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From the Trenches

By Kerri Palamara, MD, MACP

Some call it burnout. Some call it languishing. Others call it loneliness. Regardless of the term you use, it is increasingly clear that the struggle we face as physicians is not only more prevalent but also different from how it's ever been. Many say, “I can't wait for things to go back to normal.” To that, I say, “It had better not!” Rather than things going back to a place where burnout is the norm for physicians, we have an opportunity to create a new normal focused on physician thriving rather than struggling.

The ACP Well-being Champions are working hard to be a part of writing this new normal. As they consider how to do this, they have found several ways to focus their efforts: working with physicians 1:1 to promote individual well-being, fostering local communities of well-being, improving the practice and organizational environment, and working to change the system itself through advocacy and education. Well-being Champions are armed with a toolkit, including webinars, workshops, measurement tools, and monthly group coaching. With these supports, 152 ACP Champions across 73 chapters have engaged in over 700 activities since 2018.

Through monthly group coaching, our Well-being Champions can connect with each other, learn from each other's challenges and successes, generate new ideas, and brainstorm how to collaborate on initiatives. The following guidance can also apply to practices or organizations seeking to adapt a similar approach to well-being interventions. For those who are newly engaging in this work, we recommend hosting facilitated discussions and listening sessions that build community and connection through social engagements (e.g., coffee chats, affinity groups, and happiness hours). Other strategies include sharing quick wins with local leaders of organizations, disseminating resources about wellness practices and principles, measuring well-being in their chapter using the Mini Z, and networking with other Well-being Champions through group coaching.

For those who have successfully engaged in their work as a Well-being Champion and are looking to expand their reach, we recommend collaborating with other chapters on interactive live events. We encourage increased visibility through presentations at chapter scientific meetings, as well. At this point, most Champions have enough connections to be a 1:1 resource in their chapter, as well. Well-being Champions who are established in their role can use their connections and network to engage in sharing best practices on systems-level change to improve physician well-being. Experienced Well-being Champions also can become trusted resources within their chapters for 1:1 coaching, group coaching, and mentorship of new Well-being Champions.

The newest evolution of the Well-being Champions work, multichapter collaboration for events and activities, is an inspirational way for Well-being Champions from different chapters to collaborate, share the load, broaden expertise and representation, and amplify reach and impact. Examples of such activities include interactive webinars, peer-support projects, podcast development, and group coaching.

If you are interested in hosting an event for your chapter with a Well-being Champion or if you'd like to learn more about the Well-being Champion activities in your chapter, contact acpwellbeing@acponline.org. Finally, if you are seeking individual resources to support your well-being, please visit the ACP Physician Well-being and Professional Fulfillment web page.

By Mark Linzer, MD, MACP, and Sara Poplau, Hennepin Healthcare, Minneapolis

An important part of addressing well-being is collecting data to understand the successes and challenges. One of the meaningful parts of data collection is looking at the story it tells. In 2015, we aimed to assess if improvements in work conditions in primary care can improve clinician stress and burnout.

In our Agency for Healthcare Research and Quality–funded study, Healthy Work Place (1), the data told us that several interventional categories had better outcomes. There was no overall treatment effect (that is, interventions based on worklife data don't always work). However, interventions that focused on workflow redesign (such as providing time to nurses to help with forms or pairing a medical assistant with a clinician), improving communication (such as having clinicians meet with leaders or using meeting time to discuss clinically relevant information), and quality improvement projects to address care concerns (such as instituting automated refill lines or screening for depression) were associated with improvements in professional satisfaction or burnout. Although we were not able to test every intervention in each category, the overall finding was that interventions that fell within these three categories had the best chances of success.

Colleagues elsewhere have found what previous research has supported: Hiring team members, such as nurse practitioners, to help with inbox management (2) and coverage for physicians when they are away (3) can help alleviate burnout. Float clinicians provide crucial support for predictable life events and can potentially prevent burnout among those affected by absences.

Another real-world tested intervention is the creation of “desktop slots” in schedules to allow time during the day to catch up on documentation and inbox management (2, 4). We trialed this intervention with the most productive clinicians and found they were able to catch up on work, decrease their burnout, and still be productive. In fact, after a few months, they felt better and returned the desktop slots. The University of California, San Francisco, also implemented this strategy as part of a comprehensive approach to reduce overall burnout (2).

An intervention that costs almost nothing was discovered while working with a group of physician parents with young children. Burnout was high, and they were ready to leave the practice. After examining the problem, we learned that their last patient appointment was scheduled as a complicated visit at 4:30 p.m. For this group, that patient was often someone who could need admission to the hospital. However, the last daily appointment was also a time when staff were leaving for the day, all while the clinicians' children were waiting to be picked up at daycare. The stress of this was too much. We spoke with hospital leadership, obtained permission to reengineer the workday, and were able to move the complex appointment to earlier in the afternoon. Burnout dramatically declined over the next year.

Research shows that documentation burden (5) is real. Scribes (6) can be an important solution to this burden. They do cost money, but they also help free up time to see more patients and work more efficiently. In a surgery-based group, we found physicians were spending a great deal of time on the computer with less time available for the operating room. Once we explained the situation, leadership approved the use of scribes. Using scribes decreased documentation burden and stress; in fact, electronic health record–related stress as measured by the Mini Z decreased to 0.

What makes a good intervention? In our experience, it is one that comes from a combination of listening and data. Once the problem is uncovered, interventions can be implemented and stress and burnout can be remeasured to assess improvement. It also helps to keep the intervention focused and straightforward; everyone needs to be able to see exactly what is done so it can be replicated elsewhere in the organization. The most meaningful interventions are ones that address the needs you discover. Remember, you can start small for a limited time and experiment to find ways to address the challenges. And the best thing you can do is share your findings with others!

References

  1. Linzer M, Poplau S, Grossman E, et al. A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) study. J Gen Intern Med. 2015;30:1105-11. [PMID: 25724571] doi:10.1007/s11606-015-3235-4
  2. Lee JS, Karliner LS, Julian KA, et al. Change in faculty perceptions of burnout and work life in an academic general medicine clinic: a pre-post study. J Gen Intern Med. 2019;34:1973-74. [PMID: 31183687] doi:10.1007/s11606-019-05083-7
  3. Linzer M, Rosenberg M, McMurray JE, et al. Respecting the lifecycle: rational workforce planning for a section of general internal medicine. Am J Med. 2002;113:443-8. [PMID: 12401545]
  4. Linzer M, Levine R, Meltzer D, et al. 10 bold steps to prevent burnout in general internal medicine [Editorial]. J Gen Intern Med. 2014;29:18-20. [PMID: 24002633] doi:10.1007/s11606-013-2597-8
  5. Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med. 2017;15:419-26. [PMID: 28893811] doi:10.1370/afm.2121
  6. Martel ML, Imdieke BH, Holm KM, et al. Developing a medical scribe program at an academic hospital: the Hennepin County Medical Center experience. Jt Comm J Qual Patient Saf. 2018;44:238-49. [PMID: 29759257] doi:10.1016/j.jcjq.2018.01.001

Want to be featured in our newsletter? Share your success stories and those of inspirational colleagues (both ACP Champions and partners) by e-mailing acpwellbeing@acponline.org.

Back to the May 21, 2021 issue of ACP IM Thriving