Practice of Medicine
Physician Burnout and Its Impact on Medical Liability: An Interview with Martin Stillman, MD, JD
Martin Stillman, MD, JD, is a physician, a lawyer and a mediator who has a particular interest in understanding and minimizing physician burnout. He is a practicing internist at Hennepin County Medical Center in Minneapolis, Minnesota, where he also serves as the Mediation and Conflict Resolution Officer, an Assistant Chief for the Department of Medicine and Assistant Director of the Institute of Professional Worklife. Additionally, he is an Associate Professor of Medicine at the University of Minnesota Medical School and teaches about medical error, medical malpractice, disclosure of unexpected patient outcomes and the risk management aspects of physician/patient relations and communication. In this article, Dr. Stillman responds to questions on the topic of physician burnout and its impact on medical liability risk.
MagMutual: As a physician who also has a law degree, how did you become interested in the topic of physician burnout?
Stillman: I have had an interest in the intersection of medicine and the law for a long time. In my role as Mediation and Conflict Resolution Officer at my hospital, I work to reduce and mediate conflict between providers or groups of providers so that they can move forward in a productive way and, ultimately, deliver safer patient care. Physician burnout has been an issue that continues to come up, and I developed an interest in educating others about burnout and burnout reduction.
MagMutual: How do you define physician burnout?
Stillman: Physician burnout is usually the result of some sort of prolonged stress that leads to several significant implications. They can include higher rates of depression, fatigue and anxiety. In some physicians who are burned out, there is a higher rate of substance abuse. Burned out physicians have increased incidents of sleep disturbances, broken relationships, and even increased rates of suicide. Physician burnout can appear as a loss of interest and enthusiasm for work or increased frustration and emotional exhaustion. All of this can lead to decreased empathy for patients, as well as a decreased sense of personal worth and professional accomplishment.
MagMutual: In your experience, what is the magnitude of physician burnout, and how does it differ from burnout experienced in other types of careers?
Stillman: One thing we know is that burnout among U.S. physicians continues to be on the rise. It is currently estimated to affect more than 50 percent of U.S. physicians. There is a difference between the burnout experienced by physicians, compared to other occupations. In one study that looked at physician burnout compared to the general population, 49 percent of doctors were burned out, compared to 28 percent in the general population.i Additionally, the rates of emotional exhaustion were roughly 43 percent for physicians, compared to 25 percent in the general population. Thirty-six percent of the doctors were satisfied with their work-life balance, compared to 61 percent in the general U.S. working population. That study begins to get at the magnitude of the issue and the increase we are seeing in physician burnout. Additionally, when looking at how physician burnout compares to previous years, the data shows an increase in every specialty.ii
MagMutual: Which physicians are most at risk for burnout?
Stillman: In general, some of the frontline specialties, such as emergency medicine, family medicine, internal medicine and pediatrics, have a higher occurrence of burnout. The data also supports the conclusion that mid-career physicians appear to be at increased risk, compared to physicians in the early and late stages of their career. We also know that women appear to be affected by burnout more than men. But I mention these generalizations with some warning. Part of the problem with just calling out a few areas or specialties is that it may make a person think these are the only areas that have burnout, where other specialties don't. That is simply not the case. Sometimes the measurements show that the difference in physician burnout between specialties is minimal. Therefore, the concern I have in naming a few specialties as the hardest hit is that it can detract from what I see to be a global issue of burnout affecting many if not all areas of practice.
MagMutual: How is burnout measured?
Stillman: When researchers look to measure burnout, they are relying on self-assessment tools. There are primarily three self-assessment tools that have been well accepted in terms of their reliability. One is the American Medical Association’s Mini Z Burnout Survey. The second is the Maslach Burnout Inventory and the third is the Professional Fulfillment Index (Physician Wellness Survey). These tools vary in length, with some being more in-depth than others. Sometimes there is an advantage to using a shorter survey that is easier to fill out, which may result in higher participation when you're looking at a large department or hospital. At the same time, sometimes it is more helpful to collect the in-depth information that a longer survey allows. Currently, there is a study underway that is trying to compare the self-assessment inventories to evaluate how a score on one tool relates to the others, which will be helpful.
MagMutual: How does physician burnout impact the risk of medical errors, and ultimately, patient care?
Stillman: This is an important question and an area that is currently and understandably receiving increasing attention. There are many studies that look at the impact of burnout on patients retrospectively, where physicians are asked to rate their level of burnout after an error occurs. When these metrics have been used, multiple studies have suggested that there is a correlation that exists between increased burnout and increased levels of patient errors. Some feel that when you have a retrospective self-reporting method for medical errors, it is not necessarily a true measure of errors that may or may not have occurred. But despite some of the concerns of retrospective analysis, I believe that when concerns are raised about physician burnout, legitimate patient safety flags are raised.
