Physician burnout is a growing crisis within the health care profession, with the latest research showing how the COVID-19 pandemic magnified long-standing issues that have accelerated the U.S. physician burnout rate. That’s why reducing physician burnout is a key part of the AMA Recovery Plan for America’s Physicians.
American Medical Association President Jack Resneck, Jr., MD, the U.S. Surgeon General, Vice Admiral Vivek H. Murthy, MD, MBA, and a panel of physician wellness experts: Anjalee Galion, MD; Nigel Girgrah, MD; and Christine Sinsky, MD, discuss the symptoms and drivers of physician burnout and examine solutions to address this crisis.
Speakers share their experiences, analyze the latest research and its implications for our nation’s health, and discuss the system-level changes necessary to reduce burnout and restore physician wellness.
Moderator
- Jack Resneck, Jr., MD, AMA president
Panelists
- Vice Admiral Vivek H. Murthy, MD, MBA, U.S. surgeon general
- Anjalee W. Galion, MD, physician wellness officer, Children’s Health of Orange County
- Nigel Girgrah, MD, PHD, chief wellness officer & medical director, liver transplantation, Ochsner Health
- Christine Sinksy, MD, vice president, professional satisfaction, AMA
Transcript
Dr. Resneck: Hello and welcome. I'm Dr. Jack Resneck, president of the American Medical Association. On behalf of the AMA, I'm thrilled you've joined us for this session. We've assembled an impressive panel of physician leaders, medical experts and the U.S. surgeon general to talk about the real and intensifying crisis of physician burnout. We'll talk about some of the causes, needed solutions, and also the importance of addressing mental health.
Although we hope the worst of the COVID-19 pandemic is now behind us, this has been a tough three years for our profession, and many drivers of burnout remain. The contours of this crisis are painfully clear.
As the nation experiences a tripledemic this winter, with hospital beds filling again due to a mix of influenza, the RSV virus, COVID-19 and other respiratory illnesses, physicians continue to hold together a health care system stretched far too thin. Once cheered for this work, my physician colleagues now face anti-science aggression by some in positions of power and influence, along with a well-coordinated onslaught of medical disinformation from social media and other channels.
Subscribe to AMA Update
Get videos with expert opinions from the AMA on the most important health care topics affecting physicians, residents, medical students and patients—delivered to your inbox.
At the same time, we're fighting efforts by some to interfere with decisions made between doctors and patients in our exam rooms. The recent criminalization of comprehensive reproductive health care in many states following the Dobbs decision has been accompanied by increasing hostility and threats directed at physicians and other medical workers.
Demoralizing across-the-board Medicare payment cuts recently took effect just as practices are dealing with surging costs amid labor shortages and supply chain interruptions. Ever growing administrative burdens, including bloated prior authorization obstacles erected by health plans, force physicians to spend hours each week fighting to get treatments approved while patient care is delayed and denied.
Taken together, these factors create a toxic environment that hampers physicians' ability to do what drew us to medicine in the first place, deliver high-quality, compassionate care to our patients. Most of us haven't lost the will to do our jobs, but we're frustrated that our health care system just puts too many obstacles in our way. The result is physician burnout. It's real and it's rising.
The most recent survey from the AMA, Mayo Clinic and Stanford Medicine showed an alarming 63% of physicians experienced symptoms of burnout in 2021, up from 38% the previous year. One in every five physicians intends to leave practice within two years, while one in three plan to cut back their hours. Doctors are tired. Seeing some of them wear down and leave the profession they dedicated their lives to really worries me.
We're facing a shortage of up to 124,000 physicians by 2034. So this isn't just important for physicians. It's vital for patients and for the health of our nation.
Organized medicine continues to give voice to these concerns and the solutions we need. The answer won't be found in telling physicians to be more resilient or set aside time for yoga or enjoy a free dinner with their hospital CEO, not by far. While wellness is important, focusing on physician resilience blames the victim. We need to fix what's broken—and it's not the doctor.
While the AMA is partnering with practices and health systems to implement proven strategies and remove pain points that make caring for patients harder, we're also addressing the larger obstacles that drive burnout at the system level. That's the foundation for our Recovery Plan for America's Physicians.
