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Within hospital medicine, there has been a recent increase in programs that provide virtual or telehealth hospitalists, primarily to hospitals that are small, remote, and/or understaffed. According to a 2013 Cisco health care customer experience report, the number of telehealth consumers will likely markedly increase to at least 7 million by 2018.1
Since telehospitalist programs are still relatively new, there are many questions about why and how they exist and how they are (and can be) funded. Questions also remain about some limitations of telehospitalist programs for both the “givers” and the “receivers” of the services. I tackle some of these questions in this article.
What is a telehospitalist?
What are the drivers of telehospitalist programs?
One primary driver of telehealth (and specifically telehospitalist) programs is an ongoing shortage of hospitalists, especially in remote areas and critical access hospitals where coverage issues are especially prominent at night and/or on weekends. In many hospitals, there is also a growing unwillingness on the part of physicians to be routinely on call at night. Although working on call used to be on par with being a physician, many younger-generation physicians are less willing to blur “work and life.” This increases the need for dedicated night coverage in many hospitals.
Another driver for some programs (especially at tertiary care medical centers) is a desire to more thoroughly assess patients prior to transfer to their respective centers (the alternative being a phone conversation with the transferring center about the patient’s status). There is also a growing desire to keep patients local if possible, which is usually better for the patient and the family and can decrease the total cost of their care.
Another catalyst to telehospitalist program growth is the growing cultural comfort level with two-way video interactions, such as Skype and FaceTime. Since videoconferencing has permeated most of our professional and personal lives, telehealth seems familiar and comfortable for both providers and patients. In a recent consumer survey, three out of every four consumers responded that they are very comfortable communicating with providers via technology, as opposed to seeing them in person.1
Another driver for some programs is financial. Depending on the way the program is structured, it can be not only financially feasible but financially beneficial, especially if the program can consolidate coverage across multiple sites (more on this later).
One other driver for some health care systems is the need to cover areas with on-site nurse practitioners and physician assistants. Using a telehospitalist makes it easier to get appropriate and required oversight for this coverage model across time and space.
What are the advantages of being a telehospitalist?
Some of the career advantages of being a telehospitalist include the shift flexibility and convenience. This work allows a hospitalist to serve a shift from anywhere in the world and from the convenience of their home. Some telehospitalists can easily work local night shifts when they live many time zones away (and therefore, don’t actually have to work a night shift). Many programs are designed to have a single hospitalist cover many hospitals over a wide geography, which would be logistically impossible to do in person. This is especially appealing for multihospital systems that cannot afford to have a hospitalist on site at each location.
The earning potential can also be appealing, depending on the number of shifts a hospitalist is willing to work.
What are the limitations of being a telehospitalist?
There are limits to what a telehospitalist can perform, many of which depend on the manner in which the program and the technology are arranged. Telehealth can vary from a cart-based videoconferencing system that is transported into a patient’s room to an independent robot that travels throughout sites. The primary limitation is the need to rely on someone in the patient’s room to act as virtual hands. This usually falls to the bedside nurse and requires a good working relationship and patience on their part. The bedside nurses have to “buy into” the program in advance and may need to have scripting for how to explain the process to the patients.
Another major challenge is interacting with different electronic health record systems. Becoming agile with a single EHR is challenging enough, but maneuvering several of them in a single shift can be extremely trying. Telehospitalists can also be challenged by technology glitches or failures that need troubleshooting both on their end and on-site. Although these problems are rare, there will always be a concern that the patient will not get his or her needs met if the technology fails.
How does the financing work?
Although this is a rapidly changing landscape, telehospitalists are not currently able to generate much revenue from professional billing. Unlike in-person visits, Medicare will not reimburse professional fees for telehospitalist visits. Although each payer is unique, most other (nonMedicare) payers are also not willing to reimburse for televisits. This may change in the future, however, as Medicare does pay for virtual specialty services such as telestroke. In addition, many states have enacted telemedicine parity laws, which require private payers to pay for all health care services equally, regardless of modality (audio, video, or in person).
