Burnout and the Patient Experience

Focus on putting patient care at the forefront. Reducing physician burnout will require allowing doctors to do what they do best: treating patients.

A Strategist's Guide to Clinician Well-being in a Time of Crisis

As health care professionals across the globe face the continued onslaught of the coronavirus disease 2019 (COVID-19) pandemic, health care organizations must brace for the anticipated near and long term consequences for clinician well-being. Preventing a parallel crisis of clinician burnout will take careful planning and thoughtful allocation of resources.¹ ² However, strategic planning during a crisis is incredibly challenging for any organization — never mind one at the front lines of a pandemic. In this report, we outline principles of decision making and strategic execution that health care organizations must consider in addressing the near- and long-term mental health needs of their clinical work force.

I. Forecasting Outcomes

Although the COVID-19 pandemic has been described as a central health crisis of our generation,³ prior disasters scenarios offer grim insights into the pandemic’s impact on clinician well-being. Indeed, following the 2003 severe acute respiratory syndrome (SARS) outbreak and the 2015 Middle East Respiratory Syndrome (MERS) outbreak, responding clinicians displayed higher rates of psychological distress, including fear, sleep problems, “numbness,” and survival guilt.⁴ And while most individuals are resilient enough to avoid clinical trauma responses, they can still experience subclinical symptoms that greatly impair their quality of life and result in professional burnout.⁴ These symptoms pose a danger not just to clinicians — whose rates of suicide exceed those of other professions⁵ ⁶ –but also to their patients.⁷ ⁸ ⁹ ¹⁰ ¹¹ ¹² ¹³

In a June, 2020 viewpoint, Shanafelt and colleagues published early insights into the anxieties facing health care professionals as a consequence of the COVID-19 pandemic. Among other issues, the authors cited anxieties related to finding necessary child care services during school closures and increased work hours.³ While this viewpoint was published over 6 months ago, it is unlikely these anxieties have eased in the current climate given the recurrent viral surges and lack of return to “normal” life.

II. Aiming to Fail Fast

Health care organizations have had to contend with significant operational and financial uncertainty as a result of the pandemic.¹⁴ ¹⁵ The challenges of modern-day decision making only amplify this uncertainty. As Day and Schoemaker have argued, modern organizations face pervasive information overload, which can compromise detection of critical signals and lead to confusion and diversion in decision making.¹⁶ To mitigate these risks, organizations must be able to “fail fast” in strategic planning. This requires them to rapidly develop, scale and evaluate programs in order to understand where limited resources can be allocated most effectively.¹⁴

However, “failing fast” with programs aimed at clinician well-being is incredibly challenging. The drivers of clinician well-being are multi-factorial¹⁷ and often require high effort, systems-level changes, such as reducing clerical burden for physicians.¹⁸ Changes of this magnitude take time and resources — both of which are limited in a crisis. Organizations must therefore rely on data to inform a selection of effective programs.

Unfortunately, there is a lack of robust data currently available to guide organizational responses to clinician well-being. A recent Cochrane review highlighted this point: in a systematic meta-analysis, the authors evaluated interventions for frontline health care professionals during or after a disease outbreak, epidemic or pandemic. They identified a lack of quantitative and qualitative evidence to support interventions that are beneficial to the resilience and mental health of these frontline workers.¹⁹

Without data to inform strategic planning, health care organizations must instead rely on research and improvement science to facilitate the rapid identification and scaling of effective interventions. In practice, however, this process is hindered by data collection. This is because organizations have traditionally assessed clinician well-being using survey and qualitative methods⁹ ²⁰ ²¹ — which rely on adequate participation from busy clinicians. Paradoxically, then, organizations are forced to make strategic decisions based on engagement from the very clinicians at highest risk of burnout.

This feedback mechanism is problematic for several reasons. Beyond the fact that professional burnout can be accompanied by exhaustion and disengagement — which can lead to selection and other sources of bias in data collection — these methods also functionally limit the timeliness of data, as leaders try to avoid “piling on” to clinicians’ schedules with additional tasks. In practice, this leads to stochastic assessments of clinician well-being that may be of questionable validity.