Today we'll talk about efforts to eradicate burnout and restore joy in medicine and the larger systemic obstacles and unnecessary friction that frustrate physicians and interfere with high-quality patient care.
To guide us through what needs to be fixed is U.S. Surgeon General Vivek H. Murthy. As the nation's doctor, Dr. Murthy's mission is to help lay the foundation for a healthier country, relying on the best scientific information available to provide clear, consistent and equitable guidance and resources for the public. Dr. Murthy serves as a key advisor to President Biden's pandemic response operation. Under President Obama, he created initiatives to tackle the nation's most significant health issues, including the Ebola and Zika viruses, the opioid crisis and the growing threat of stress and loneliness to America's physical and mental well-being.
He's the author of “The Healing Power of Human Connection in a Sometimes Lonely World.” Dr. Murthy is a leading advocate on the dangerous rise in health misinformation and the alarming rise in burnout in the health worker community. We've got a lot to talk about, so much that we've had to divide it into two sessions. So after you hear from the surgeon general, stay tuned for additional perspectives from our panel. Welcome, Dr. Murthy.
Dr. Murthy: Thanks so much, Dr. Resneck.
Dr. Resneck: It's great to be here and have the chance to talk with you. I want to begin with a rather somber point as we delve into this issue and the very real and negative consequences of physician burnout. And that's the tragedy of Lorna Breen, really as a devastating reminder of the backlash and consequences when physicians do reach out and seek mental health. How do we change the perception of physicians seeking mental health to make it less stigmatized and more clear that when people need it, it's a resource that's available?
Dr. Murthy: Well, I'm so glad that we're talking about this because, as you know so well and as many of the physicians listening know well, too, the crisis of burnout in our profession has been brewing for a long time. It was worsened by the pandemic but preceded the pandemic. And stories like Dr. Breen's are just absolutely tragic reminders that we have much more work to do to do right by people who are stepping up and entering this profession because they want to help and are finding often that it's too hard to do so. And it shouldn't be that way.
So how do we start to change that? Well, I think we have to ask why it is so hard for people to step forward and get care right now. And yes, you can talk for a moment about the structural challenges there in actually accessing care. Many of our lower income health workers don't have access to insurance coverage either. There are real structural challenges.
But there's a cultural issue here, too, which is that from a stigma perspective, there are still many people in our profession who don't feel comfortable asking for help or getting help when it's available. To change that, we've got to do a few things.
Number one, we have to lead by example. So leaders in medical societies, in hospitals, in clinics, and really across the board have to recognize that when they step up and utilize care and when they do that publicly, it helps other clinicians see that it's OK to do the same. When they talk about their stories and their struggles, it doesn't make them weak, it actually makes them human and other people can see themselves in them.
But the second thing we have to do is share more data so that people understand just how deeply clinicians across the board are affected by mental health concerns. This is not the concern of 1% or 2%. The vast majority of clinicians at some point experience mental health struggles, whether it's depression or anxiety, challenges with managing stress or with handling the loneliness and isolation that sometimes can come with our work. I do believe that that data would be helpful for people to see.
But third, there are changes we can make in policy that will actually help to address stigma. You think, for example, about the licensing process and how in surveys just a few years ago, 40% of physicians said that they hesitated to access mental health services because they worry that it would negatively affect their licensure. And so if you look, in fact, at the state licensure applications and questionnaires, there are questions there that would make you scared potentially to be honest about the fact that you've had to seek care, whereas we should not be punishing people for seeking care when they need it.
And finally, let's just keep this in mind, too. We all take cues from each other, right? Even if you're not in a leadership position or you don't have a fancy title, it doesn't mean that you don't have influence. But when you reach out to a colleague and you ask them how they're doing, when you yourself reach out for help when you're struggling, it's not just good for you, but it's good for others. People see that, OK, this is something we can talk about. It's OK to ask for help. And it often feels good to give help, too, when asked.
So these are all steps that we can all take collectively to help tear down that unfortunate shame and stigma which still deeply surround mental health in our profession.