For now, the financial case for employing telehospitalists for most programs has to be made using benfits other than the generation of professional fees. For telehospitalist programs that can cover several sites, the cost is substantially less than employing individual on-site hospitalists to do low-volume work. Telehospitalist programs are also, likely, less costly than is locum tenens staffing. For programs that evaluate the need for transfers, a case can be made that keeping a patient in a smaller, low-cost venue, rather than transferring them to a larger, higher-cost venue, can also reduce overall cost for a health care system.
What about licensing and credentialing?
Telehospitalists can be hindered by the need to have a license in several states and to be credentialed in several systems. This can be cumbersome, time-consuming, and expensive. To ease the multistate licensing burden, the Interstate Medical Licensure Compact has been established.2 This is an accelerated licensure process for eligible physicians that improves license portability across states. There are currently 18 states that participate, and the number continues to increase.
For credentialing, most hospitals require initial credentialing and full recredentialing every 2 years. Maintaining credentials at several sites can be extremely time consuming. To ease this burden, some hospitals with telehealth programs have adopted “credentialing by proxy,” which means that one hospital will accept the credentialing process of another facility.
What next?
In summary, there has been and will likely continue to be explosive growth of telehospitalist programs and providers for all the reasons outlined above. Although some barriers to efficient and effective practice do exist, many of those barriers are being overcome quite rapidly. I expect this growth to continue for the betterment of hospitalists, our patients, and the systems in which we work. For a more in-depth look into telemedicine in hospital medicine, view a report created by a work group of SHM's Practice Management Committee.
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].
References
1.Cisco. (2013 March 4). Cisco Study Reveals 74 Percent of Consumers Open to Virtual Doctor Visit. Cisco: The Network. Retrieved from https://newsroom.cisco.com/press-release-content?type=webcontent&articleId=1148539.
2. Interstate Medical Licensure Compact Commission. (2017). Interstate Medical Licensure Compact. Retrieved from http://www.licenseportability.org/index.html.
Within hospital medicine, there has been a recent increase in programs that provide virtual or telehealth hospitalists, primarily to hospitals that are small, remote, and/or understaffed. According to a 2013 Cisco health care customer experience report, the number of telehealth consumers will likely markedly increase to at least 7 million by 2018.1
Since telehospitalist programs are still relatively new, there are many questions about why and how they exist and how they are (and can be) funded. Questions also remain about some limitations of telehospitalist programs for both the “givers” and the “receivers” of the services. I tackle some of these questions in this article.
What is a telehospitalist?
What are the drivers of telehospitalist programs?
One primary driver of telehealth (and specifically telehospitalist) programs is an ongoing shortage of hospitalists, especially in remote areas and critical access hospitals where coverage issues are especially prominent at night and/or on weekends. In many hospitals, there is also a growing unwillingness on the part of physicians to be routinely on call at night. Although working on call used to be on par with being a physician, many younger-generation physicians are less willing to blur “work and life.” This increases the need for dedicated night coverage in many hospitals.
Another driver for some programs (especially at tertiary care medical centers) is a desire to more thoroughly assess patients prior to transfer to their respective centers (the alternative being a phone conversation with the transferring center about the patient’s status). There is also a growing desire to keep patients local if possible, which is usually better for the patient and the family and can decrease the total cost of their care.
Another catalyst to telehospitalist program growth is the growing cultural comfort level with two-way video interactions, such as Skype and FaceTime. Since videoconferencing has permeated most of our professional and personal lives, telehealth seems familiar and comfortable for both providers and patients. In a recent consumer survey, three out of every four consumers responded that they are very comfortable communicating with providers via technology, as opposed to seeing them in person.1
Another driver for some programs is financial. Depending on the way the program is structured, it can be not only financially feasible but financially beneficial, especially if the program can consolidate coverage across multiple sites (more on this later).
One other driver for some health care systems is the need to cover areas with on-site nurse practitioners and physician assistants. Using a telehospitalist makes it easier to get appropriate and required oversight for this coverage model across time and space.
What are the advantages of being a telehospitalist?