III. Dynamic Scanning

With insights into clinician well-being provided at a quarterly or annually cadence, how can a health care organization plan to effectively mitigate burnout and other symptoms of distress? The simple answer is it can’t — at least relying on traditional feedback mechanisms alone. Organizations must be willing to innovate beyond these methods to perform meaningful surveillance of clinician well-being at a systems level. And while data collected from clinicians through surveys, interviews, and focus groups are incredibly valuable, they are not sufficient in providing continuous signal detection and timely attention from leaders — critical tasks in any organization.²²

Increasingly, machine learning has emerged as a potential approach to this type of dynamic scanning. We recently explored this approach in our health care strategy consulting business through partnership with Receptiviti — a social psychology and data science technology platform that uses natural language processing, social psychology and artificial intelligence to drive business insights across a variety of industries. In collaboration with our firm, Adaptive Strategic Partners, Receptiviti recently developed a Healthcare Workers Wellness Index to test the viability of their software in trending clinician well-being.²³ The Healthcare Workers Wellness Index uses machine learning analysis of publicly-available data on Reddit, where self-identified doctors and nurses post daily submissions and comments in medical subreddits. Over the last several months, the platform’s language psychology algorithms assessed daily submissions and comments from thousands of self-identified doctors and nurses to understand their emotions and psychological wellbeing longitudinally across COVID-19. The platform also conducted comparative analyses with data from 2019, to study the impact of the pandemic.

The results from this proof-of-concept stage are staggering: in analyzing thousands of submissions from doctors and nurses, the Receptiviti platform identified a clear and progressive increase in signs of psychological distress over the course of the COVID-19 pandemic in relation to 2019. A particularly interesting trend was a steady decline in signs of analytical thinking, such as complex problem solving and higher order executive functioning.²³ These findings are congruent with anticipated trends in burnout among clinicians during the pandemic. However, unlike other data collection methods, machine learning can empirically quantifytrends in real-time — offering crucial insights into the magnitude of these outcomes.

IV. Systematically Scanning for Early Indicators

Imagine a scenario in which clinical staff in a busy health care organization are routinely monitored for signs of burnout or psychological distress. If a disturbing signal is noticed within an individual clinician or team, organizational leaders can systematically deploy targeted resources to offer clinicians dynamic levels of support, and to reduce stressors. With this technology, programmatic interventions for well-being can be rapidly tested and scaled. Well-being can be trended longitudinally against other performance indicators to identify common predictors of burnout across patient care settings. Once identified, these predictors can be buttressed by targeted interventions to mitigate the risk of burnout.

This scenario may sound inconceivable in the current health care climate, but advances in machine learning and other technologies have made this a realistic scenario in the near term. Health care organizations must recognize this potential and plan to incorporate clinician well-being as a target for automated, systems-based improvement. This will require health care organizations to identify a systematic process for scanning for early indicators of clinician burnout — much like they have invested in trigger tool technologies to detect adverse patient safety events.²⁴ Afterall, clinician well-being is a systems issue that impacts all levels of a health care organization.⁷ It should thus be assessed and addressed with the same rigor and technology investments as other patient safety and quality indicators. It’s a strategy that is certain to succeed.

References

1. Dzau VJ, Kirch D, Nasca T. Preventing a Parallel Pandemic — A National Strategy to Protect Clinicians’ Well-Being. N Engl J Med. Published online 2020:1–2. doi:DOI: 10.1056/NEJMp2011027

2. Galligan M, Palmer W, Truumees T. Answering the Call for Clinician Well-being: an Imperative for Health Care Organizations. Medium. Published 2020. Accessed February 12, 2021. https://palmerwesley.medium.com/answering-the-call-for-clinician-well-being-an-imperative-for-health-care-organizations-da8a0b635830

3. Shanafelt T, Ripp J, Trockel M. Understanding and Addressing Sources of Anxiety among Health Care Professionals during the COVID-19 Pandemic. JAMA — J Am Med Assoc. 2020;323(21):2133–2134. doi:10.1001/jama.2020.5893

4. Albott CS, Wozniak JR, McGlinch BP, Wall MH, Gold BS, Vinogradov S. Battle Buddies: Rapid Deployment of a Psychological Resilience Intervention for Health Care Workers during the COVID-19 Pandemic. Anesth Analg. 2020;131(1):43–54. doi:10.1213/ANE.0000000000004912

5. Center C, Davis M, Detre T, et al. Confronting Depression and Suicide in Physicians: A Consensus Statement. J Am Med Assoc. 2003;289(23):3161–3166. doi:10.1001/jama.289.23.3161

6. Eckleberry-Hunt J, Lick D. Physician Depression and Suicide: A Shared Responsibility. Teach Learn Med. 2015;27(3):341–345. doi:10.1080/10401334.2015.1044751

7. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim : Care of the Patient. Ann Fam Med. 2014;12(6):573–576. doi:10.1370/afm.1713.Center