Dr. Resneck: It's a great point you raised just around example setting and the power of others being able to see somebody step forward when they need help. And also glad to hear you're bringing up the licensure and credentialing. We've seen some successes in some states recently about getting those questions off of some of those applications so that people are just being asked about current impairment and not something that maybe happened five years ago. So couldn't agree more.
So I mentioned studies showing that nearly 63% of physicians experience symptoms of burnout and that was really just a soaring number from one that had been in the 30s just the year before. What do you think the first step or steps are to addressing this?
Dr. Murthy: Well, burnout is a deep, multipronged issue and it's not one issue, sort of factor that's driven it. It's been multiple factors over many years.
But with that said, I think we have to start by listening to clinicians and bringing them to the table to share their ideas about how we get past it. This isn't the kind of issue where we can have a few people together in a small room determining what the strategy should be and then implementing it for the entire profession. We have to have engagement and buy-in in the ideas from people on the front lines. So that's got to be the first step.
But there are other things we've got to do as well. We've got to recognize that there are too many burdens and not enough support when it comes to practicing medicine now. And how do we change that? Well, in terms of increasing support, we can provide more flexibility to clinicians to be able to take care of many of the things they need to do in their life—getting medical care themselves, being there when a child is sick. When you can't do that for your family in particular, it adds an extraordinary amount of stress to clinicians' lives.
But the other way we can add support is by making mental health care more accessible. And this is not only about making sure that there is adequate insurance coverage, both coverage itself and then adequate networks to provide that coverage. But it's also about making sure that we have the flexibility to bring the care to where people are.
One of the silver linings of the pandemic was that it significantly accelerated the use of telemedicine, particularly for mental health care. We've got to make sure that that does not go backward, that the authorities for that are permanent, that the utilization continues to increase, but that we bring care to where our clinicians are, which is often at work.
I remember talking during the early days of the pandemic to a group of nurses from around the country who said, you know what? We actually have insurance coverage. We have providers in our network. Our problem is we're at the hospital all the time. And it's hard for us to just find time in the day to go drive 30 or 45 minutes and spend a few hours in a clinician's office and then come back. But if you had a terminal here, where we can go into a private room and have a counseling session, we would love that. So we've got to make those supports more accessible. That's on the support side.
On the reduction of burden side, this gets to taking away the barriers that have cropped up and multiplied that stand between doctors and the patients they're seeking to care for. I haven't met a doctor across the country who has said, I really got into medicine because I wanted to chart—I wanted to spend time in front of a computer terminal.
People got into this profession, like all of us did—you, me, all of us—because we wanted to spend time with patients. We wanted to understand them, hear their stories, help make diagnoses, walk them through treatments, and be a partner with them in the healing process. And so we've got to start removing these barriers.
One of the things which I know that you and the AMA have been wonderful partners on has been in addressing prior authorizations, which this administration is very committed to doing. CMS has put out multiple proposed rules now to help address this very thorny issue of prior authorizations, which is adversely impacting efficiencies and the quality of care that clinicians, that patients receive. And so we've got to start taking away some of these barriers.
And some health systems have been doing a great job at trying to identify some of the seemingly small but, as I think of them, noxious irritants that actually cloud and color the doctor's experience. For example, the University of Hawaii Health System had their keep it simple, “Getting Rid of Stupid Stuff” program, their GROSS program, which I loved because not only was it a good idea, but they were able to show the impact of that, which is that they saved thousands of hours of nursing time and saved time for clinicians as well.
It's those types of engagements that can help us improve the quality of the experience that clinicians and patients have. And when combined with increased support, we can do a lot, I think, to help address burnout.
Lastly, I'll just say we can't start soon enough. There's been good work that's been happening thanks to the leadership of organizations like the AMA and individual clinicians and communities and increasingly health systems and with many partners in government, including CMS, our office and others. And that's all good but we've got to do everything we can to accelerate that work because our health workforce is at risk. Our colleagues are struggling and they're suffering. And it's not only them that are on the line, but it's the patients they care for, who they care for, whose health is now at risk and whose access is at risk.
So health worker burnout is not just a problem for health workers. This is a national priority and it's one that deserves our collective attention. And that's one of the reasons why earlier last year we put out from my office a Surgeon General's Advisory on health worker burnout, to call our country's attention to how significant this crisis is, and to lay out a pathway through which we can address it.