Some of the career advantages of being a telehospitalist include the shift flexibility and convenience. This work allows a hospitalist to serve a shift from anywhere in the world and from the convenience of their home. Some telehospitalists can easily work local night shifts when they live many time zones away (and therefore, don’t actually have to work a night shift). Many programs are designed to have a single hospitalist cover many hospitals over a wide geography, which would be logistically impossible to do in person. This is especially appealing for multihospital systems that cannot afford to have a hospitalist on site at each location.
The earning potential can also be appealing, depending on the number of shifts a hospitalist is willing to work.
What are the limitations of being a telehospitalist?
There are limits to what a telehospitalist can perform, many of which depend on the manner in which the program and the technology are arranged. Telehealth can vary from a cart-based videoconferencing system that is transported into a patient’s room to an independent robot that travels throughout sites. The primary limitation is the need to rely on someone in the patient’s room to act as virtual hands. This usually falls to the bedside nurse and requires a good working relationship and patience on their part. The bedside nurses have to “buy into” the program in advance and may need to have scripting for how to explain the process to the patients.
Another major challenge is interacting with different electronic health record systems. Becoming agile with a single EHR is challenging enough, but maneuvering several of them in a single shift can be extremely trying. Telehospitalists can also be challenged by technology glitches or failures that need troubleshooting both on their end and on-site. Although these problems are rare, there will always be a concern that the patient will not get his or her needs met if the technology fails.
How does the financing work?
Although this is a rapidly changing landscape, telehospitalists are not currently able to generate much revenue from professional billing. Unlike in-person visits, Medicare will not reimburse professional fees for telehospitalist visits. Although each payer is unique, most other (nonMedicare) payers are also not willing to reimburse for televisits. This may change in the future, however, as Medicare does pay for virtual specialty services such as telestroke. In addition, many states have enacted telemedicine parity laws, which require private payers to pay for all health care services equally, regardless of modality (audio, video, or in person).
For now, the financial case for employing telehospitalists for most programs has to be made using benfits other than the generation of professional fees. For telehospitalist programs that can cover several sites, the cost is substantially less than employing individual on-site hospitalists to do low-volume work. Telehospitalist programs are also, likely, less costly than is locum tenens staffing. For programs that evaluate the need for transfers, a case can be made that keeping a patient in a smaller, low-cost venue, rather than transferring them to a larger, higher-cost venue, can also reduce overall cost for a health care system.
What about licensing and credentialing?
Telehospitalists can be hindered by the need to have a license in several states and to be credentialed in several systems. This can be cumbersome, time-consuming, and expensive. To ease the multistate licensing burden, the Interstate Medical Licensure Compact has been established.2 This is an accelerated licensure process for eligible physicians that improves license portability across states. There are currently 18 states that participate, and the number continues to increase.
For credentialing, most hospitals require initial credentialing and full recredentialing every 2 years. Maintaining credentials at several sites can be extremely time consuming. To ease this burden, some hospitals with telehealth programs have adopted “credentialing by proxy,” which means that one hospital will accept the credentialing process of another facility.
What next?
In summary, there has been and will likely continue to be explosive growth of telehospitalist programs and providers for all the reasons outlined above. Although some barriers to efficient and effective practice do exist, many of those barriers are being overcome quite rapidly. I expect this growth to continue for the betterment of hospitalists, our patients, and the systems in which we work. For a more in-depth look into telemedicine in hospital medicine, view a report created by a work group of SHM's Practice Management Committee.
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].
References
1.Cisco. (2013 March 4). Cisco Study Reveals 74 Percent of Consumers Open to Virtual Doctor Visit. Cisco: The Network. Retrieved from https://newsroom.cisco.com/press-release-content?type=webcontent&articleId=1148539.
2. Interstate Medical Licensure Compact Commission. (2017). Interstate Medical Licensure Compact. Retrieved from http://www.licenseportability.org/index.html.
Within hospital medicine, there has been a recent increase in programs that provide virtual or telehealth hospitalists, primarily to hospitals that are small, remote, and/or understaffed. According to a 2013 Cisco health care customer experience report, the number of telehealth consumers will likely markedly increase to at least 7 million by 2018.1
Since telehospitalist programs are still relatively new, there are many questions about why and how they exist and how they are (and can be) funded. Questions also remain about some limitations of telehospitalist programs for both the “givers” and the “receivers” of the services. I tackle some of these questions in this article.
