Pediatric specialist Ryan Walsh, MD, reached a breaking point in 2012. He was so physically and emotionally exhausted from work that he considered leaving Stanford and his lifelong home in Palo Alto.
Then chief of a major clinical program at Stanford Medicine, he felt overwhelmed by the relentless demands of his job, said Walsh, who asked that his real name not be used. He began to have sleep problems and anxiety attacks and had trouble focusing.
Walsh had classic signs of burnout, and he’s not alone. Nearly half of the nation’s doctors report feeling emotionally exhausted and ineffective, and having lost a sense of meaning in their work, according to studies by Tait Shanafelt, MD, Stanford’s chief wellness officer.
But Stanford Medicine, under the leadership of Lloyd Minor, MD, dean of the School of Medicine, is out front nationally in combatting the trend with a campaign to confront the myriad issues that lead to burnout and implement programs to improve physicians’ well-being.
The goal of the Stanford program, considered a national model, is to increase professional fulfillment by improving the work experience and building an efficient, high-quality system that promotes teamwork and work-life integration, among other things.
Although not the primary focus, it also aims to support physicians’ efforts to take care of themselves, through offerings such as peer support and mindfulness training. A key to the program is data collected from daily practice records as well as from surveys about Stanford physicians’ work satisfaction and wellness, which enables the team at WellMD, Stanford’s physician wellness center, to identify problems and work with Stanford Medicine’s leaders to solve them.
The 2019 survey of 1,437 Stanford physicians (about two-thirds of eligible physicians) shows the effort is starting to make a difference. In it, clinicians reported slightly fewer burnout symptoms on average, compared with the most recent previous survey, in 2016, when 34% had signs of distress.
Concerted efforts to bring about change resulted in faculty members in six departments experiencing a dramatic improvement, Shanafelt said. Physicians in nine departments reported little or no difference, while those in two departments reported that symptoms had worsened, according to the survey. The center now plans annual surveys.
“Your experience at Stanford depends on which of those departments you are in,” Shanafelt said. “There is much more work to be done, but we are encouraged by the progress of the departments that have made improving professional fulfillment a top priority. Their experience illustrates what is possible when departments actively focus on this issue, and we are actively engaging the other departments with the hopes they embark on improvement in a deeper way.”
Doctors may experience burnout when faced with crushing work demands, lack of control, a toxic workplace and burdensome paperwork. Inefficient work processes, like clinics or operating rooms that don’t function smoothly, also can be major contributors.
The toll is enormous: Clinicians suffer from higher rates of alcohol and substance abuse and suicide than other professionals. Moreover, when doctors suffer, so do their patients. Studies link burnout to patient dissatisfaction, higher costs, poor patient results and medical errors.
“When people have higher burnout, the unprofessional behavior and the caustic way that people treat one another often increases. There is less teamwork,” Shanafelt said. “There is also higher turnover among physicians. That results in access issues for patients, and it erodes continuity of care” as patients lose doctors who are familiar with them and their health situations.
As doctors leave or reduce their hours, the cost of care increases sharply, according to a new study in the Annals of Internal Medicine by investigators from the Stanford WellMD Center as well as Harvard and the American Medical Association. They found burnout-related physician turnover costs the nation $5 billion annually, or about $7,600 per physician per year.
Shanafelt, a national leader in developing initiatives to counter burnout, began exploring the issue nearly two decades ago when he was a senior resident in medicine at the University of Washington and noticed a disturbing tendency among the interns he supervised.
“I was watching people who I knew went into practice with altruistic values. They’d become quite cynical and were talking about their patients in ways that were incongruent with those values,” said Shanafelt, a hematologist and the Jeanie and Stew Ritchie Professor at Stanford.
He decided to launch a study of burnout trends among medical residents in December 2000, which showed for the first time that their suffering was linked to quality of care and patient health. Its publication in early 2002 in the Annals of Internal Medicine launched the issue of physician burnout into the national spotlight. Shanafelt moved to the Mayo Clinic, where he established a center to study the problem and develop interventions, conducting groundbreaking research that continues today.
At Stanford Medicine, faculty members began mobilizing around the issue a decade ago by forming a physician wellness committee, led by Bryan Bohman, MD, associate chief medical officer at Stanford Health Care. Bohman said it was clear that physician wellness was vital to the future of medical practice. He and his colleagues built the case for a full-fledged center, which eventually became the WellMD Center, and with major support from Minor and leaders at the two hospitals they recruited Shanafelt in September 2017 to be its first director.
