Introductory Chapter: Enhancing Physician Wellness to Prevent Burnout Promotes Clinician and Patient Safety

Abstract

Patient safety is central to modern healthcare delivery systems, with ever increasing focus on delivering the best possible, safest care, at cost levels that are both reasonable and sustainable.(1) In this third installment of Contemporary Issues in Patient Safety, we explore a host of interconnected topics that directly and indirectly affect the value- and safety-driven, patient-centric dynamic of today. Among the various topics explored in this book, provider burnout as a contributor to medical and surgical error deserves a much closer examination. The Editors would like to devote this Introductory Chapter to burnout, its insidious nature, as well as the need for recognition and prompt management.

’Iατρέ, θεράπευσον σεαυτόν (Physician heal thyself) Ancient Greek Proverb.

1. Introduction and objectives

Patient safety is central to modern healthcare delivery systems, with ever increasing focus on delivering the best possible, safest care, at cost levels that are both reasonable and sustainable [1]. In this third installment of Contemporary Issues in Patient Safety, we explore a host of interconnected topics that directly and indirectly affect the value- and safety-driven, patient-centric dynamic of today. Among the various topics explored in this book, provider burnout as a contributor to medical and surgical error deserves a much closer examination. The Editors would like to devote this Introductory Chapter to burnout, its insidious nature, as well as the need for recognition and prompt management.

2. Focus on provider burnout

Physician burnout has a major impact on patient safety, patient satisfaction, and healthcare outcomes. Physician burnout also has major implications for physician job satisfaction, longevity, and wellbeing. Data and information for this exploratory review was obtained via literature search that included PubMed, Medline, and Google Scholar. Fatigue, especially when working in intense clinical environments, prolonged shifts, and overnight shifts plays a major role in inducing burnout with resultant increases in medical errors, worse patient outcomes, and patient dissatisfaction with healthcare providers. Multiple strategies have been implemented to prevent and treat burnout including limiting work hours, incorporating sleep and exercise into shiftwork, and engaging physician providers in administrative decision making.

Health professionals including physicians have reported high levels of emotional and physical burnout induced by a combination of factors including fatigue from extreme work hours, excessive overnight shift work, increasing amounts of administrative work, pandemic induced stress, and exposure to workplace violence [2]. Physician burnout affects healthcare delivery by directly and indirectly impacting patient safety, patient outcomes, patient experience, and our overall ability to deliver effective and safe care throughout hospital networks. Burnout syndrome results from extreme professional demands, depersonalization in the work environment, excessive fatigue, and psychiatric depression, all of which combine to impair work performance and result in dissatisfaction in both personal and professional spheres [3, 4, 5]. Physician burnout results in a loss of sense of mission, diminished self-esteem, and progressive lack of enthusiasm, affecting one’s ability to provide their best effort for patients [6].

Physician burnout commonly manifests as emotional lassitude, loss of empathy, depression, and feelings of lack of personal accomplishment [7, 8]. It tends to be a progressive and insidious process, often difficult to detect in its earlier and intermediate phases, and quite frequently does not manifest overtly until it is quite advanced [9, 10]. Clinician burnout impacts physicians’ professionalism and effective communication with other providers [8]. Burnout does not appear to be related to number of years worked; medical students, physicians in training, and experienced attending physicians alike note emotional burnout, with emergency physicians reporting the highest levels among all specialties of up to 70% of practitioners [3, 9, 11]. Burnout impairs hampers compassionate communications with patients, lowers patient satisfaction, increases door-to-doctor waiting periods resulting in decreased number of patients seen per hour in the emergency department and other outpatient settings, and increases the odds of job dissatisfaction [3, 7, 12]. All these factors related to burnout impair work productivity and efficiency, increases the likelihood of safety accidents, exacerbates personal relationship difficulties of clinicians, increases readmission rates, and jeopardizes the overall safety and quality of health care provided [12, 13, 14]. In the current book, significant focus is placed on the phenomenon of physician burnout, various associated risk factors, as well as an in-depth discussion on the impact of physician burnout on patient safety and outcomes. Finally, we discuss different options for resolving and preventing burnout.

Many elements contribute to physician burnout including work induced anxiety, shift duration, excessive work hours especially hours worked overnight and during holidays, patient illness severity, number of patients cared for, excessive administrative responsibilities, frustration about the inability to address patients’ needs, and inadequate clinical and emotional support in the workplace (See Figure 1) [5, 6]. Research has demonstrated the correlation of exhaustion and depression to independently and in combination provoke the likelihood that physicians in training will perceive that they have committed medical errors [15]. Public health crises such as the Covid epidemic from 2020 to 2022 place stress on the clinical work force, including physicians and nurses. Nearly 20% of 9300 surveyed physicians and 40% of surveyed nurses in a Coping with COVID questionnaire noted that they had considered retirement from medical practice because of the challenges of the COVID epidemic in addition to those of their typical practice environment [16].

Figure 1.

Factors contributing to physician burnout.

Round the clock, 24-hour per day, shift-based work schedules necessitate that some healthcare personnel will work during individual circadian nadirs overnight and provoke fatigue [17]. Prior research indicates weariness and torpor most frequently and prominently manifest at 4 AM for shift workers, consistent with the notion that circadian rhythms of nocturnal workers impact fatigue along with shift duration [18]. Sleep deprivation hampers motor coordination, emotional IQ , and most importantly, reasoning cognition which combined result in inferior clinical performance [19, 20]. Exhaustion impairs reasoning comparable to alcohol intoxication; specifically, research has demonstrated that mental capacity deteriorates following 17-hours of intense cognition and wakefulness mimicking the impact of blood alcohol concentrations of 50 mg/dL [21]. The odds of reporting at least one fatigue related clinically significant medical miscue impacting patient safety and outcomes accrues by a factor of eight during months in which residents work five or more overnight shifts, in comparison to months in which they do not work overnight [22]. The relationship between onerous working hours, especially hours worked overnight, resulting in mental and physical exhaustion have disproportionately impacted physicians in training since the development of the residency training system decades ago [23]. In addition to impairing job performance and productivity, exhaustion escalates the risk of personal accidents and injuries of clinicians outside the hospital [23, 24]. Burnout is further exacerbated by the acuity and intensity of the clinical environment most notably emergency departments and critical care units during overnight shifts [25]. Job related burnout places the clinicians themselves at risk psychological, personal, and physical impairment (See Figure 2) [24]. Mental and physical fatigue increases the likelihood of occupational injuries in the work place such as body fluid exposures and motor vehicle accidents during transit home after long and/or overnight shifts [17].