What is a telehospitalist?
What are the drivers of telehospitalist programs?
One primary driver of telehealth (and specifically telehospitalist) programs is an ongoing shortage of hospitalists, especially in remote areas and critical access hospitals where coverage issues are especially prominent at night and/or on weekends. In many hospitals, there is also a growing unwillingness on the part of physicians to be routinely on call at night. Although working on call used to be on par with being a physician, many younger-generation physicians are less willing to blur “work and life.” This increases the need for dedicated night coverage in many hospitals.
Another driver for some programs (especially at tertiary care medical centers) is a desire to more thoroughly assess patients prior to transfer to their respective centers (the alternative being a phone conversation with the transferring center about the patient’s status). There is also a growing desire to keep patients local if possible, which is usually better for the patient and the family and can decrease the total cost of their care.
Another catalyst to telehospitalist program growth is the growing cultural comfort level with two-way video interactions, such as Skype and FaceTime. Since videoconferencing has permeated most of our professional and personal lives, telehealth seems familiar and comfortable for both providers and patients. In a recent consumer survey, three out of every four consumers responded that they are very comfortable communicating with providers via technology, as opposed to seeing them in person.1
Another driver for some programs is financial. Depending on the way the program is structured, it can be not only financially feasible but financially beneficial, especially if the program can consolidate coverage across multiple sites (more on this later).
One other driver for some health care systems is the need to cover areas with on-site nurse practitioners and physician assistants. Using a telehospitalist makes it easier to get appropriate and required oversight for this coverage model across time and space.
What are the advantages of being a telehospitalist?
Some of the career advantages of being a telehospitalist include the shift flexibility and convenience. This work allows a hospitalist to serve a shift from anywhere in the world and from the convenience of their home. Some telehospitalists can easily work local night shifts when they live many time zones away (and therefore, don’t actually have to work a night shift). Many programs are designed to have a single hospitalist cover many hospitals over a wide geography, which would be logistically impossible to do in person. This is especially appealing for multihospital systems that cannot afford to have a hospitalist on site at each location.
The earning potential can also be appealing, depending on the number of shifts a hospitalist is willing to work.
What are the limitations of being a telehospitalist?
There are limits to what a telehospitalist can perform, many of which depend on the manner in which the program and the technology are arranged. Telehealth can vary from a cart-based videoconferencing system that is transported into a patient’s room to an independent robot that travels throughout sites. The primary limitation is the need to rely on someone in the patient’s room to act as virtual hands. This usually falls to the bedside nurse and requires a good working relationship and patience on their part. The bedside nurses have to “buy into” the program in advance and may need to have scripting for how to explain the process to the patients.
Another major challenge is interacting with different electronic health record systems. Becoming agile with a single EHR is challenging enough, but maneuvering several of them in a single shift can be extremely trying. Telehospitalists can also be challenged by technology glitches or failures that need troubleshooting both on their end and on-site. Although these problems are rare, there will always be a concern that the patient will not get his or her needs met if the technology fails.
How does the financing work?
Although this is a rapidly changing landscape, telehospitalists are not currently able to generate much revenue from professional billing. Unlike in-person visits, Medicare will not reimburse professional fees for telehospitalist visits. Although each payer is unique, most other (nonMedicare) payers are also not willing to reimburse for televisits. This may change in the future, however, as Medicare does pay for virtual specialty services such as telestroke. In addition, many states have enacted telemedicine parity laws, which require private payers to pay for all health care services equally, regardless of modality (audio, video, or in person).
For now, the financial case for employing telehospitalists for most programs has to be made using benfits other than the generation of professional fees. For telehospitalist programs that can cover several sites, the cost is substantially less than employing individual on-site hospitalists to do low-volume work. Telehospitalist programs are also, likely, less costly than is locum tenens staffing. For programs that evaluate the need for transfers, a case can be made that keeping a patient in a smaller, low-cost venue, rather than transferring them to a larger, higher-cost venue, can also reduce overall cost for a health care system.
