Transforming Physician Burnout into Physician Wellness

Episode Overview

Transcript:

Daniel J. Marino: Welcome to Value-Based Care Insights. I'm your host, Daniel Marino. The economic pressures that we're seeing in the country are definitely plaguing health care. Many hospitals, health systems, and physician groups continue to struggle with high costs and wage inflation, and probably the biggest one is turnover or a lack of staff and a lot of the key areas of the health care units' hospital units, physician practices, and so forth. No doubt that nursing and some of the challenges with recruiting nursing has continues to be an issue. Physicians though are really feeling the pressure. They're feeling the pressure in a number of areas. One, they don't have enough staff to really begin to support good patient care, to support all of the things that they need to do to make their practice efficient. There's a lot of carryovers still from all of the pressures that were placed upon physicians as a result of COVID, and it's really a serious concern when you speak to many physicians, particularly primary care here today I am, I'm glad to be joined by my colleague, Dr. George Mayzell. George is a physician executive who specializes in helping organizations transform the delivery of care through population health strategies, through care management design. He's done a lot of work in physician leadership programs and is just fantastic support to many physician leaders across the country. George, welcome to the program.

George Mayzell: Thank you, Dan. It's good to be here.

Daniel J. Marino: So George, I was recently talking to a colleague of mine who is a physician leader, and he made an interesting comment to me that physician burnout, burnout within his physician community has never been higher. Physicians are frustrated, there's a lot of dissatisfaction, and frankly, he's really almost frustrated because it's hard for him to change this philosophy or these feelings of dissatisfaction that he's seeing within his physician practices. What are you hearing? What are you seeing? I know you've spent a lot of time looking into physician burnout. Thoughts?

George Mayzell: Yeah, Dan, I think what you heard was just literally the canary in the coal mine. Burnout was a huge issue before COVID. It was a big concern to a lot of organizations. However, when COVID was at its peak, everybody's focus turned away from it because frankly, there was really no choice. It became all hands on deck, Let's solve the problem now that we're at least moving to the other side of COVID. Arguably we're seeing burnout is even worse than ever because COVID put increasing stress on the system. I think it exposed a lot of the flaws that were previously there. And in fact, the AMA had a recent survey. It just came out and it said that three out of five physicians have at least one symptom of burnout. Actually, the number was 62.8%. Think about that. Well over half of the physicians have at least one symptom of burnout. And again, burnout is not a benign problem. It's not just a physician problem, it's a system problem. because of all the impacts, it has, not just on the individual docs, but also on the culture of the system and directly and indirectly on the patient care. So it's a big issue.

Daniel J. Marino: Yeah, I agree with you. And burnout, just the term burnout has really a negative connotation to it. In my mind, denotes frustration, and dissatisfaction. I almost think about it the opposite way, where we have to really focus on improving physician wellness. How do you create a better environment that gets us back to, particularly for physicians, the reason why they got into health care, to begin with?

George Mayzell: Yeah, I think that's right on. We use the term burnout because it's accepted. We've talked about it for years, dating way back in all other forms of work but more recently in health care and burnout's a terrible term. It's a very negative term. And when you think about physicians or in fact any health care worker, these are resilient people. These folks have proven that they can get through a grueling academic schedule, a grueling residency or internship or another clinical rotation schedule. These are folks that have a lot of stamina and a lot approved it. And so the term burnout is just a really bad term. A lot of folks will call it moral injury, they call it incongruity, a lot of different things. But what it really is, it's not about taking care of patients. That's not what physicians and health care workers complain about. It's all the stuff that gets in the way and surrounds taking care of patients.

So burnout is not really the right term. We'll use it because it's expedient, but really it's much more than that. And when we talk about burnout, just to be clear, the definition of burnout, there are a lot of definitions, but they really revolve around three main symptomatologies. One is just emotional exhaustion, just so tired. This is not just one time, this is day in and day out, just really can't even get out of bed. The second is feeling low, personal accomplishment, feeling like no matter what you do, it's not gonna fix things. And the last thing is the depersonalization of patients not looking at patients as people but of things to get through and by and over. So those are the three major diagnostic criteria. But again, as you said, we, we've kind of moved past this thinking of burnout and think about how do we get folks past burnout onto reminding them why people went into health care in the first place and bringing back the wellness and the joy of practicing medicine. 