8. Morrow E, Call M, Marcus R, Locke A. Focus on the Quadruple Aim: Development of a Resiliency Center to Promote Faculty and Staff Wellness Initiatives. Jt Comm J Qual Patient Saf. 2018;44(5):293–298. doi:10.1016/j.jcjq.2017.11.007

9. Webber S, Babal JC, Shadman KA, Coller RJ, Moreno MA. Exploring academic pediatrician perspectives of factors impacting physician well-being. Acad Pediatr. Published online 2020. doi:10.1016/j.acap.2020.02.018

10. Brunsberg KA, Landrigan CP, Garcia BM, et al. Association of Pediatric Resident Physician Depression and Burnout With Harmful Medical Errors on Inpatient Services. Acad Med. 2019;94(8):1150–1156. doi:10.1097/ACM.0000000000002778

11. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: A prospective longitudinal study. J Am Med Assoc. 2006;296(9):1071–1078. doi:10.1001/jama.296.9.1071

12. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136(5):358–367. doi:10.7326/0003–4819–136–5–200203050–00008

13. Dewa CS, Loong D, Bonato S, Trojanowski L, Rea M. The relationship between resident burnout and safety-related and acceptability-related quality of healthcare: A systematic literature review. BMC Med Educ. 2017;17(1). doi:10.1186/s12909–017–1040-y

14. Nembhard IM, Burns LR, Shortell SM. Responding to Covid-19: Lessons from Management Research. NEJM Catal. Published online 2020. doi:10.1056/CAT.20.0111

15. Majzun R, Idemoto P, Gorman K, et al. Scenario Planning Tools for Children’s Hospital Leaders.; 2021.

16. Day GS, Schoemaker PJ. See Sooner, Act Faster: How Vigilant Leaders Thrive in an Era of Digital Turbulence. The MIT Press; 2019.

17. Stewart MT, Reed S, Reese J, Galligan MM, Mahan JD. Conceptual models for understanding physician burnout, professional fulfillment, and well-being. Curr Probl Pediatr Adolesc Health Care. Published online 2019. doi:10.1016/j.cppeds.2019.100658

18. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177(12):1826–1832. doi:10.1001/jamainternmed.2017.4340

19. Pollock A, Campbell P, Cheyne J, et al. Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review. Cochrane Data. 2020;11(CD013779). doi:10.1002/14651858.CD013779

20. Trockel M, Bohman B, Lesure E, et al. A Brief Instrument to Assess Both Burnout and Professional Fulfillment in Physicians: Reliability and Validity, Including Correlation with Self-Reported Medical Errors, in a Sample of Resident and Practicing Physicians. Acad Psychiatry. 2018;42(1):11–24. doi:10.1007/s40596–017–0849–3

21. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377–1385. doi:10.1001/archinternmed.2012.3199

22. Brown A. Scanning the Periphery [16]. Harv Bus Rev. 2005;83(11):135–148.

23. Receptiviti. Healthcare Workers Wellness Index. Accessed February 12, 2021. https://www.receptiviti.com/healthcare-workers-wellness-index

24. Maaskant JM, Smeulers M, Bosman D, et al. The Trigger Tool as a Method to Measure Harmful Medication Errors in Children. J Patient Saf. 2018;14(2):95–100. doi:10.1097/PTS.0000000000000177

The Need for Adaptive Planning

Uncertainty is at an all time high and disrupting healthcare business models. Adaptive Strategic Planning is a proven and disciplined framework to formulate strategic plans in volatile and complex environments.

Our recent work with boards and leadership teams is focused on future-proofing our clients strategic plans in wake of COVID-19. We use an outside-in view of planning that embraces external uncertainties as a source for superior opportunities and profits.

What is the most significant long-term change to the healthcare industry as a result of COVID-19?

The Evolution of the Patient Experience

Adaptive Strategic's unique approach applies scenario planning and patient journey mapping to surface insights on how to improve the patient experience. Hospital's that are mastering the virtual patient experience are seeing greater levels of community trust, engagement, and wellness visit volumes.

How is your institution’s patient / customer journey evolving to match the needs addressed in the infographic below?

The Burnout Pandemic

We as a society are normalizing the catastrophic impact of burnout on employees. The problem with normalizing employee burnout: it allows for continued employee burnout. Organizations need to recognize that burnout signals can been seen sooner and acted on faster. Leading to not only an improvement in the bottom line, but also a higher quality of life for their workforce. #burnoutprevention #employeewellness