What about licensing and credentialing?
Telehospitalists can be hindered by the need to have a license in several states and to be credentialed in several systems. This can be cumbersome, time-consuming, and expensive. To ease the multistate licensing burden, the Interstate Medical Licensure Compact has been established.2 This is an accelerated licensure process for eligible physicians that improves license portability across states. There are currently 18 states that participate, and the number continues to increase.
For credentialing, most hospitals require initial credentialing and full recredentialing every 2 years. Maintaining credentials at several sites can be extremely time consuming. To ease this burden, some hospitals with telehealth programs have adopted “credentialing by proxy,” which means that one hospital will accept the credentialing process of another facility.
What next?
In summary, there has been and will likely continue to be explosive growth of telehospitalist programs and providers for all the reasons outlined above. Although some barriers to efficient and effective practice do exist, many of those barriers are being overcome quite rapidly. I expect this growth to continue for the betterment of hospitalists, our patients, and the systems in which we work. For a more in-depth look into telemedicine in hospital medicine, view a report created by a work group of SHM's Practice Management Committee.
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].
References
1.Cisco. (2013 March 4). Cisco Study Reveals 74 Percent of Consumers Open to Virtual Doctor Visit. Cisco: The Network. Retrieved from https://newsroom.cisco.com/press-release-content?type=webcontent&articleId=1148539.
2. Interstate Medical Licensure Compact Commission. (2017). Interstate Medical Licensure Compact. Retrieved from http://www.licenseportability.org/index.html.
Burnout: No laughing matter
Much has been written about burnout in U.S. physicians over the course of many years. Burnout is a syndrome that is exemplified by emotional exhaustion, depersonalization, and a low sense of personal accomplishment. It appears that hospitalists are particularly prone to burnout, being at the very front line of patient care. In addition, the prevalence of burnout appears to be getting worse. According to a survey from the American Medical Association, the prevalence of burnout in 2011 was 45%. Three years later in 2014 the prevalence was up to 55%.1,2
Although triggers for the onset and intensity of burnout likely vary by specialty, a recent Medscape Lifestyle Report found the most common causes of burnout among physicians included (see graphic):3
• Bureaucratic tasks.
• Work hours.
• Computerization.
• Compensation.
• Lower work satisfaction.
• Disrupted personal relationships.
• Substance misuse.
• Depression.
• Suicide.
Burnout also leads to lower productivity, higher job turnover, and early retirement. In addition, from a systems perspective, burnout is associated with higher medical errors, reduced quality of patient care, and lower patient satisfaction. And, at its most extreme, burnout is deadly: Sadly, every year, 300-400 physicians in the United States commit suicide. Female physicians are 2.3 times more likely to commit suicide than are female nonphysicians; for males, the risk is 1.4 times higher among physicians compared to the general population.1
Proactive approaches
Despite all these sobering statistics on the prevalence and outcomes of burnout among physicians, the ongoing question is, what can we do about it? Although awareness and recognition of burnout has grown substantially over time, successful interventions to prevent or mitigate burnout have not. Many potential interventions and ideas have surfaced and have been published, but none have had impressive impacts or have been adopted widely within or across institutions. According to a Modern Healthcare survey of approximately 100 health care CEOs, only about one-third reported that their organization had programs to address physician burnout, although about another one-third reported attempts to develop such programs.1
The good news is that at least there is a lot of activity around trying new interventions to reduce burnout, including in medical schools and graduate training programs. The thought is that if you can employ healthy resilience tactics during training, these can be carried throughout a career to diminish the risk and/or severity of burnout, despite any challenges that arise along the way.
Some of these interventions are aimed at individuals (to enhance personal resilience and coping skills) while others are aimed at the level of organizations (to reduce organizational stress and/or workload). A recent Modern Healthcare article found several good examples:1
• New York’s Albert Einstein College of Medicine’s WellMed program has been designed to help students develop healthy and balanced habits and attitudes, and to enhance their personal resilience, for the short and the long term.