Physician, heal thyself
Bohman said that for too long, physicians have shouldered the burdens of an increasing workload and clerical demands with a kind of stoic heroism.
“They may be unable to get their work done and take good care of their patients without extraordinary, superhuman efforts, so they will go ahead and make those extraordinary, superhuman efforts, even at the cost of their own health and well-being,” he said. “If you lose sight of when selflessness transitions into self-abuse, you ultimately may damage yourself, your patients, your co-workers and the whole system of care.”
Moreover, when things go wrong, he said, physicians tend to blame themselves, rather than a flawed system. A powerful force behind burnout is the pervasive feeling among physicians that they have to be perfect and work excessively hard to feel a sense of self-worth, he said.
“When you make a mistake, do you beat yourself up or do you see it as, ‘Hey, I’m human. I can make mistakes like anyone, but how do I mitigate that? How do I make sure those mistakes don’t harm the patient? How do I learn from this mistake and turn it into a positive?’” Bohman said.
Stanford Medicine has offered self-compassion training to physicians, which helps them reframe their thinking so they learn to be as kind and compassionate to themselves as they would be to a good friend. Clinicians also can opt for mindfulness training to help minimize their stress and enable them to focus on the moment without being distracted by frustration, worry and negative thoughts. Surveys show that these skills can buffer against burnout and lead to professional fulfillment, Bohman said.
But no amount of self-compassion or mindfulness can shield physicians from basic inefficiencies in the system — daily obstacles and irritations that can turn a clinic day into a frustrating slog.
Shanafelt said the goal is to bring about wholesale culture changes in the organization and practice environment, beginning with a commitment to wellness from leaders.
As part of the effort, WellMD in July launched a multi-million-dollar project funded by the California Medical Association to reduce physician burnout by providing support to doctors statewide. The initiative will also bring new resources to Stanford physicians.
“Addressing the systemic issue of physician burnout is essential to not only increasing physician well-being but ultimately delivering better patient care,” Minor said. “I’m confident that this comprehensive project that incorporates research-driven strategies developed at Stanford Medicine will help get to the core of the problem.” Minor and the two hospital CEOs are fully behind the effort to make physicians’ professional fulfillment a priority, Shanafelt said. From there, it’s critical for each department to wage its own fight.
“The dean can’t fix it for you. The WellMD Center can’t fix all the problems across our hospitals and clinics,” Shanafelt said. “So many of the friction points are unique to each specialty and department. That’s why we are engaging departments and local leaders and partnering with them to begin to help each department address the specific changes that are the biggest local irritant.”
Nearly all of the 18 clinical departments now have a well-being director charged with identifying and leading efforts to address sources of inefficiency and discontent. The surgical and anesthesia specialties, for instance, are tackling operating room scheduling and delay issues.
“If a surgeon is waiting an hour and a half between cases and going home at 8 p.m., we can’t ask them to meditate for an hour and a half between cases,” Shanafelt said. “We have to change the workload and staffing levels so everybody is getting home at a reasonable time.”
The Department of Pediatrics has undertaken several initiatives in partnership with the WellMD Center, including one to help division chiefs strengthen leadership qualities that are important to the department’s physicians. Previous studies led by Shanafelt at Mayo Clinic and subsequently confirmed in studies of Stanford physicians show these supervisor behaviors are a major factor in physicians’ professional fulfillment.
In the past year, the department faculty members answered an anonymous survey to evaluate their division chiefs on a series of behaviors, such as providing helpful feedback, acknowledging a job well done, assisting with career development and empowering the physicians to do their jobs. Division chiefs received the results, along with training and professional coaching to improve their skills, said Daniel Murphy Jr., MD, a professor of pediatrics at Stanford who helps lead the group of departmental well-being directors.
“This is about respect, empowerment, encouragement and recognition, and you can train people to do that,” Murphy said. “This is the culture that makes people feel really fulfilled and can make their practices smoother and more effective.”
This investment in leadership development ultimately will be offered to clinical departments throughout the medical center, Shanafelt said.
In addition to encouraging the department-specific initiatives, the WellMD Center is making available some resources and programs to boost well-being across the medical center.
