There is a way to reduce physician burnout. Health care organizations can use a framework that deconstructs the different sources of stress and rewards in the lives of clinicians and that guides strategies for improving the balance. The key is to understand the difference between stresses and rewards that are inherent to caregiving and those that are external to it, deriving from the work environment. These distinct sources warrant different responses; conflating them can frustrate clinicians and worsen the problem.
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Sometimes the endless discussion about burnout in health care creates its own form of burnout — a sense of hopelessness about being able to stop an epidemic. But there is a way to counter burnout. Health care organizations can use a framework that deconstructs the different sources of stress and rewards in the lives of clinicians and that guides strategies for improving the balance. These distinct sources warrant different responses; conflating them can frustrate clinicians and worsen the problem.
The framework divides sources of stress and rewards into two types: those that are inherent to caring for suffering patients and those that are external to this, coming from the environment clinicians work within. This perspective on clinician burnout aligns with the framework for reducing patient suffering previously described by my colleagues and me. That framework distinguishes suffering directly caused by disease (for example, the symptoms and fear associated with a serious diagnosis) from suffering caused by dysfunction of the health care delivery system (for example, the anxiety caused by poor coordination). The goal of clinicians and their organizations is to mitigate suffering inherent to patients’ conditions and to prevent suffering caused by the dysfunction of the external delivery system.
Inherent Stresses and Rewards
For clinicians, the role of caregiver is a constant source of both rewards and stresses; these are inextricably intertwined, so much so that to remove one would be to change the nature of the clinical role. Taking care of suffering patients is emotionally draining and demanding physically and intellectually — but this is why clinicians command so much respect from their families, friends, and society. The pressure of making life-and-death decisions with imperfect data is intense, but the exhilaration of making the right decision, or performing a procedure well, or even just knowing that the patients’ outcome could not have been better — these are deeply satisfying experiences that are difficult to separate from those pressures.
Because these inherent stresses and rewards are intertwined, simply trying to eliminate the stressors is not realistic. However, leadership can work to reduce the impact of this stress and amplify the rewards. Feedback that lets clinicians know others appreciate it when they deliver care with empathy, coordinate their efforts with others, and communicate effectively with patients is positive reinforcement that can help clinicians put the stresses of their roles in perspective. Creating a team culture around clinicians can remind them that they are not alone and give them a group of peers whose respect they deeply value and whom they do not want to disappoint.
External Stresses and Rewards
Unfortunately, the health care environment adds stresses and rewards that are external to the care of patients and that demand a qualitatively different response. Many of these stresses are related to financing health care and regulating its quality (for example, data must be painstakingly collected to process payments or track clinical performance). Much of this data is collected through electronic medical records (EMRs), which is efficient for data gathering but not always for patient care, making the EMR a focus of resentment. Beyond this documentation burden, the modern work environment requires interaction with severalfold more personnel than a generation ago, which multiplies the opportunities for poor management, suboptimal teamwork, disruptive peer behavior, bullying, and a toxic culture. Ironically, although more clinicians may interact to care for each patient, having enough staff in each role remains a concern that contributes to the stress of the environment.
Unlike the stress embedded in the clinical role, the negatives from the environment are not directly tied to rewards with a deeper meaning. As a result, even if these external stresses are part of the process that creates income for clinicians, they are considered frustrations and barriers that get in the way of patient care and clinicians’ engagement. These are the issues that make clinicians say I did not sign up for this.
For such external sources of distress, stress-reduction techniques can help in the short term. But the long-term plan should be to reduce and prevent organizational dysfunction rather than to expect individuals to simply be more resilient. To suggest that burnout due to overwhelming external stresses is an individual problem and to try to address it with interventions solely targeted at individuals will only increase discontent.
Measuring What Matters
The good news is that it’s possible to measure and understand these different sources of reward and stress. Leadership needs to be aware of the inherent and external sources it can’t influence (such as the limitations of medicine), while also focusing on the sources it can affect, such as making sure clinicians feel appreciated and have the resources they need. The table below describes examples of measures that can be used to assess internal rewards and external stresses.
Separating out the impact of inherent and external stresses ensures that leadership doesn’t confuse or ignore the different sources of distress. Both have bearing on the likelihood of burnout — or recovery from it — but must be approached differently. Leadership needs a comprehensive strategy with interventions designed to reduce the friction of a suboptimal work environment, support coping with the tough but meaningful work, and reinforce the meaning and purpose experienced by clinicians.
To address burnout, leadership must consciously distinguish between inherent and external stress and rewards and manage each appropriately.
On the inherent side, it’s critical to promote engagement and help clinicians find balance in caring for patients. This begins by amplifying the inherent rewards of their important role by, for example, emphasizing the goal of reducing patient suffering and recognizing clinicians’ efforts and successes to that end. At the same time, it’s important to mitigate the impact of the inherent stress of the clinical role, acknowledging how hard the work is and offering support and resources to manage these stressors. For example, debriefing clinicians after the death of a patient and providing ongoing support in dealing with loss helps in processing the emotional toll of patient care. The resilience created by helping clinicians cope with inherent stress is transformative and strengthens commitment. This resilience allows them to face overwhelming burdens yet remain engaged instead of experiencing burnout.
Addressing external stress and rewards requires real efforts to reduce dysfunction in the environment and optimize the process of providing care. This includes promoting resilience and wellness to help clinicians cope with the intensity and volume of their work, but it also means making tangible progress in reducing the negatives in the work environment that lead to burnout. Among the most important efforts are, first, designing high-functioning teams and processes that allow each member to work at the top of their license, and second, increasing the efficiency and use of EMRs so that clinicians can spend more time interacting with patients. If external stressors become overwhelming, no amount of inherent reward can counterbalance them.
Pursuing both of these paths requires hard work, and following either alone is unlikely to be effective or well-received by clinicians. Success will lie in acknowledging the very different but complementary work streams that will remove the barriers in the environment and enhance the reward inherent to being a successful caregiver. Organizations that strike the right balance between stress and reward can expect their clinicians to feel pride about their work for the organization, a ready willingness to recommend the organization to others, and an intent to continue there for many years.
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