Figure 2.

Impact of physician burnout.

In addition to the challenges of providing their patients with quality medical care through continuously enhancing their scientific knowledge and compassion, clinicians’ ever expanding workplace responsibilities include but are not limited to maintenance of numerous certifications related to their specialties, incorporation of the complexities of new electronic health records, adhering increasingly stringent and complex regulatory guidelines, medical cost analysis, patient perceptions of satisfaction of medical care provided (Press Ganey scores), and undergoing progressively more stringent degrees of scrutiny related to adherence to quality of care metrics [4]. These factors individually and in combination impact the quality of patient care, physician productivity, physician retention within healthcare networks, income, mental duress, and contribute to burnout [8, 21]. Organizational challenges such as self-aggrandizing leadership conduct, unrealistic work load demands, inadequate allocation of resources in the clinical arena, substandard rewards, antagonistic interpersonal interactions, and insufficient opportunities for career advancement contribute to clinician dissatisfaction and erodes clinician morale [5]. Workplace and leadership inadequacy resulting in an inability to provide adequate, safe standards of care can be profoundly discouraging to physicians struggling to provide high quality, safe healthcare [12].

Recognizing the relationship between physician wellness and the safe, efficient functioning of healthcare organizations represents a crucial first step in confronting static health care workplace customs and culture that has heretofore been too reliant on physical stamina of the clinical workforce [16]. Medical staff including physicians must be part of a screening process for detection of burnout. A component of building a multimodal culture of wellness and healing to allay the development of burnout involves creating a culture in which healthcare providers can safely report mental anguish including feelings of burnout and have adequate access mental health care [6, 16]. Promoting physicians self-care can incorporate management of stress via mindfulness, talk therapy, physical activity, and meditation [8, 16, 22]. The Maslach Burnout Inventory (MBI), a self-reporting questionnaire for burnout screens three domains: emotional exhaustion, depersonalization, and depressed self-esteem [8]. Alternatively, the American Medical Association endorses the 10-item Zero Burnout Program for screening for emotional exhaustion [22], and has advocated for its five step process (research, measure, act, recognize, convene) to help guide physicians, care teams, and health system leaders on putting tactics and strategies to enhance practice productiveness, promote professional well-being, and move beyond burnout [8]. US governmental agencies including the US Surgeon General, the Centers for Disease Control and Prevention, the National Institute for Occupational Safety and Health have promoted efforts to support healthcare worker cognitive health and wellness [16].

Once burnout has been identified, expert opinion has advocated for a multifaceted strategy for treatment and deterrence utilizing individual and administrative tactics and strategies [8]. Documented correlations between burnout, exhaustion, and patient safety prompted the Institute of Medicine to recommend modifying physician trainee work hours to enhance wellness by decreasing shift duration, limiting incidence of overnight shifts, and safeguarding time off duty [11]. Brief naps during overnight shifts have correlated with enhanced wakefulness, comprehension, and recollection during overnight shifts especially in patient intense environments such as the intensive care unit and the emergency department [18]. Brief periods of exercise during shiftwork, especially overnight shifts, has correlated with improvement clinicians’ mood and cognitive functioning [26]. Sage clinical leadership will incorporate medical staff’s recommendations regarding reasonable workloads and in departmental functioning to enhance the clinicians’ sense of support and team building thereby combating medical errors and improving clinical performance [14]. Encouraging mindfulness and team building, such as the patient-centered medical home provide physicians with emotional support and mentoring [22]. The medical home is a team focused healthcare administrative paradigm to provide comprehensive patient care through enhancing collaborative efforts. Colleagues, peers, and mentors provide role models and leadership to colleagues on how to prevent burnout and provide emotional support in the workplace to overcome work induced anxieties and depression [8].

3. Future directions

One of the challenges in assessing the impact of clinician burnout on patient safety is that much of the current research consists of subjective observational data and self-reported safety outcomes. Future investigations must focus on accounting for discrepancies between clinicians’ perceptions of practice safety and quality in contrast to genuine objective assessment. Furthermore, scientific evaluation must examine the complex connections between clinicians and their working environments to further assess the relationship between burnout and patient safety [12]. Health worker burnout is not limited to individual physicians but also affects nurses, pharmacists, and other health professionals; because of its impact on health workers, it has the potential to impact the nation’s health and economic security [6].

4. Conclusions

To address the growing recognition that physician welfare is an essential element of high-quality healthcare, methods and research must address physician and system level identification of, prevention of, and treatment of burnout [11]. Part of physician training and maintenance of certification must incorporate education about preventative techniques against emotional and physical exhaustion for individual physicians. On network and system levels, administrative and leadership management must strive to balance the needs of patients and physicians ensuring that clinicians are not overburdened in providing their best care, providing proper work and emotional support, ensuring quality interactions between providers, and support for providers in distress. Governmental and regulatory agencies can contribute meaningfully by providing regulations and standards to ensure both patient safety and prevention of excessive clinician responsibilities resulting in burnout.