Dr. Resneck: That's great. You mentioned telehealth. The administration's flexibilities at the beginning of the pandemic were just transformative in really allowing us to seamlessly integrate that mode of care, I think, for our existing patients. It's been fantastic. And seeing Congress extend that has been great.
You mentioned prior auth. A huge thank you from the AMA. We're just in the process of really reviewing the details of those proposed new regulations. But I would say that physicians and patients, too, I think, are really heard. I hear their voices as I look at these regulations and think about what an enormous burden this has been for the profession, how much it affects patient care. And that's demoralizing, I think, for physicians to know that there are things getting in the way of actually providing that care that they're motivated to get for their patients.
Dr. Murthy: I'm so glad that the AMA, that the administration and other partners have focused and really zeroed in on this because I've had, and all of us have had, our own personal stories of managing and grappling with and battling, really, prior authorizations. And it's hard enough sometimes to make a diagnosis. It's hard enough to then actually get treatment for a patient.
But to be denied the care, often time-sensitive care that a patient needs because of a bureaucratic process that often feels like it's set up to inhibit care and prevent expenditures rather than improve quality of care, that hurts patients and doctors. And blow after blow, when you're struck by that day after day, it's tough. It's incredibly difficult not to lose faith sometimes in the system.
So I think our work to address prior authorizations and other barriers, this is really aimed at getting back to what medicine really should be, which is an opportunity for clinicians to focus on doctoring, on providing the kind of care that patients need, which means spending time with them. And every minute that a doctor is spending battling with an insurance company instead of listening to a patient and talking to them about their illness is a minute that's not well spent and everyone suffers.
Dr. Resneck: I couldn't say it better myself. I think when you and I were in training in years past, this prior auth was focused on a few brand new expensive drugs or procedures or tests. And I think our colleagues are now feeling it on even generic prescriptions sometimes that they write, where they're ending up having to fight on the phone. So it's a huge issue and I appreciate your shining a spotlight on it.
You mentioned the advisory that you put out, and I did really enjoy reading it and thought it was fantastic. I appreciated your leadership in this area. The advisory, you dedicated it to the thousands of health care workers who lost their lives during the COVID-19 pandemic. You said, "They put their own health and safety at risk so they could heal and comfort others. The call to action is dedicated to their memory."
You also in there drew specific attention to a lot of historically marginalized physicians and other health care workers who are disproportionately affected. Can you tell us a little bit about the response you've seen to this so far and the impact that you think that the advisories had?
Dr. Murthy: Well, thank you for the kind words, and that was really, that advisory we issued on health worker burnout was really a labor of love. It was a personal topic for many of us who—and we have doctors and nurses and others in our profession, in our office who have been on the front lines. And we've seen how this has impacted our colleagues and all of us and so this is very personal for us.
The truth is the dedication that we issued at the beginning to those who have lost their lives in our profession, this is actually the kind of approach that clinicians have taken for years before the pandemic.
How often is it that you've seen our colleagues put their safety at risk because they knew that they needed to take care of somebody? How often have you seen them put their own personal lives on hold because they knew that a patient had an acute need that had to be met? How often have you seen them cancel plans because a patient had a dire need in that moment?
We've all seen that. And that's actually the DNA of our clinicians and of our colleagues. We shouldn't abuse that as a society or take that for granted. We want to honor that kind of instinct. We also want to make it sustainable. And for many people, it just isn't right now.
I've been very grateful that the response to the advisory has been overwhelmingly positive and, interestingly, from many clinicians out there who said they just haven't felt seen and heard and they feel like they are being taken for granted, that people assume that they will just always be there, even though they are dealing with more and more and more.
But we've also been excited about the partnerships that have been evolving since that came out, partnerships with health systems, which we are finding more and more are stepping up to ask, what can we do to actually accelerate our work on well-being? We also have more and more partnerships within government itself, including, for example with CMS, where we're doing work around issues like prior authorizations.