• Baystate Health in Massachusetts hosts a physician leadership academy that offers training in communication, unconscious bias, strategy, and other management skills, to enhance individual resilience and organizational engagement.
• HealthPartners, a not-for-profit, Minnesota-based health care organization, has specific programs to engage physicians and allow them to have organizational impact, as well as programs to simplify technology use.
Organization efforts are key to prevent, treat
The key to reducing burnout does seem to be employing a combination of self-directed and organization-directed interventions, each of which enhances resilience and reduces workplace stressors (i.e., administrative tasks and workload). Specific to hospitalists, Leslie Flores, MBA, recently wrote about burnout at The Hospital Leader blog. Her list included several specific examples to reduce the top causes of burnout among busy hospitalists:4
• Modifying the skill mix in hospital medicine groups so that less costly support staff are doing much of the work not requiring a physician’s expertise, freeing up hospitalists to provide better care to more patients.
• Reducing unnecessary interruptions and the stress they cause, via both technology and process improvement.
• Paying deliberate attention to hospitalist personal and professional well-being.
• Adjusting hospitalist schedules and work flow so that hospitalists can be more efficient (that is, do less low-value work and re-work) and have better work-life balance.
• Ensuring that hospitalists have the training, clinical competencies, and support to comfortably perform in expanded clinical roles.
Many of these systemic solutions were recently validated as likely able to have an impact on burnout (and seem to be more effective than interventions focused on individual resilience).5 A recent meta-analysis found that physician-directed interventions were associated with small but significant reductions in burnout; these were primarily mindfulness-based stress reduction techniques, educational interventions targeting physicians self-confidence and communication skills, exercise, or a combination of these features. More impactful were organization-directed interventions, which were associated with more significant reductions in burnout; these were primarily aimed at reducing workload and enhancing teamwork and leadership.
In sum
It is important for all of us hospitalists to understand and try to mitigate burnout within our teams. Although individual-focused interventions can have some effect, most efforts should primarily be focused on system-based interventions, to reduce administrative burdens and workload. Through such system design and redesign, we can likely reduce burnout amongst our teams, and therefore improve the sustainability of our specialty.
References
1.http://www.modernhealthcare.com/article/20161029/MAGAZINE/310299983
2. http://www.mayoclinicproceedings.org/article/S0025-6196(15)00716-8/abstract
3.http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview#page=5
4. http://blogs.hospitalmedicine.org/Blog/making-hospital-medicine-a-sustainable-specialty/
5.http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2588814
Much has been written about burnout in U.S. physicians over the course of many years. Burnout is a syndrome that is exemplified by emotional exhaustion, depersonalization, and a low sense of personal accomplishment. It appears that hospitalists are particularly prone to burnout, being at the very front line of patient care. In addition, the prevalence of burnout appears to be getting worse. According to a survey from the American Medical Association, the prevalence of burnout in 2011 was 45%. Three years later in 2014 the prevalence was up to 55%.1,2
Although triggers for the onset and intensity of burnout likely vary by specialty, a recent Medscape Lifestyle Report found the most common causes of burnout among physicians included (see graphic):3
• Bureaucratic tasks.
• Work hours.
• Computerization.
• Compensation.
• Lower work satisfaction.
• Disrupted personal relationships.
• Substance misuse.
• Depression.
• Suicide.
Burnout also leads to lower productivity, higher job turnover, and early retirement. In addition, from a systems perspective, burnout is associated with higher medical errors, reduced quality of patient care, and lower patient satisfaction. And, at its most extreme, burnout is deadly: Sadly, every year, 300-400 physicians in the United States commit suicide. Female physicians are 2.3 times more likely to commit suicide than are female nonphysicians; for males, the risk is 1.4 times higher among physicians compared to the general population.1
Proactive approaches
Despite all these sobering statistics on the prevalence and outcomes of burnout among physicians, the ongoing question is, what can we do about it? Although awareness and recognition of burnout has grown substantially over time, successful interventions to prevent or mitigate burnout have not. Many potential interventions and ideas have surfaced and have been published, but none have had impressive impacts or have been adopted widely within or across institutions. According to a Modern Healthcare survey of approximately 100 health care CEOs, only about one-third reported that their organization had programs to address physician burnout, although about another one-third reported attempts to develop such programs.1
The good news is that at least there is a lot of activity around trying new interventions to reduce burnout, including in medical schools and graduate training programs. The thought is that if you can employ healthy resilience tactics during training, these can be carried throughout a career to diminish the risk and/or severity of burnout, despite any challenges that arise along the way.
