By Christopher Colenda, MD, MPH, DLFAPA
On his 55th birthday, Alton went to work as usual. The Chief Medical Officer of a large academic medical center, Alton had led an exceptional life, rising from industrial Midwest origins through college, medical school, residency, fellowship, faculty appointment and a succession of administrative posts. He was an accomplished faculty member and researcher – a sort of Horatio Alger as an academic physician.
On this day he arrived and, instead of going to his office, walked to facility’s “Wellness Center” and asked to see the new Chief Wellness Officer. “I’m done,” he said. “I can’t do it any more.”
This scenario might seem a little dramatic, but it is not all that unheard of in academic medicine today. Good physicians and administrators are struggling or calling it quits, for a variety of reasons that are often collected under the “burnout” umbrella. Alton, and others like him, struggle with their emotional capacity to manage stress. We know this is an issue with physicians and caregivers in general, and in my view the problem is heightened within academic medicine.
Non-patient Activities as an Occupational Hazard
Those in crisis often say, “I don’t understand what’s happening to me. I manage these problems every day. Why is today different?” Burnout is an occupational stress hazard that is commonly defined in terms of emotional exhaustion, depersonalization and low sense of personal accomplishment. It is linked, unfortunately, to a number of adverse outcomes in the clinical environment such as lapses in professionalism, poor work performance, depression, substance abuse, medical errors and suicidality. [See references 1-5, among others.]
Originally thought to reflect the interpersonal stresses experienced by healthcare professionals who were engaged in patient care, more recent thinking attributes the condition to increases in non-patient related activities. These include perceived loss of professional autonomy; increased administrative burdens in the delivery of healthcare; production line mentality reinforced by RVU compensation models; navigating complex electronic health records; work environments that are rigid and do not reward innovation; and even stress associated with efforts to manage work-life balance.
The prevalence for physician burnout has been reported to be about 50% in both the popular press and academic literature. However, systematic literature reviews have shown that this prevalence is exceedingly broad, in part because of the lack of consistency in defining the syndrome, heterogeneity of physician groups studied, and how tools used to measure burnout have varying definitions and psychometric properties [2, 3].
To address such issues for physicians (and general staff as well), Chief Wellness Officers and similar titles are becoming more mainstream. “Healthcare organizations are trying to be more holistic” in supporting employees and especially physicians, my colleague Linda Komnick has noted .
Why Physicians in Academic Medicine Are Susceptible
AMCs are and have been complex environments in which physician faculty navigate their career destinations. In the spirit of better serving constituents, modern AMCs have added community engagement and population health to their traditional tripartite missions of research, education and clinical care. The “quintuple” missions have created a work ecosystem that is much complex and multidimensional than in previous generations. I believe this evolution has created exposure to additional stress points within the institutional culture and climate.
Simultaneously, physician faculty are more diverse; desire more flexible work environments that affirm work-life balance; seek reward systems that are transparent; and expect institutional policies and leaders to be accountable, responsible and accessible. They may not be receiving these expectations just yet.
The desire for work-life balance is particularly vexing. Faculty and executives are encouraged to take time off and explore other outlets in their lives while, paradoxically, still being asked to take on more responsibility within the quintuple-mission environment. The expectation to “achieve balance” thus becomes an added burden.
There are additional and more subtle sources of stress that may contribute to burnout. Many junior faculty struggle with early-career decisions such as the selection (or assignment) of their academic appointment track that best meets their professional goals and career expectations. Coupled with appointment track challenges are inconsistent programmatic and individual mentorship supports necessary for junior faculty to achieve their career objectives.
AMC compensation models have also changed over the years. Physician faculty experience mixed messages about their personal compensation that rewards or incentivizes clinical activities that are in conflict with other academic priorities such as teaching and scholarship. And last, faculty may experience personal or family life challenges additional to their daily burden, such as childcare or aging parent care.
The problem of faculty burnout has led to calls by national organizations, such as the Blue Ridge Group, the AAMC and National Academy of Medicine, to address the well-being of faculty in academic medicine as a national priority and moral imperative. [See references 7-9.]
Elevating the risk of physician faculty burnout to a national priority is an important step in the right direction. The problem is complex and additional high-quality research is required to better understand the interaction of individual and environment risk factors that contribute to burnout in academic settings. The solutions, like the problem, will be complex. Rather than simply emphasizing “finding balance,” solutions must also create a strong culture of workplace engagement that builds better organizations and strengthens personal resilience. After all, how many Alton’s do we need to witness before we make a change?
Important References and Resources
- Freudenberger HJ. Staff burn-out. J Soc Issues.1974;30(1):159-165. doi:10.1111/j.1540-4560.1974.tb00706.x.
- Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of burnout among physicians. A systematic review. 2018; 320(11): 1131-1150. doi:10.1001/jama.2018.12777.
- Schwenk TL, Gold KJ. Physician Burnout – A serious symptom, but of what? JAMA. 2018; 320;1109-1110. PMID 29872359.
- Rao SK, Kimball AB, Lehrhoff SR, et al. The impact of administrative burden on academic physicians: results of a hospital-wide physician survey. Acad Med. 2017;92(2):237-243. doi:10.1097/ACM.0000000000001461.
- Panagioti M, Geraghty K, Johnson J, et al. Association between physician burnout and patient safety, professionalism, and patient satisfaction: A systematic review and meta-analysis. JAMA Intern Med. 2018; 178(10): 1317-1330. doi: 10.1001/jamainternmed.2018.3713.
- Bryant, Meg. Hospitals look inward, add C-suite officer to boost staff wellness. https://www.healthcaredive.com/news/hospitals-look-inward-add-c-suite-officer-to-boost-staff-wellness/516451/. Accessed November 1, 2018.
- Blue Ridge Academic Health Group. The hidden epidemic: the moral imperative for academic health centers to address health professionals’ well-being. http://whsc.emory.edu/blueridge/publications/archive/blue-ridge-winter2017-2018.pdf. Accessed July 28, 2018.
- Association of American Medical Colleges: Well-Being in Academic Medicine. https://www.aamc.org/initiatives/462280/well-being-academic-medicine.html. Last Accessed October 22, 2108.
- National Academy of Medicine: Action Collaborative on Clinician Well-Being and Resilience. https://nam.edu/initiatives/clinician-resilience-and-well-being/ Last Accessed October 22, 2018.
About the Author
Christopher Colenda, MD, MPH serves in an Of Counsel capacity with Witt/Kieffer’s Academic Medicine and Health Sciences Practice. He supports the recruitment of presidents and CEOs, deans, departmental chairs, and other senior-level positions for academic health centers. He is President Emeritus of the West Virginia University Health System, and Dean Emeritus of the College of Medicine at Texas A&M University Health Science Center.