Daniel J. Marino: Yeah, I agree. And you're really seeing that feeling of dissatisfaction transcend all the way through a health care hospital organization. You recently wrote a book, The Resilient Health Care Organization, How to Reduce Physician and Health Care Worker Burnout. One of the things that you mentioned in the book was that you need to have the right model of care. The model of care provides a support structure that allows nurses and physicians to work together as a team to really begin to support that care delivery model in a way that we're meeting the needs of patients. But when you think about what the care model is today just due to the reduction in, let's say the nurses or the turnover in nurses and just the lack of ability to really recruit strong nurses, boy, that's gotta put a tremendous amount of pressure on the physicians to really uphold the relationship with the patient, of which the nurse is a big part of that. But just to really be able to deliver care up to the standards that need to be given and to really support patients in their time of need.

George Mayzell: Yeah, that's exactly right.  When we look at burnout solutions, or at least causality and about one can argue, that maybe one quarter is really at the individual level. Most of it is at the corporate level, which is where you were going. And that's really about how physicians and other health care workers are able to practice medicine. As you brought, there's a lot of issues that go into this. One, as you mentioned, is staffing. If folks are understaffed or frankly have a less qualified staff or less trained staff, it puts an increasing burden on all those things I was talking about that interfere with patient care. The physician wants to spend time diagnosing and treating the patient. They don't wanna spend time putting patients in the room and filling out sheets and working on the EMR and those sort of things. We recognize that those are part and parcel of care, but that shouldn't really be a big part of the focus.

The other piece that you kind of indirectly mentioned is the EMR. And that's a huge issue in terms of really unfortunately getting in the way of providing good care. Again, I recognize that it's a necessary evil. It's not going away. It has a lot of good things attached to it and it. But when the EMRs were originally designed, they weren't designed around the clinical care process. They were designed around billing and the hospital process. So we need to see about making those tools more efficient. The last thing you indirectly mentioned, but I'll bring to the forefront, is really well, two other things. One is matching cultures. The culture of the organization needs to match with the culture of the physician, the values patient-focused, really trying to do the right thing for all the right reasons. That goes a long way. And then the other item is workflow, and that's really coordinating things so that things are aligned to minimize all those distractions around the patient care process. So all that has to flow into things, and each one of those is a complicated and complex process, but really important to get past some of this burnout into the joy of practicing that.

Daniel J. Marino: So George, the employment models obviously have changed over the last number of years. More independent physicians have become employed. I think early on they did this for economic reasons. They did this to, I think reduce some of the administrative functions or issues, a lot of which that you just talked about with regards to the EMR and workflow and so forth. Are you still seeing or hearing from your colleagues that they're happy with the employment model? Are some of them thinking about maybe going back to private practice?

George Mayzell: The employment model used to be independent physicians and then hospital-employed physicians. That was sort of the traditional model that was around for a while. And of course now what we're seeing, which has added a lot of complexity, is we're seeing private equity jumping in and buying physician groups. We're seeing the number one employer in the country for primary care is now United health care through Optum. So we're seeing what we call pay providers, which is managed care companies now owning providers. So all each one has its own intrinsic alignment challenges, depending on which model but they all sort of potentially have some challenges in one, how much autonomy does this physician still have? Can they pick and choose and nuance their schedule? I was just talking to a group of providers who were incredibly frustrated because they didn't have the ability to expand their schedule when they had some challenging patients, even when they knew of it in advance.

And that just put a lot of extra pressure on the system. So that autonomy and that flexibility are huge. The second part of that employment model is the compensation model that accompanies it, accompanies the model. Again, they all can be different, but most of them are generally based on how many patients they see, either an RVU model or another billing comp model. This puts increasing pressure on the physician and also clearly can lead to more burnout. There are some that are mixed models with some incentive-based models, well as quality and outcomes and other things which are coming more into play, which is important. But certainly, all those different compensation models can add to either alignment or misalignment, Again, depending on the model and the system. And the other item that you mentioned earlier, which I'll emphasize, here again, is the staffing piece. In private practice, the physician had control over staffing to a degree in terms of how many nurses they hired and how many techs, and so on.