But this is what we need to do more of because unless we work together in collaboration with medical societies and with government and with health systems and EHR vendors and educational institutions, we won't get at all the factors that are driving burnout. And I think we also have to collectively speak as one voice to the public and help people know that, again, this is not a niche issue. But the issue of physician burnout stands to affect the health care of everyone in America, and that's why it has to be a national priority.
Dr. Resneck: During the pandemic, in this role I just get to see my physician colleagues around the country and what they're doing. I think as they ran towards the fire and put their lives on the line, I just was filled with pride in what my physician and other health care worker colleagues were doing around the country.
And we did go from this place in the beginning where people were banging pots and pans and hollering and supporting physicians out their windows to after a while during the pandemic, physicians were more and more having to face this whole other threat of disinformation and purposeful misinformation, whether patients were getting it through social media or other means. And I think it has been an additional burden in a way on the profession and driven more burnout. Do you have thoughts about that?
Dr. Murthy: That's been heartbreaking to see. I really believe that the vast majority of members of our profession are heroes. They're there to sacrifice and to care for the people who come to them in need. And that's what they've done admirably throughout this pandemic.
But seeing that appreciation in some cases turn into indifference, in other cases turn into vitriol, that's been incredibly painful. 80% of health workers say that they sustained either physical or emotional attacks during the pandemic, 80%. And if you imagine going to a job where you think there's an 80% chance that you're going to be abused, I mean, who would want to come to work? Yet our colleagues continue to show up.
Now, one thing that's important to ask is what's driving that vitriol? And one of my deep worries is that we've had not only a polarized response but a tremendous amount of misinformation that has spread online, that has made people question science, has made them question validated data, that's made them question the scientists and clinicians that they typically entrust with their health. And, look, people should ask questions. We should be rigorous about how it is that we come to make the recommendations that we make.
But I think what we saw was something very different during the last couple of years, which is in some cases information being willfully spread. In other cases, they were very well-intentioned people who were sharing misinformation because they couldn't tell the difference between what was true and what wasn't.
And I think to really address that misinformation, we've got to do a few things. And this, by the way, needs to be a priority because when I look at the future and I think about what are the great threats that we have to our health, health misinformation really stands out as one of those. Because we can have the best science, we can have the best clinicians in the world but if people don't believe that illnesses are real, if they don't believe that the treatments proven to work can help them, they will not seek out that care. And, sadly, we are seeing that in some cases play out right now with COVID vaccination and even with treatments.
So, what do we have to do about it? Well, there's a lot we have to do as a society and I everyone has their role. Specifically as a medical profession, I think, number one, we have to recognize that we still are one of the most trusted professions in the country. And the question is, what are we going to do with that trust? How do we utilize this moment to speak with people and listen to what their concerns are? Because sometimes people have legitimate concerns. And I when we swat them away when we make them feel like they are perhaps not intelligent or gullible for believing misinformation, they tune out and understandably so. So we've got to, number one, listen to people and understand why they believe what they believe.
I think the second thing that we have to do is we have to ensure that we have a bigger voice in the public square, right? Right now our voices are often limited to the exam room. But out there, I know for a fact that people in communities want to hear from the clinicians in their community.
There are so many moments in the last couple of years where schools, at school town halls, it was parents who were doctors who actually stepped into those meetings to actually try to explain to people what science was telling us about COVID-19. The same is true in faith gatherings, where our churches and synagogues and mosques, when congregations were confused, it was a doctor from the community at times who was able to step in and provide some information that was trustworthy and reliable.
We have to do more of that. We can't cede the public square to people who don't necessarily have the qualifications to assess data or don't have experience caring for patients. Everyone can have a voice but we should have more of a voice for those who are truly experts.
The third thing that we've got to do, though, is also make sure that we are advocating for and supporting efforts to ensure that the people across the country have greater health literacy. Being health literate is not a simple thing. It is hard for even those with a college degree and a PhD to even sometimes understand what science tells us, right? These are very difficult things. And it's also hard for sometimes even doctors to know what the difference is between information and misinformation when they see it online.
So this is not about intelligence. This is about training us to be able to distinguish what's true and not true in a rapidly evolving information environment. And we haven't really kept up with that. We haven't helped guide people in how to approach health literacy. But that's something we should be doing from the youngest of ages because it's a vital tool for survival right now.
