Burnout: Measurement Tool(s), Cause(s) and Impact(s)

by Kay Miller Temple, MD

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Physician Burnout: Definition(s), Cause(s), Impact(s), Solution(s)

Burnout. Defined by the World Health Organization (WHO) as "phenomena in the occupational context and should not be applied to describe experiences in other areas of life." Many researchers agree that it's a job-related stress issue, but they also add that it results in "emotional exhaustion, depersonalization, and reduced personal accomplishment."

Christina Maslach and Michael Leiter, two of the original researchers on the topic in the late 1990s, revisited burnout several years ago. They provided the reminder that, again, burnout is an "occupational hazard" for many workers in people-oriented professions. They reviewed the three key elements of burnout: "overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment." Created from their original research, the Maslach Burnout Inventory (MBI) is now a standard measurement tool specifically measuring emotional exhaustion, depersonalization, and personal accomplishment. A sample question from the tool that records a response on a 0-6 scale of "never" to "every day" is this: "I don't really care what happens to some patients." Additional measurement tools have also been created and researchers have validated shorter assessments, asking questions like, "I feel burned out from my work" and "I have become more callous toward people since I took this job."

Burnout: Cause(s)

The opening paragraph of a recent article on burnout statistics summarized the potential causes of physician burnout:

"The past decade has been a time of tremendous change in the US health care system. Consolidations and mergers have substantively altered practice structure, with a majority of physicians now in employed practice models. Health care regulations and policies, including the Affordable Care Act, Meaningful Use, and the Medicare Access and CHIP Reauthorization Act of 2015 have transformed the day-to-day work of US physicians. Widespread penetration of electronic health records (EHRs) has increased administrative burden and led to decreased physician face time with patients. The average physician now spends roughly half of their workday and an additional 28 hours per month on nights and weekends completing EHR tasks. To the dismay of many physicians, measures of administrative efficiency (eg, how quickly in-box messages are answered or charts closed for billing purposes), imperfect patient satisfaction measures, and productivity metrics (eg, relative value unit generation) have reshaped how many organizations define what it means to be a 'good doctor.'"

In other words, research indicates that burnout is related to increased workloads necessary to maintain profit margins and government regulations along with insurance-driven requirements. Since many of those documentation burdens take place on the "front lines," administrative teams find themselves asking their physician workforce to capture everything for the associated essential elements in the electronic health record (EHR), an information structure that many experts argue was built to address regulatory and billing needs rather than built to meet clinical practice needs and usability for both providers and patients.

In a 2018 commentary in the Annals of Internal Medicine, researchers from several high-profile healthcare organizations provided additional comment on burnout as a result of the extensive physician-dependent EHR documentation connected with value-based billing. The authors summarized their perspective linking the EHR clerical data entry burden with burnout: "The nation's shift toward value-based care is welcome, but physician burnout is also a critical priority—we risk losing many physicians if the root causes are not addressed."

What Does Burnout Look Like Among Rural Providers?

Because of recognized health disparities, are there differences in the well-being of clinicians who care for the rural patient, repeatedly described as older, sicker, poorer, and living in resource- and geographically-challenged regions of America? Does burnout look different in rural areas?

A comparison perhaps best starts with looking at burnout in both the general population of workers and the national measures of physician burnout. In September 2019, researchers who've successively investigated burnout reported their findings for the general population and found that burnout was 28.6 % in 2011, 28.4% in 2014 and 28.1% in 2017. In comparison, physician burnout was 45.5% in 2011, 54.4% in 2014, and 42.7% in 2017.

Though research design and small numbers of respondents prevent a direct comparison, some of the available research allows a snapshot into the world of burnout for rural healthcare providers, showing burnout is present in similar or even greater numbers.

• Rural physician assistants
  In a 2016 paper, researchers used the Maslach Burnout Inventory (MBI) — which measures emotional exhaustion, depersonalization, and personal accomplishment — to assess prevalence and cause of burnout in the 160 respondents of nearly 1,400 rural physician assistants surveyed. Sixty-four percent of respondents noted emotional exhaustion, the same percentage noted depersonalization, and 46% noted low to moderate feelings of personal accomplishment. Causes for burnout were noted as lack of administrative support, more nursing home attendance, house calls, night call, and personnel management duties. Professional isolation ranked as more problematic than geographic isolation.
   