Again, there was an economic cost, but at least they had some decision-making on that control. Often in these new models where there's a large company or a hospital or a private equity company that's managing the practice, the physicians or other clinicians don't really have control, assuming they can even find people, which is a challenge, but assuming they don't always have control over that staffing overhead, again, can really, really lead to increasing pressures on the physician side. So again, there's a lot more than just those things, but those are the things that come top of my mind.

Daniel J. Marino: Yeah, absolutely. Right. I think all of those items make it really critical and I think are putting a lot of pressure on the employed physicians. If you're just tuning in, I'm Daniel Marino and you're listening to Value-Based Care Insights. I'm talking today with George Mayzell, Dr. Mazel, regarding physician burnout and a lot of the challenges that we're continuing to see within our physician community. So George, when you think about the employed model, are physicians feeling more pressure to maintain a certain volume level, or are they seeing more pressure to reduce the cost to do more with less? Maybe to take on a little bit more because they don't have that staffing resource with them?

George Mayzell: I think the answer is in many cases, yes, not all. Again, in the old days where physicians would see patients and then to get compensated for who they saw it was sort of an incentive-based model, but there was ownership of the practice and there was total control over how many staff you had and how long you worked and so on. And these new models, some of that control has gone away. So those incentive-based models can put a lot of pressure on physicians. And again, depending on exactly how it's set up they could be a huge challenge to physicians in terms of trying to make sure that they could give quality care while also maintaining enough volume in the practice. So all those things we just mentioned. So I think it's not one size fits all that every employed model is worse than the old days perhaps.

But I think I would say that many of them are because again, I think sometimes employing professionals are not quite the same as employing folks at a manufacturing plant. And sometimes that's not always as recognized as it needs to be. Taking care of sick patients is very challenging, not just from a knowledge base and a throughput, but also emotionally. So taking all those into account that autonomy on the physician side becomes really critical in terms of making sure that everything's alignment in terms of the compensation model, the autonomy, the flexibility, and all those other things that need to go into a model that supports physicians and helps to bring back some of the joy in medicine while also being, again financially competitive.

Daniel J. Marino: When you think about the drivers of physician alignment, how much does physician leadership come into play? We're seeing more and more health care systems or hospitals employing physicians in leadership roles. Do they have the autonomy to really make a change? Is this a good thing in terms of the direction and support for physicians?

George Mayzell: Yeah, there's a lot of studies out there that say physician leadership or organizations that have a lot of good physician leadership, strong physician leadership has less problems with burnout. There's no doubt there's a negative correlation between more leadership and less burnout. Right? Again, I think to the answer to your question, is every organization's a little different. Not only do we have to have good physician leadership, but there has to be training for that leadership. And that leadership has to be accompanied by the responsibility and accountability to influence and create change that supports great patient care and good patient and good physician outcomes. So all that's connected, again, we move from the triple aim to quadruple aim, which brings staffing and physician wellbeing into the equation. And I think we've undersold that because it's so important. Again, physician burnout is not just about physicians, it's about the care of the patient. There's been a huge correlation between errors and safety issues and other things when physicians and other health care professionals are burned out or partially burned out.

Daniel J. Marino: But I'll tell you though, some of the organizations that I've worked with, and we're doing some strategy work right now with a few different clients, those health care organizations that have strong physician leadership appear to have more of a culture that is more proactive driving patient care, working through some of these issues. Now, again, the turnover issue, there's nothing you can do about that. You've got to have a plan in place, and I think you have to work through that. And you've gotta have the best physician leader in the world, and if you have turnover, you're gonna have turnover. But what I am seeing is, and you touched on this, physician leaders who have the right level of training, who have the right level of development, who certainly are respected by their peers, and have the right aligned incentives appear to be able to overcome a lot of these cultural challenges with burnout. I don't know if you're seeing the same thing, but in a few of the health care organizations that I've worked with, boy, that to me, has really been a differentiator.