So these are a few things that we can and should be doing. But one last thing I would offer, which is that if we want to, I think, be as thoughtful about this as possible, I think we have to be honest about what worked and didn't work in the public dialogue during COVID-19. And for many of us who are familiar with the scientific process, we're used to debate and discussion and information from trials evolving over time and sometimes conclusions shifting as the data shifts. But that was not a very familiar process to a lot of people on the outside, who looked at that and said, why am I being told one thing today and now another thing tomorrow? Why do things keep changing?
I think part of what we have to do also is do a better job of bringing members of the scientific community together to be able to discuss different points of view but then come out with a general, if not a consensus, a majority opinion about where things stand. And some of the questions we have to discuss is who's at those tables? How do we make sure that the tent is big enough to make sure different points of view are represented? How do we make sure that minority opinions don't get suppressed or squeezed out? Because sometimes there's something really valuable there that we need to hear.
So how we create and model, I think, a big tent where we can listen, where we can evaluate, but then where we can come forward with thoughtful scientific conclusions is something, I think, we can do a better job of as a profession. And if we do that publicly, I think it will help members of the community who want to know, what should I do for my health and for the health of my family?
Dr. Resneck: Your points about health literacy are important, and I think it even goes back to science education in elementary and secondary education so people actually understand the scientific process. Then you're right, we have an important role to play in bringing more people into those tents and thinking about how we communicate.
I'm thinking about the sort of anti-science aggression and how hard that has been on the profession, and then on top of it, at the same time, we have states and legislators trying to sort of insert themselves in exam rooms in different places around the country and interfere with that important doctor-patient relationship, where we really do a lot of shared decision making. And it really is about sharing our expertise and then meeting the patient where they are with their expectations and values.
But whether it's reproductive health care or gender affirming care, we're seeing doctors also have to worry about having state legislators or others sitting on their shoulder in the exam room. Do you think that's added to the burdens?
Dr. Murthy: Well, absolutely. When you go to medical school, as you and I did and our colleagues did, and you're learning medicine, you're learning how to take data, how to make sure you use it to help a patient, how to understand their psychology, how to support them. What you're not learning about is how to contend with the intrusion of government or other entities in the relationship you have with your patient. And I think that has added fear and undue stress to a relationship that's already been challenged between doctors and patients by all the other intrusions and burdens that have been layered on top of it. So I do think this is a big challenge.
I think what's important for all of us to recognize—and it should not be political, it should not be a partisan issue—is when we support doctors and patients in working together to come up with the best decisions for patients that everyone generally does do better because we have—this is, I think, where we have to come at it with humility. None of us can recognize the full complexity at play when a patient is making decisions for their health. We do not know the interplay between their socioeconomic factors, their faith, their values, their past experiences.
All of these things come together to help inform a very complex, nuanced decision, and we can't paint that with a single brush. Whenever we try to do that, I think we ultimately contribute to harm. And that's why I think we have to trust that patients and their clinicians can make these decisions together, and we should be supporting them in that process. And when we don't, I just think we make the lives and the work of clinicians harder. And we make better health outcomes more difficult.
Dr. Resneck: I think it's that complexity that drew us and probably most of our colleagues who are watching today to medical school in the first place. We wouldn't do these jobs if they were easy and simple, and that's one of the reasons that when I think about legislators trying to lock medical decision making into statute, that it just doesn't make sense because these decisions are really complex.
I'm going to give you one more question and then I'll let you offer some concluding comments. We've also talked about the tripledemic a little bit that we're witnessing right now. And in your own work, you've really led the national response to Ebola and to Zika, and you were a key advisor to Biden's pandemic response operation.
Can you talk a little bit about the relationship between stress and mental health and loneliness and physician burnout and, in particular, the unique type of burnout that physicians experience during a period of history like this when we're in the midst of the COVID pandemic?
Dr. Murthy: Stress is something that is certainly no stranger to members of our profession from the earliest of ages. Stress is almost in part of our training, part of our education process, part of our work lives.
But there's good stress and there's bad stress. And when we go to the gym, for example, we stress our muscles. And if we stress them in a good way, where we put on an adequate load that's not too much, not too little, and where we give ourself adequate time for rest in between, then we get stronger. We get healthier.
