The Triple Aim, which should now be well-known to our readers, includes the triple goals of improving the health of the population, reducing per-capita costs by reducing waste, and improving the individual experience of care.1 The Triple Aim has since morphed into the “Quadruple Aim,” with the addition of the fourth goal of reducing physician burnout.
A recent article places the economic cost of burnout at approximately $4.6 billion annually.2 This has now caught the attention of chief financial officers and other financers of healthcare. The cost of physician burnout, which is expressed typically by high rates of physician turnover and a reduction in clinical hours, hides the additional cost of an increased probability of committing a medical error. We now have a solid evidentiary base that links burnout to uncivil (ie, rude) behavior, which, in turn, raises the probability of error and irreparable harm.3
What more do we need from a policy perspective to refocus our energies in 2020 and find ways to reduce physician burnout? I don’t think our readers need a detailed review of the etiology of burnout. It is of course, multifactorial.4,5
Many physicians today believe that as providers join large corporate delivery systems, their autonomy may be reduced, and they may not always be treated as respectfully as they were in the past. The burden of managing the electronic health record, with many hours spent in front of a screen rather than in front of a patient, has also been suggested as part of the etiology of burnout. Finally, the proliferation of quality metrics, many of which may be of modest value, has added additional burden to the daily life of physicians, especially our primary care colleagues.3,4,6
With all this as background, I was surprised to stumble across a fascinating report published in 2019, titled “Physicians Still Miserable: Seven Solutions to Address Burnout: What Physicians Want Their Employers To Do,”6 that I’d like to summarize here. The report is from Geneia, a consulting company that is a privately held, wholly owned subsidiary of Capital Blue Cross, headquartered in Harrisburg, PA. Geneia’s core mission is to help its clients succeed in value-based care.
This focus on value-based care right away piqued my interest, because the company’s mission is aligned with the content of several of my past editorials in American Health & Drug Benefits, including “No Outcome, No Income” and “The Dream of Value-Based Care.”7,8
The consultants at Geneia have previously created what they call the Physician Misery Index. The index debuted in January 2015, and was then used in the company’s 2018 survey discussed in this report.6 As the company admits, there is no peer-reviewed evidence with regard to the research reliability and validity of said index, but Geneia believes that this self-assessment tool, with its 6 key factors, such as “I frequently feel rushed when seeing patients,” is reproducible over time.6
The report and the survey results are fascinating.6 A total of 66% of all the (more than 400) physicians surveyed have noted that they had considered a different career option outside of clinical practice, representing an increase of 11% since the company’s 2015 survey.6 Of the physicians in corporate- or hospital-owned entities, 73% report that they are considering a different career option compared with 60% of doctors who are in physician-owned organizations. In other words, the few remaining independent doctors are, at least according to this report, less dissatisfied than physicians in corporate- or hospital-owned organizations.6
What I especially enjoyed about this report was its focus on potential solutions for physicians. The key potential solutions offered by this report, based on the national survey of physicians, are6:
- Asking healthcare organizations to allocate more time for patient visits
- Providing scribes, especially to primary care doctors, to decrease the burden of the electronic health records
- Pushing US corporate leaders to create a culture of well-being among employees
- Providing access to leadership development and mentoring programs
Although each of these major solutions deserves more detailed commentary, solution number 4 especially resonates with me. Specifically, 86% of all doctors who responded to the survey noted that leadership development, and the ability to connect to a mentoring program, were their top priorities, because they relate to reducing physician burnout. When further broken down along age-related lines, doctors younger than age 50 years and those aged 50 or older ranked the ability to garner continuing medical education credits as a top priority, with a change of leadership and management as their second priority.6
Having spent decades at Jefferson working to develop, implement, and disseminate leadership development programs for physicians, I was heartened to note that so many of my colleagues felt that this was, if you would, part of the perceived road to redemption. You may ask—how does one obtain survey data from doctors about burnout, and will they answer surveys honestly and in a timely and forthright manner? In this survey, Geneia has considered this issue and has asked doctors what would stimulate them to give honest feedback.
The physicians in this survey noted that they were more likely to complete a survey when organizations provided examples of positive changes made as a result of previous surveys.6 I view this through the lens of performance improvement. In other words, when you close the feedback loop in a nonpunitive way and with local peer support, most physicians want to make positive changes when they relate to improving care for their patients.
For me, the clear take-home message here is the need to allocate resources to support leadership development and mentoring programs for physicians. We do not want our colleagues to necessarily completely change careers, but we do want them to obtain additional skills so they can sit at the organizational table and participate in important conversations about how to succeed in value-based care, which, again, is Geneia’s core mission.
At the end of the day, should we bring back the doctors’ lounge as a way to reduce physician burnout? Personally, I don’t think that this is the answer. More resources and programs devoted to training doctor leaders are of much more value than free hospital coffee.
The road from volume to value is clearly bumpy and is filled with potholes and dangerous turns. To navigate this road, we need better-prepared physician leaders who can mentor their colleagues, reduce burnout, decrease harm, and help us deliver care that is safe and of high value.
David B. Nash, MD, MBA, is Editor-in-Chief, American Health & Drug Benefits, Founding Dean Emeritus, Jefferson College of Population Health, Philadelphia, PA.
- Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Aff (Millwood). 2008;27:759-769.
- Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. 2019;170:784-790.
- Katz D, Blasius K, Isaak R, et al. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ Qual Saf. 2019;28:750-757.
- Weeks WB. Physician burnout—overdiagnosis and unproven interventions [Letters]. JAMA Intern Med. 2018;178:576-577.
- Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177:1826-1832.
- Geneia. Physicians Still Miserable: Seven Solutions to Address Burnout: What Physicians Want Their Employers To Do. Harrisburg, PA: 2019. https://content.geneia.com/2019/seven-ways-to-remedy-burnout/index.html. Accessed January 30, 2020.
- Nash DB. No outcome, no income. Am Health Drug Benefits. 2019;12(6):274-275.
- Nash DB. The dream of value-based care. Am Health Drug Benefits. 2017;10(1):5-6.