To help faculty gain better work-life integration, for example, the center has collaborated with the chief information officers of both hospitals to develop a tool to measure “work after work” — the time doctors spend logging in at home to complete increasing amounts of paperwork. The center now has real-time data on every division, clinic and department at Stanford Medicine, Shanafelt said.
“We are looking at what is working in clinics that are doing well, where we need to focus and what groups need resources,” Shanafelt said. “We are putting this data on the trends in the hands of each chair and chief, so they accurately understand the magnitude of the hidden work, recognize the variability across their clinics, and begin to implement system changes to drive improvement. We can’t just blame EPIC [the electronic medical record system] when we have profound variability in our own clinics.”
That data is also being reported to the hospital leaders as well as to the hospital boards, so there is accountability to spur improvement at the highest levels.
Some departments and clinics are now using scribes to minimize paperwork. For instance, in a recent clinical appointment at Lucile Packard Children’s Hospital Stanford, a scribe stood in a corner behind a portable computer while pediatric ophthalmologist Scott Lambert, MD, examined the eyes of a young patient. Lambert concluded that the boy needed glasses, and he filled out a new prescription online.
The scribe transcribed the encounter and retrieved a printed copy of the new prescription from the computer. Lambert never had to take a note or turn his attention away from the patient.
“It’s really a painful part of my day to spend a couple of hours working on my notes,” said Lambert, who is chief of the division of pediatric ophthalmology. “So a scribe makes life much more pleasant.” A number of other departments are now evaluating the possibility of adding scribes to reduce work after work.
Besides robbing them of personal time, the crush of digital paperwork also isolates doctors from the community they crave.
“I attended a conference on physician wellness and one of the speakers asked each table to come up with the most important thing contributing to burnout. The consensus was that it was the demise of the doctors’ lounge, which gave us a sense of camaraderie,” said obstetrician-gynecologist Harise Stein, MD. “That is one of the things that keeps you going.”
Stein directs the Physician Resource Network, a newly revitalized peer support program overseen by the WellMD Center that offers confidential help for clinicians who need someone to talk to, whether it’s about an adverse event, career obstacle, feeling burned out or challenges with work-life integration. Faculty members who use the program are paired with a Stanford physician who does not know them, who has been trained as a peer supporter and who is volunteering time to help colleagues.
“We provide listening, coping support, perspective, resources and options,” Stein said. “Our main job is not to tell somebody what to do, but to help them figure out what they want to do and help them find the resources to do that.”
In 2018, the WellMD Center helped several departments start programs to build camaraderie, bringing small groups of doctors together to meet over dinner and reflect on a given question. For instance, they may be asked what makes their work meaningful, despite its challenges; or reflect on the repercussions of their work on family members.
Earlier this year, Stanford family practitioner and clinical professor of medicine Eva Weinlander, MD, met with a handful of colleagues from different departments and at various stages of their careers. Over a dinner of pasta with clams at a Palo Alto restaurant, they talked about how they show appreciation and gratitude toward their families.
“We work in silos and we don’t know what other people are going through,” said Weinlander, director of faculty wellness for the division of primary care and population health. “Getting together over dinner brings back the humanity and connects us with the people around us whom we don’t get to know except superficially. Having them share their stories is a good reminder of your own purpose and meaning.”
Simply connecting with colleagues has helped clinicians feel more fulfilled in their work lives, according to research studies and a survey of the 116 faculty who took part in the dinner meetings in 2018. The WellMD Center is now helping five other interested departments launch similar groups.
The comprehensive approach of Stanford’s WellMD Center has sparked a proliferation of similar programs around the country as leaders have come to recognize that helping physicians remain healthy and fulfilled is not only good human relations policy but can also save organizations money. Every dollar spent on wellness brings in a $3 to $6 return on investment as a result of reduced medical errors, less physician turnover, improved patient satisfaction and improved quality of care, according to an October 2018 commentary in the journal Health Affairs by Minor, Shanafelt and 13 authors from other institutions.
“Many of the things that make practice easier may also save money in the long run,” Murphy said.
As for Walsh’s bout with burnout, he said he regained his equilibrium through mindfulness, counseling and a transition into a different job at Stanford that he loves. He still meditates and does breathing exercises to help him remain calm and focused. “Two years ago, I thought I’d be retired by today, but the work is too compelling,” he said. “I think the lesson is that health care is important but difficult work for physicians, and the stresses inherent in that put us at risk for burnout. But the good news is that it’s not inevitable or permanent.”