• An academic rural Kansas community
  Survey results published in 2019 looked at the issue in the Salina, Kansas medical community, home to KU School of Medicine Salina Campus. Investigators looked at both burnout associated with a rural practice and the association of burnout related to teaching medical students. Using an abbreviated MBI, investigators received responses from over half of the invited respondents. The top three contributors to burnout were negative feelings about administrators, encounters with difficult patients, and documentation requirements. Regarding burnout measures associated with teaching duties, the report noted, "Physicians in the high teaching category (a derived score from contact time with both medical students and residents) had higher median values for EE [emotional exhaustion] and D [depersonalization] compared with physicians with low or no teaching responsibilities." However, the survey also found that physicians working with medical students "had significantly higher PA [personal accomplishment] scores than those who did not teach medical students."
   
• Rural clinic sampling
  Burnout data directly associated with rural family medicine physicians are scarce, if not nonexistent. However, it might be possible to extrapolate a sense of burnout from a 2019 study by Kentucky researchers looking at the specialty's burnout in relationship to practice type. Combining responses of Rural Health Clinics, Indian Health Clinics, and non-federal government clinics, investigators found that around 41% of respondents indicated burnout — with an almost identical level found for Federally Qualified Health Clinic-employed physicians. The study's final results revealed that "for all practice types, a practice environment that increases physician stress with poor control over workload, conflicting values with leadership, and arduous documentation burdens predicted burnout."

In summary, the available rural research hints that burnout for rural providers might be similar or greater than the magnitude noted in the overall statistics for the nation's providers. Rural burnout triggers also seem to mirror national findings: heavy workload, administrator conflict, administrative duties, and documentation duties.

Burnout: Significant Impact(s)

A landmark paper in 2017 outlined the business side of physician burnout by first reflecting on turnover and lost productivity costs, followed by a consideration of costs associated with its impact on quality, safety, and patient satisfaction. The researchers' explanation starts with a clear statement regarding the root cause of burnout.

"Burnout is primarily a system-level problem driven by excess job demands and inadequate resources and support, not an individual problem triggered by personal limitations,^" the authors said.

Turnover and Productivity Costs

Because robust research proves that burnout triggers physicians to leave their organizations, the investigators went on to share that past studies suggested the costs to replace a physician is two to three times the physician's annual salary. At the time of the article's publication, recruiting costs alone were upwards to $88,000.

In addition to recruitment costs, the researchers pointed out several impacts on revenue due to provider turnover. The first is obvious: no provider, no revenue production during the interval required to find a replacement. Second, productivity of the remaining healthcare team members decreases as they attempt to absorb the duties of the separated individual, a situation that also contributes to burnout. Last, revenue is also lost during the time for the new recruit's onboarding process until they're proficient with patient care processes in their new practice setting.

The authors also noted research that demonstrated how burnout influences productivity in both salaried and productivity-based employment models. Salaried physicians often request a lower workload, for example, decreasing their time equivalent from full-time to half-time work. For productivity-based physicians, a common decision was to see fewer patients: for example, 18 patients rather than 25 patients per day. The authors pointed out that decreases in both models translated to fewer surgeries, fewer imaging studies, and other revenue-generating interventions.

Though not related to revenue generation, other experts noted that though productivity decreased in these models, usually the benefit packages for these physicians stayed the same, often a significant fixed cost for their organizations.

"Due to the high fixed costs of many health care organizations, even a small change (eg, 1%-2%) in productivity can have large effects on an organization's bottom line," the researchers stated.

Though research seems to be absent on these issues in rural areas, other experts suggested these turnover costs might have even more impact in view of clinician recruitment challenges as almost a norm and the narrow profit margins of hospitals and clinics.

Quality and Safety

While experts have pointed to potential direct and indirect costs of financial penalties associated with subpar quality metrics, the 2017 report highlighted how burnout's relationship to quality, safety, and patient satisfaction are linked to additional costs: for example, litigation and patient injury costs related to the increased rate of medical errors by burned-out residents and physicians. Additionally, these researchers also mentioned the domino effect within a healthcare team when one burned-out provider can cause "an erosion of teamwork over the next 9 months and resulted in decreased patient safety both directly as well as indirectly through its impact on team-based care."