George Mayzell: Yeah, I think that's absolutely right. On the other thing, I would also add that in the right organizations with the right physician and other leadership, you see less turnover and turnover is really expensive. I'm probably biased, which is probably okay but they understand the care process. They understand how to balance patient care and outcomes and then what we're adding to that is the economic realities of health care. But I think, again, biased included, who better to try to make those balancing acts than someone who knows and understands patient care and patient outcomes and the workflow involved in getting patients treated properly?

Daniel J. Marino: I couldn't agree with you more. So if you're working with an organization and you know, discovered that they have a lot of physician debt dissatisfaction, what piece of advice would you give to some of these leaders in terms of where to start, how to address it, how to begin to move the sort culture dial, if you will, to from physician burnout or dissatisfaction to more around physician wellness and wellbeing?

George Mayzell: Well, I think the first step is the most important, but also in some ways, the easiest. You have to measure it and you have to acknowledge it, and you have to understand it. So it's about surveys, but it's also about conversations, executive leadership, rounding talking to the people, and figuring out why. There are always reasons. And then of course, if you don't do anything with that, then nothing happens. But then the second step is bringing the right people in to help change some of those high-issue items. And again, we know what our satisfiers are, but each individual organization has to figure out what's causing that dissatisfaction. And then that's where the physician leadership comes in, nursing leadership for that matter and looking at the culture and looking at the values of the system. That's where you might wanna realign the comp model to create that alignment. And that's why you bring everybody to the table as a team and figure out, how do we all wanna take great care of patients? And we all know we have to have some financial accountability to get there. How do we make that all happen in a balanced type of way? The first part is just acknowledging that it's real and it's expensive, and frankly, it's a differentiator in good organizations first, not good organizations.

Daniel J. Marino: It really is. And I really think I'm a huge proponent of having a plan. You have a plan, what your tasks are, and where you're going, and you measure your success. We do that a lot when we help organizations with strategic planning. I think you really need to have a plan on how you're going to improve physician wellness. And in my mind, it really comes down to four things. I think a lot of what you mentioned here, George, I think it's really coming down to what is the plan to reduce some of the administrative burdens. Incorporated in that plan is how you're gonna address turnover, staff turnover, nursing turnover, and recruitment. Physician leadership, I think has to be part of that. This really does need to be physician-led, as you said, and aligned incentives are key. But the last point I think is really important. You have to begin to measure this along the way. So if you've got a plan in place with a number of objectives and tasks that you wanna begin to achieve over time to improve physician wellness or wellbeing, to be able to measure this, to be able to create some surveys, to be able to allow physicians to provide a voice in my mind, taken together with those other factors really is what's going to drive the change.

George Mayzell: I agree a hundred percent. You don't change what you don't measure, so you have to measure it, and then you have to acknowledge it's an issue and create a plan to improve it, and then have a long-term view that you're tracking on a regular basis along the way to know that you're moving in the right direction.

Daniel J. Marino: Absolutely right. Well, George, this has been great. Any final insights or pieces of advice you might give to any of our listeners if they're really struggling with physician burnout or want to improve their physical wellness within their own organization? Any thoughts?

George Mayzell: I think the most important thing is to acknowledge that this is an issue and the importance opf active listening, to understand what's going on and why, and to be open-minded about creating some changes in the organization and talking to your physicians and making sure you understand what's the biggest thing that's concerning them, and then actively fix that so that you get some credibility. And then do the other things that we just talked about, making a plan and having a long term view to the ultimate solutions.

Daniel J. Marino:  I absolutely agree. I think to take all those things taken together are just key, and it doesn't just go away, and you really have to work and put some time in and some energy to really improve these key areas. And our physician community is so important to our care model, so important to our organization, so important to our physicians. It does really have to come down to that plan and the execution of that. Hopefully, you receive some good information, some good insights. Until the next insight. I am Daniel Marino, bringing you 30 minutes of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners.