Burnout has long been recognized as an occupational hazard for various people‐oriented professions, such as human services, education, and health care. These jobs require an ongoing and intense level of personal, emotional contact. If you speak to any physician they will likely confirm that although such relationships can be rewarding and engaging, they can also be quite stressful. One cultural aspect of these occupations is that they strive to be selfless and put others' needs first; they tend to work long hours and do whatever it takes to help others; to go the extra mile and to give one's all. This can put significant burden on physicians as work settings also tend to be high in demands and low in resources.

1. ADDRESSING PHYSICIAN BURNOUT:
IS IT THE ENVIRONMENT OR LACK OF
RESILIENCY?
Troy Russell MD, MPH
January 22nd, 2019
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ABOUT THE PRESENTER AND DIRECTED AUDIENCE
I n t r o d u c t i o n t o t h e P r e s e n t e r
Troy Russell MD, MPH
Board certified full-time practicing primary care physician
Assistant medical director in a Federally Qualified Health
Center in Massachusetts
Masters in Public Health in health policy and high performing
health systems
Performed original research and literature review on burnout,
best practices in outpatient clinical workflow and the
contribution from the electronic medical record.
Presentation is based on literature review and guided by the
work of Dr. Christine Sinsky MD
Founder and CEO of Carescribr
C o n f l i c t s o f I n t e r e s t :
*Opinions expressed are my own

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INTRODUCTION TO THE TOPIC OF MEDICAL
PROFESSIONAL BURNOUT
R e s e t t i n g E x p e c t a t i o n s f o r C l i n i c i a n s a n d T e a m s
1Ref

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INTRODUCTION TO THE TOPIC OF MEDICAL
PROFESSIONAL BURNOUT
R e s e t t i n g E x p e c t a t i o n s f o r C l i n i c i a n s a n d T e a m s
Exhaustion, depression and irritability are not normal aspects of
being a physician.
Pushing through feelings of emotional exhaustion does not
define a “good” versus “bad” physician
Reducing clinical hours or quitting medicine is not the only
solution, or even the best one

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INTRODUCTION TO THE TOPIC OF MEDICAL
PROFESSIONAL BURNOUT
D e f i n i t i o n o f B u r n o u t : M a s l a c h a n d J a c k s o n
Maslach Burnout Inventory (MBI) has 22 items
focusing on occupational burnout, and are not specific
to healthcare.
Is Burnout Depression? Normal work distress? It may
be related, but needs to be looked at separately.
Three Defining Dimensions:
Emotional Exhaustion Depersonalization Lack of Personal Accomplishment
2Ref

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INTRODUCTION TO THE TOPIC OF MEDICAL
PROFESSIONAL BURNOUT
P r o f e s s i o n a l D e m o r a l i z a t i o n
Conscientiousness
Compliance
Compartmentalization
01 The influence of physician identity
02 Medicine has baked in stressors, part of the job description
03 Amplified personality traits among physicians

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INTRODUCTION TO THE TOPIC OF MEDICAL
PROFESSIONAL BURNOUT
S u r v e y R e s p o n d e n t s b y S p e c i a l t y
Allergy & Inmmunology 1%
Anesthesiology 6%
Cardiology 4%
Critical Care 1%
Dermatology 2%
Emergency Medicine 5%
Family Medicine 14%
Gastroenterology 2%
Infectious Diseases 1%
Internal Medicine 14%
Nephrology 1%
Neurology 3%
Ob/Gyn 6%
Oncology 3%
Ophthalmology 2%
Orthopedics 3%
Otolaryngology 2%
Pathology 2%
Pediatrics 8%
Physical Medicine & Rehabilitation 2%
Plastic Surgery 1%
Psychiatry 6%
Public Health & Preventive Medicine 1%
Pulmonary Medicine 1%
Radiology 4%
Rheumatology 1%
Surgery, General 3%
Urology 1%
Diabetes & Endocrinology 1%
3Ref

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INTRODUCTION TO THE TOPIC OF MEDICAL
PROFESSIONAL BURNOUT
M e d s c a p e N a t i o n a l P h y s i c i a n B u r n o u t
& D e p r e s s i o n R e p o r t 2 0 1 8
Clinically depressed 3%
Coloquially depressed 12%
Burned out 42%

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INTRODUCTION TO THE TOPIC OF MEDICAL
PROFESSIONAL BURNOUT
W h y D o W e C a r e A b o u t B u r n o u t ?
Clinician Turnover
─ Job dissatisfaction a major reason clinicians leave a practice
Clinical Decision-Making
─ Emotion impacts decision-making
Quality of Care
─ Physicians with burnout have 5-10% higher likelihood of reporting having a
recent major medical error
─ Patients of physicians with burnout less compliant, less satisfied
─ Burnout can impact prescribing quality
Coordination of Care
─ Burnout depletes motivation to communicate with others
─ May impact patient communication

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INTRODUCTION TO THE TOPIC OF MEDICAL
PROFESSIONAL BURNOUT
O n e E x a m p l e : B u r n t O u t P h y s i c i a n s R e d u c e T h e i r H o u r s
& D e c r e a s e A c c e s s
“In summary, the increase in burnout observed in US
physicians between 2011 and 2014 likely translated
into approximately a 1% reduction in the professional
effort of the US physician workforce. This loss is
roughly equivalent to eliminating the graduating
class of 7 US medical schools.”
5Ref

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INTRODUCTION TO THE TOPIC OF MEDICAL
PROFESSIONAL BURNOUT
O n e E x a m p l e : B u r n t O u t P h y s i c i a n s R e d u c e T h e i r H o u r s
& D e c r e a s e A c c e s s
“…Although this approach (reducing clinical hours) may help individual physicians, at
the societal level it has the potential to exacerbate the pending physician workforce
shortage. To preserve adequate access to care, there is a societal imperative to
provide physicians a better option than burning out, working part time, or leaving
the profession.”
MD/DO
(246,090)
NP
(56,000)
PA
(30,000)
If saving just 1 min in documentation per patient (~20 patients a day) results in one additional visit a day…
~330,000 providers x 1 additional visit x 220 work days = 72.6 million additional primary care visit
capacity
Last reported Number of PCPs in 2010:
5Ref

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CONTRIBUTORS TO PHYSICIAN BURNOUT
I s t h e P r o b l e m R e s i l i e n c y o r t h e E n v i r o n m e n t ?
0%
10%
20%
30%
40%
50%
60%
Face Time EHR/Desk Work
Allocation of Physician Time
Office Day
In Exam Room
32 physicians
reported 1 to 2 hours
of after-hours work
each night, mostly for
EHR tasks
6Ref

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CONTRIBUTORS TO PHYSICIAN BURNOUT
L i s t e n i n g t o T h o s e o n t h e F r o n t l i n e
William Osler famously remarked, “Listen to your patients;
they’re telling you their diagnosis.” We also need to listen to
our clinicians.
Elizabeth Métraux
7Ref

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CONTRIBUTORS TO PHYSICIAN BURNOUT
W h o c o n t r i b u t e s t o P h y s i c i a n s ’ B u r n o u t ?
Too many bureaucratic tasks (eg. Charting, paperwork) 56%
Spending too many hours at work 39%
Lack of respect from administrators/employers,
colleagues, or staff 26%
Increasing computerization of practice (EHRs) 24%
Insufficient compensation 24%
Lack of control/Autonomy 21%
Feeling like just a cog in a wheel 20%
Lack of respect from patients 16%
Government regulations 16%
Decreasing reimbursements 15%
Emphasis on profits over patients 15%
Maintenance of Certification requirements 12%

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CONTRIBUTORS TO PHYSICIAN BURNOUT
S i x C o n t e x t u a l F a c t o r s ( - / + ) A s s o c i a t e d w i t h B u r n o u t
01 Workload: amount of work and its spillover
02 Control: opportunity to make choices and decisions
03 Reward: ability to receive recognition and financial rewards
04 Community: quality of social contacts and relationships
05 Fairness: sense that organization is equitable, transparent, consistent
06 Values: consonance between one's personal values and those of the
organization

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CONTRIBUTORS TO PHYSICIAN BURNOUT
Table 1. Time Spent by Family Physicians to Care for Patients, by type of Visit, United States, 2003
Type of Visit % of Total
Visitsa
Mean Length
of Visits
(Minutes) a
% of Clinical
Time
Hours/Week Hours/Day
Acute 49.3 17.3 45.8 18.4 3.7
Chronic 36.1 19.3 37.4 15.0 3.0
Preventive 14.6 21.4 16.8 6.8 1.3
Total or mean 100.0 18.6 100.0 40.2b 8.0
a Data obtained from National Ambulatory Medical Care Survey (9)
b Source: American Academy of Family Physicians (10)
Table 2. Time Required to Meet Current Clinical Guideline Recommendations
Type of Visit Hours/Day Hours/Week % of Clinical Time
Acute 3.7a 18.4 17.0
Chronic 10.6b 53.0 18.9
Preventive 7.4c 37.0 34.1
Total or mean 21.7 108.4 100.0
a Calculated in Table 1
b Source: Østbye et al (8)
c Source: Yamall et al (7)
To fully satisfy the USPSTF
recommendations, 1773
hours of a physician’s annual
time, or 7.4 hours per
working day, is needed for
the provision of preventive
services.
8Ref
9Ref

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CONTRIBUTORS TO PHYSICIAN BURNOUT
M e d s c a p e E H R R e p o r t 2 0 1 6 : P h y s i c i a n R a t e T o p E H R s
48%
54%
64%
71% 71%
17% 15%
12% 10% 10%
36%
31%
24%
19% 19%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Younger than 30 30-45 46-55 56-65 Older than 65
The Effect of EHRs on Workflow, by Physician Age
Slows it down Has No Impact Speeds it up
10Ref

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CONTRIBUTORS TO PHYSICIAN BURNOUT
M e d s c a p e E H R R e p o r t 2 0 1 6 : P h y s i c i a n R a t e T o p E H R s
11%
38% 39%
14%
32%
48%
43%
36%
57%
14%
18%
50%
0%
10%
20%
30%
40%
50%
60%
Amount of face-to-face time
with patients
Management of patient
treatment plans
Ability to respond to patient
issues
Number of patients I can see
EHRs’ Effect on Patient Encounters
Improves No change Got worse

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CONTRIBUTORS TO PHYSICIAN BURNOUT
M e d s c a p e N a t i o n a l P h y s i c i a n B u r n o u t & D e p r e s s i o n R e p o r t 2 0 1 8
38%
48%
0%
10%
20%
30%
40%
50%
60%
Men Women
Are Male or Female Physicians More Burned Out?

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STRATEGIES TO ADDRESS PHYSICIAN BURNOUT
Routine, individualized feedback
on wellbeing gathered in
anonymous, online format
Intervention aimed to leverage
physicians' competitive nature to
improve motivation for change
Nearly half of participants
(n=1000) indicated they were
considering making at least 1 change
to reduce burnout
SELF-ASSESSMENT & FEEDBACK
Reflection: slow down, connect past
and present, question assumptions,
look at multiple perspectives
— Debriefing
• Following adverse medical events
• Within team routinely
REFLECTIVE APPROACHES
11Ref

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STRATEGIES TO ADDRESS PHYSICIAN BURNOUT
S e l f - c a r e = B u r n o u t C u r e ? T h i s i n s u l t s a n d i n f u r i a t e s . . .
“I am not burning out from lack of exercise, eating non-nutritious food, or working long
hours in a stressful environment. I am burning out because I took an oath to give my
patients the best care, to do no harm. Yet, all too often obstacles are placed in the road that
prevents me from doing that...While meditation, yoga and mindfulness training may work
for some (I’m all for easy solutions to complex problems), burnout will never go away
until the root causes are addressed. And who really is going to do that?”
Dr. Linda Girgis MD
Physician blogger at http://drlinda-md.com/
12Ref

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INTRODUCTION TO THE TOPIC OF MEDICAL
PROFESSIONAL BURNOUT
R e s e t t i n g E x p e c t a t i o n s f o r C l i n i c i a n s a n d T e a m s
13Ref

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INTRODUCTION TO THE TOPIC OF MEDICAL
PROFESSIONAL BURNOUT
R e s e t t i n g E x p e c t a t i o n s f o r C l i n i c i a n s a n d T e a m s
14Ref

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STRATEGIES TO ADDRESS PHYSICIAN BURNOUT
T e a m w o r k M a k e s t h e D r e a m W o r k . . .
Ineffective teamwork may be demanding for its members, leading to a higher workload and decreasing well-
being. In contrast, if teamwork quality is high, teamwork may act as a resource, supporting clinicians in
providing safe patient care and increasing their overall well-being.

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15Ref

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STRATEGIES TO ADDRESS PHYSICIAN BURNOUT
P r o b l e m s a n d I n n o v a t i o n s
PROBLEMS INNOVATION
Unplanned visits with overfull agendas • Pre-visit planning
• Pre-appointment laboratory tests
Inadequate support to meet the patient demand for care • Sharing the care
• Expanded nurse or medical assistant rooming protocol
• Standing orders
• Extended responsibility for health coaching, care coordination,
and integrated behavioral health to non-physician members of
the team
• Team responsibility for panel management
Great amounts of time spent documenting and
complying with administrative and regulatory
requirements
• Scribing
• Assistant order entry
• Standardized prescription renewal
Computerized technology that pushes more work to the
physician
• In-box management
• Verbal messaging
Teams that function poorly and complicate rather than
simplify the work
• Improving team communication through
 Co-location
 Huddles
 Regular team meetings
• Improving team functioning
 Systems planning
 Work flow mapping
*These roles require 2- or 3-to-1 clinical support per physician.

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STRATEGIES TO ADDRESS PHYSICIAN BURNOUT
S c r i b e s i n M u l t i p l e S e t t i n g s
Two of 3 studies reported scribes had no effect on patient satisfaction; 2
of 2 reported improved clinician satisfaction; 2 of 3 reported an increase
in the number of patients; 2 of 2 reported an increase in the number of
relative value units (RVUs) per hour; 1 of 1 reported increased revenue; 3
of 4 reported improved time-related efficiencies; and 1 of 1 reported
improved patient–clinician interactions.
16Ref

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17Ref

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STRATEGIES TO ADDRESS PHYSICIAN BURNOUT
I m p a c t o f S c r i b e s o n P h y s i c i a n S a t i s f a c t i o n , P a t i e n t S a t i s f a c t i o n ,
a n d C h a r t i n g E f f i c i e n c y : A R a n d o m i z e d C o n t r o l l e d T r i a l
When working with a scribe, physicians were much more satisfied with how
their clinic went, the length of time they spent face-to-face with patients, and
the time they spent charting. These findings suggest that scribes may have a
protective effect on physicians’ well-being. Implementation of team
documentation is an important component of achieving the Quadruple Aim, a
patient-centered approach to care that also emphasizes improving the work life
of physicians. Spending less time on documentation frees up the physician to
pursue direct clinical care and care coordination, thus enhancing joy of
practice and preventing burnout. In academic centers, scribes provide faculty
physicians more time to teach medical students and residents.
17Ref

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CONCLUSIONS
Self-Assessment and Feedback
Environmental Factors
○ Workflows
○ Teamwork
○ Adequate and Properly Allocated Resources
Carescribr Presentation Series

31. LEARN MORE
31
Visit our website to find out more about Carescribr
Follow us @MyCarescribr on Facebook and LinkedIn
Contact me directly at trussell@carescribr.com
T H A N K Y O U !

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REFERENCES
1) https://www.bostonglobe.com/metro/2019/01/17/report-raises-alarm-about-physician-
burnout/9CGdUc0eEOnobtSUiX5EIK/story.html
2) https://www.tandfonline.com/doi/full/10.1080/0142159X.2016.1248918
3) https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235
4) Potential Impact of Burnout on the US Physician Workforce. Mayo Clin Proc. November
2016;91(11):1667-1672
5) https://www.mayoclinicproceedings.org/article/S0025-6196(16)30508-0/pdf
6) Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties; Ann
Intern Med. doi:10.7326/M16-0961
7) https://medium.com/s/story/we-cant-fix-the-problem-of-physician-burnout-until-we-address-the-
problem-of-american-neglect-65744b9d7d03
8) Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for
prevention?. Am J Public Health. 2003;93(4):635-41.
9) Yarnall KSH, Østbye T, Krause KM, Pollak KI, Gradison M, Michener JL. Family physicians as team leaders:
“time” to share the care. Prev Chronic Dis 2009;6(2):A59. http://www.cdc.gov/pcd/
issues/2009/apr/08_0023.htm.
10) https://www.medscape.com/features/slideshow/public/ehr2016
11) http://pediatrics.aappublications.org/content/116/6/1546

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REFERENCES
12) https://www.kevinmd.com/blog/2018/12/solving-physician-burnout-requires-so-much-more-than-self-
care.html
13) https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers
14) https://www.aafp.org/news/practice-professional-issues/20190116ehrstudy.html
15) http://www.annfammed.org/content/11/3/272.full
16) The Use of Medical Scribes in Health Care Settings: A Systematic Review and Future Directions.
Cameron G. Shultz and Heather L. Holmstrom. J Am Board Fam Med May 2015, 28 (3) 371-381; DOI:
https://doi.org/10.3122/jabfm.2015.03.140224
17) http://www.annfammed.org/content/15/5/427.full
Special recognition goes to Dr. Elizabeth Bromley, MD, PhD and
her presentation on this topic. Slides 4-6 draw from her grand
rounds talk at UCLA (https://youtu.be/P4ETqcPIwi0).