There have been other studies where researchers have looked at levels of burnout in inpatient nurses as a predictor of patient satisfaction. The results showed that as nurse burnout increased, patient satisfaction went down.iii This tells us a lot about liability risk. While the study didn't look specifically at medical errors, risk managers are well-versed in knowing that, in general, unsatisfied patients are a higher liability risk when substandard care becomes an issue. As I noted, physicians with burnout have higher rates of depression, fatigue, anxiety, and substance abuse, as well as less empathy for patients. When all of this is at play, it is reasonable to recognize that there is a real medical liability risk associated with burnout in respect to providing appropriate standards of care.
MagMutual: What are some of the strategies or best recommendations out there today to decrease physician burnout?
Stillman: It is difficult to identify one global answer for solving burnout, because it really depends on what is driving the burnout in a particular practice, clinic or hospital. You really need to take the time to evaluate and identify the drivers of stress in your setting. For example, if taking too much work home is a big driver of burnout and electronic health records are taking a good deal of the physician’s time, then scribes may be of benefit. At the same time, we have seen that scribes alone don't just take the burnout away. If the clinic is still chaotic and there is not good value alignment, the stress will remain.
Sometimes, finding a break in the middle of the day, like a designated time for catch up, has been shown to be helpful. In the hospital setting, it is helpful to identify any issues with the physicians’ support systems that are impacting a physician’s time, control, and stress level, such as social work, pharmacy, physical therapy, etc.
Additionally, when people have at least 10 percent of their work time devoted to something they feel particularly passionate about, it can have a protective impact against burnout. That does not mean the physician is going to get 10 percent of his or her time off. Rather, if someone has a particular area of interest and type of patient they like to see or area of medicine they would like to practice, which ends up being roughly a half day a week, fostering that passion can make a substantial difference in the physician’s work week.
MagMutual: Do you have any specific examples of successful cases where something like a workflow strategy helped to reduce physicians stress?
Stillman: I have one example that I like to give because it was pretty straightforward, and physicians couldn't initially identify the issue. There was a clinic where the new patients were being scheduled at the end of the day. Some of the patients were relatively straightforward and, of course, some were not. When patients presented who needed more time, it disrupted the end of the physician’s day, making it difficult to getting home for dinner or to pick up a child from daycare. It was an end of the day disruptor that was stressful because control over one’s schedule was lost. The scheduling template was changed to have new patients come in at the beginning of the day. Ultimately, stress was reduced among the providers in this clinic significantly by making a fairly easy schedule change. It wasn’t about seeing fewer patients but seeing them in a different way.
MagMutual: What can healthcare organizations do to improve burnout and stress?
Stillman: The first thing that they can do is recognize that burnout is real and includes physicians and other types of healthcare workers. I have seen that starting to happen in a positive way over the past ten years. Now it is much more common to go to meetings of all specialties and have some sort of educational session addressing burnout.
In addition to the humanitarian aspect of reducing burnout, there is also a valid business model that would support paying attention to burnout. We know that physicians with burnout will work less. They will leave their practice earlier than non-burnt-out physicians, and increased turnover is a real expense for any organization. In fact, it is estimated to cost a minimum of $250,000 when someone leaves. That's not referring only to the hiring cost but, of course, the time loss associated with a vacant position. The bench is not so deep in certain areas of medicine that when a physician leaves, another can just pick up where the other physician left off. There is also the ramp-up time.
When an organization recognizes that it is worth reducing burnout, they can develop a wellness plan and decide what their action items are going to be. This can be accomplished with a relatively modest infrastructure. A wellness committee can be formed with representatives from different areas within the organization, and they can begin by measuring baseline degrees of burnout among the physicians. The costs to get something going are fairly modest. Some of the survey tools don't cost anything. They are easily analyzed, and the results can be quickly distributed. That information is crucial to identify the specific areas that need to be improved. Some institutions have implemented a Chief Wellness Officer to oversee the work and ensure action is taken.
When the values of healthcare professionals are aligned with leadership, it can result in an environment that is protective with respect to burnout. There is a feeling that yes, we're working hard, but we're all in this together. Physicians need to be a part of the solution.
MagMutual: What resources are available to someone interested in developing a wellness program for their organization?
Stillman: The American Medical Association has a Steps Forward program, which has several modules that can be followed to assist in developing more specific ways to reduce burnout. The Institute of Professional Worklife or others can assist with program development when organizations want to take some more concrete steps. I would also encourage any physician or any provider who feels they need immediate help to contact their healthcare provider or a crisis line, because, for some, the risk of self-harm among burned out physicians is real and concerning.
MagMutual: What might risk managers and even medical liability insurance carriers do to address the concern of physician burnout and its associated liability risks?
Stillman: Perhaps carriers can be a driver to help obtain measurement in physician burnout. It will always be helpful to identify potential issues before they become medical errors. The good news is that the goals are aligned for everyone when it comes to physician burnout. I've always felt that the most successful risk management approach is identifying the true issues, which results in better patient care and better communication. This is no different than any other initiative to improve patient care.
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The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.