability and relentless pace that characterizes many healthcare settings.
Culture of the Organization: This has been exacerbated by the loss of community brought about through the COVID pandemic, resulting in poor communication, team cohesion, and trust.
Other prominently cited systemic drivers include excessive administrative burdens, high workload and demanding schedules, inefficient practice environments and workflows, lack of autonomy in clinical decision-making, inadequate work support, and poor leadership. Our last review discussed the impact of leadership on physician burnout.
Physician engagement and empowerment play critical roles in mitigating physician burnout. These engagements and empowerments go far beyond the mere solicitation of feedback. Engagement extends to generating, designing, and implementing targeted interventions and systematic solutions. Empowering physicians is the deliberate provision of agency, autonomy, resources, and necessary authority to effect meaningful changes to their work systems, processes, and environment. A critical factor for successful engagement is the genuine commitment from organizational leadership to act upon physician-generated solutions, not just ‘listen’.
Key operational concepts helpful when considering physician-generated solutions include the ‘pebbles’ concept and ‘job crafting’. The ‘pebbles’ concept addresses small, seemingly minor daily frustrations identified by clinicians. This approach has offered some organizations a compelling strategy for generating early wins and building momentum for broader change. The noting of ‘job crafting’ where physicians are empowered to redesign aspects of their tasks and roles, signals a necessary shift from rigid, top-down job descriptions to more personalized and flexible work designs. It necessitates recognizing that physicians can optimize their work for well-being and effectiveness if given the latitude and support to move away from a one-size-fits-all approach to job roles.
This study that we are reviewing and discussing exemplifies many of these principles, which makes it worthwhile to raise awareness of this fine piece of scholarship.
THE STUDY
I appreciate the thoughtfulness, due diligence, and effort of the team involved in this study, which is an important topic.
This study focuses on emergency room physicians, who are particularly prone to burnout. Up to 70% of emergency room physicians suffer from burnout. The set-up of the study also notes that millennials and Gen Z will soon constitute the majority of emergency room physicians. The authors note that the younger generation prioritizes the perception of work-life balance and developmental opportunities. Moreover, considering the age of the millennials and Gen Z physicians, many will be starting families after delaying due to education and training obligations earlier in their careers. This reality further stresses the balance between professional and personal priorities. With all of this in mind, the study’s objective was to create a faculty development committee to engage and empower faculty to implement programs and policies to more closely craft job requirements to the desires of the physicians.
Subsequently, the faculty development committee responded to surveys implemented to assess well-being. Based on the study, the following initiatives were initiated.
Mentorship - A mandatory assistant professor mentorship program was created to support personal and professional development and accelerate promotion.
Education - A faculty curriculum was created to enhance clinical skills and address subjects such as leadership, communication, and ACGME requirements.
Transparency and equality—A salary equity assessment and an evaluation of transparency and fairness in leadership positions were performed. Changes were made accordingly.
Wellness: A discussion was held about the limited flexibility in scheduling options, night shift and overtime distributions, and considerations for individuals with personal life challenges. Changes were made accordingly..
The study found the following.
Generally, the above initiatives were well accepted and appropriately taken advantage of. This study was descriptive, yet insightful. Key notes were that some of the efforts fostered a sense of community among junior and senior physicians. Promotion rates significantly increased, particularly among women physicians. Flexible scheduling appeared to meet with the approval of the physicians in the group, and the new policies allowed this emergency physician group to eliminate mandatory overtime.
Specific changes in scheduling included the following.
Expanded vacation options and transparent holiday scheduling.
Shift length decreased from 12 hours to 8 hours.
Creation of a voluntary physician overtime pool.
Opt-out options for the night shift are available after the age of 55.
Opt-out options for night shift are available for third-trimester pregnancy providers.
No Backup shifts from 36 weeks of gestation until 3 months after returning from parental leave.
Departmental support for parental leave up to 16 weeks (versus 6 weeks from the University) with flexibility into the pace of reintegration.
I continue to be impressed with this department’s leadership and the culture they have built. Cultures such as this require commitment from top to bottom, which is a challenge to achieve. I know many departments whose culture would not tolerate many of these changes well. It is apparent that despite the upfront costs of these changes, department leadership recognizes that it is an investment that will pay off in the long run through increased productivity and decreased physician turnover.
BOTTOM LINE
This piece of scholarship provides valuable insights despite its descriptive design. At a minimum, this article highlights the potential of engaging and empowering physicians to mitigate burnout issues. The gist of the article is that this effort was driven internally by this department. If so, the leadership of this department should be used as a paragon within its university committee.
Thank you for sharing and discussing this recent, relevant scholarship on physician burnout. The changes occurring during this transition period concern me greatly, and I believe these changes will stoke the fires of physician burnout. The impact will negatively affect healthcare for generations. However, we can do something about it.
We will likely publish our next review early next week. Until then, please remember that compassion happens. Don’t give up hope. Compassion needs you.