Some of these interventions are aimed at individuals (to enhance personal resilience and coping skills) while others are aimed at the level of organizations (to reduce organizational stress and/or workload). A recent Modern Healthcare article found several good examples:1
• New York’s Albert Einstein College of Medicine’s WellMed program has been designed to help students develop healthy and balanced habits and attitudes, and to enhance their personal resilience, for the short and the long term.
• Baystate Health in Massachusetts hosts a physician leadership academy that offers training in communication, unconscious bias, strategy, and other management skills, to enhance individual resilience and organizational engagement.
• HealthPartners, a not-for-profit, Minnesota-based health care organization, has specific programs to engage physicians and allow them to have organizational impact, as well as programs to simplify technology use.
Organization efforts are key to prevent, treat
The key to reducing burnout does seem to be employing a combination of self-directed and organization-directed interventions, each of which enhances resilience and reduces workplace stressors (i.e., administrative tasks and workload). Specific to hospitalists, Leslie Flores, MBA, recently wrote about burnout at The Hospital Leader blog. Her list included several specific examples to reduce the top causes of burnout among busy hospitalists:4
• Modifying the skill mix in hospital medicine groups so that less costly support staff are doing much of the work not requiring a physician’s expertise, freeing up hospitalists to provide better care to more patients.
• Reducing unnecessary interruptions and the stress they cause, via both technology and process improvement.
• Paying deliberate attention to hospitalist personal and professional well-being.
• Adjusting hospitalist schedules and work flow so that hospitalists can be more efficient (that is, do less low-value work and re-work) and have better work-life balance.
• Ensuring that hospitalists have the training, clinical competencies, and support to comfortably perform in expanded clinical roles.
Many of these systemic solutions were recently validated as likely able to have an impact on burnout (and seem to be more effective than interventions focused on individual resilience).5 A recent meta-analysis found that physician-directed interventions were associated with small but significant reductions in burnout; these were primarily mindfulness-based stress reduction techniques, educational interventions targeting physicians self-confidence and communication skills, exercise, or a combination of these features. More impactful were organization-directed interventions, which were associated with more significant reductions in burnout; these were primarily aimed at reducing workload and enhancing teamwork and leadership.
In sum
It is important for all of us hospitalists to understand and try to mitigate burnout within our teams. Although individual-focused interventions can have some effect, most efforts should primarily be focused on system-based interventions, to reduce administrative burdens and workload. Through such system design and redesign, we can likely reduce burnout amongst our teams, and therefore improve the sustainability of our specialty.
References
1.http://www.modernhealthcare.com/article/20161029/MAGAZINE/310299983
2. http://www.mayoclinicproceedings.org/article/S0025-6196(15)00716-8/abstract
3.http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview#page=5
4. http://blogs.hospitalmedicine.org/Blog/making-hospital-medicine-a-sustainable-specialty/
5.http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2588814
Much has been written about burnout in U.S. physicians over the course of many years. Burnout is a syndrome that is exemplified by emotional exhaustion, depersonalization, and a low sense of personal accomplishment. It appears that hospitalists are particularly prone to burnout, being at the very front line of patient care. In addition, the prevalence of burnout appears to be getting worse. According to a survey from the American Medical Association, the prevalence of burnout in 2011 was 45%. Three years later in 2014 the prevalence was up to 55%.1,2
Although triggers for the onset and intensity of burnout likely vary by specialty, a recent Medscape Lifestyle Report found the most common causes of burnout among physicians included (see graphic):3
• Bureaucratic tasks.
• Work hours.
• Computerization.
• Compensation.
• Lower work satisfaction.
• Disrupted personal relationships.
• Substance misuse.
• Depression.
• Suicide.
Burnout also leads to lower productivity, higher job turnover, and early retirement. In addition, from a systems perspective, burnout is associated with higher medical errors, reduced quality of patient care, and lower patient satisfaction. And, at its most extreme, burnout is deadly: Sadly, every year, 300-400 physicians in the United States commit suicide. Female physicians are 2.3 times more likely to commit suicide than are female nonphysicians; for males, the risk is 1.4 times higher among physicians compared to the general population.1
Proactive approaches
Despite all these sobering statistics on the prevalence and outcomes of burnout among physicians, the ongoing question is, what can we do about it? Although awareness and recognition of burnout has grown substantially over time, successful interventions to prevent or mitigate burnout have not. Many potential interventions and ideas have surfaced and have been published, but none have had impressive impacts or have been adopted widely within or across institutions. According to a Modern Healthcare survey of approximately 100 health care CEOs, only about one-third reported that their organization had programs to address physician burnout, although about another one-third reported attempts to develop such programs.1
The good news is that at least there is a lot of activity around trying new interventions to reduce burnout, including in medical schools and graduate training programs. The thought is that if you can employ healthy resilience tactics during training, these can be carried throughout a career to diminish the risk and/or severity of burnout, despite any challenges that arise along the way.
Some of these interventions are aimed at individuals (to enhance personal resilience and coping skills) while others are aimed at the level of organizations (to reduce organizational stress and/or workload). A recent Modern Healthcare article found several good examples:1
• New York’s Albert Einstein College of Medicine’s WellMed program has been designed to help students develop healthy and balanced habits and attitudes, and to enhance their personal resilience, for the short and the long term.
• Baystate Health in Massachusetts hosts a physician leadership academy that offers training in communication, unconscious bias, strategy, and other management skills, to enhance individual resilience and organizational engagement.
• HealthPartners, a not-for-profit, Minnesota-based health care organization, has specific programs to engage physicians and allow them to have organizational impact, as well as programs to simplify technology use.
Organization efforts are key to prevent, treat
The key to reducing burnout does seem to be employing a combination of self-directed and organization-directed interventions, each of which enhances resilience and reduces workplace stressors (i.e., administrative tasks and workload). Specific to hospitalists, Leslie Flores, MBA, recently wrote about burnout at The Hospital Leader blog. Her list included several specific examples to reduce the top causes of burnout among busy hospitalists:4
• Modifying the skill mix in hospital medicine groups so that less costly support staff are doing much of the work not requiring a physician’s expertise, freeing up hospitalists to provide better care to more patients.
• Reducing unnecessary interruptions and the stress they cause, via both technology and process improvement.
• Paying deliberate attention to hospitalist personal and professional well-being.
• Adjusting hospitalist schedules and work flow so that hospitalists can be more efficient (that is, do less low-value work and re-work) and have better work-life balance.
• Ensuring that hospitalists have the training, clinical competencies, and support to comfortably perform in expanded clinical roles.
Many of these systemic solutions were recently validated as likely able to have an impact on burnout (and seem to be more effective than interventions focused on individual resilience).5 A recent meta-analysis found that physician-directed interventions were associated with small but significant reductions in burnout; these were primarily mindfulness-based stress reduction techniques, educational interventions targeting physicians self-confidence and communication skills, exercise, or a combination of these features. More impactful were organization-directed interventions, which were associated with more significant reductions in burnout; these were primarily aimed at reducing workload and enhancing teamwork and leadership.
In sum
It is important for all of us hospitalists to understand and try to mitigate burnout within our teams. Although individual-focused interventions can have some effect, most efforts should primarily be focused on system-based interventions, to reduce administrative burdens and workload. Through such system design and redesign, we can likely reduce burnout amongst our teams, and therefore improve the sustainability of our specialty.
References
1.http://www.modernhealthcare.com/article/20161029/MAGAZINE/310299983
2. http://www.mayoclinicproceedings.org/article/S0025-6196(15)00716-8/abstract
3.http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview#page=5
4. http://blogs.hospitalmedicine.org/Blog/making-hospital-medicine-a-sustainable-specialty/
5.http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2588814