But imagine if I lifted a barbell that was way too heavy for me and I held that position for 30 minutes. I'd probably do some damage. And we know this from times where many of us may have been injured in the gym from improper lifting techniques. I certainly have done that, I will admit.
So there's a right way to stress our bodies and a wrong way to stress our bodies, and this applies to emotional stress as well. We certainly can contend with stress but there are a few things that make it harder for us to do so. One is when the absolute load is way too high. Another is when the duration of stress is prolonged. And the third is when we're dealing with concomitant loneliness and isolation because it turns out that loneliness is a natural—I mean, social connection, rather, is a natural buffer for stress.
If you think about it, a lot of times when we are stressed, when most people are stressed, one of the things they do is they reach out to a friend. They get in the car and drive over to see a family member. They do something that connects them with somebody they have a safe relationship with because that helps to relieve our stress.
But when we are further isolated in our work because we have long work hours or odd work hours—we're not syncing with other people's social schedules—when we start to feel just more and more weighed down by our work and don't want, don't feel like we can share that burden with others, when we become more lonely and isolated, that actually worsens the impact of stress. And that's one of the reasons why as we think about how to deal with stress, not only do we need to deal with the structural factors, not only do we need to address the stigma that prevents people from getting care, but we have to think about how to build social connection and community in our lives as well as within the house of medicine.
I'll tell you that when I was in residency training, it was not easy by any stretch of the imagination. The hours were tough, the type of work was hard, we were dealing with emotionally laden issues.
But I actually loved my time in residency for one primary reason—for many, but for one that rises to the top—and that was the people that I worked with. We had a real sense of connection. I felt like I was coming to work with friends every day when I came to work. If I was worried about screwing up, I knew that there were other people who would help me not make a mistake, would support me, who wouldn't make me feel ashamed or embarrassed. That made all the difference in the world.
But I know that after you finished training, for many clinicians, it becomes very lonely. You don't necessarily have that built-in community. People separate and go off into their lives, get occupied with other things, and we don't invest in building those bonds, we don't have the opportunity to.
So as we think about addressing stress, I want certainly to think about access to care and the structural factors driving stress. But I think that the social connections that we foster, they're not just nice to have. They're absolutely necessary if we want to make it through what are extraordinarily difficult days and a job that's incredibly important but that also can be very, very stressful.
I know today we talked about a lot of topics that are challenges for the profession. For anyone who's considering going into medicine or if you've got a child who's thinking about going to medicine or a friend who's thinking about going into medicine, a thought may pop up into your head, is this really the right recommendation to make that they actually pursue a career in medicine? I just want to advocate in this moment that the reason—that the answer is absolutely yes. This is an extraordinary profession to be a part of, despite all the thorns that we've spoken about, all the challenges that exist.
There are few lines of work where you get to be a part of a patient's life in as intimate a way as we get to be. There are few opportunities that people have to be able to help and intervene at a time of crisis and provide comfort and care when a person and their family most need it. We are so incredibly blessed to be able to do this work, and this work is needed.
So, yes, there are changes we have to make. Yes, there are reforms that we have to fight for. Yes, there are colleagues that we've got to support. But we need good people in medicine. This is still an incredibly fulfilling profession and it is so deeply needed.
I would just encourage folks out there who have encountered students or others who are thinking about whether to go into this profession to urge them to do so. For all of those who have made that leap, whether it was a couple of years ago or a few decades ago, to become a healer, I just want to say thank you for enduring the challenges that you've been through, for enduring the struggles that we're going through as a profession, and for sticking with it because the truth is people need good clinicians who are knowledgeable, who are thoughtful, who are empathic and kind.
I think we can get to a better place in terms of the quality of practice of medicine but we need good people in the profession, and I would certainly encourage all those who are interested to join up.
Dr. Resneck: What a wonderful note to end on. I feel the same way. What we get to do is such a privilege. I love the policy work that I do and getting to come to Washington but I still am a practicing physician, and to get to go back and sit in an exam room and be face to face with a patient and actually have them share their problems and challenges and concerns with you and work together towards a solution, there's nothing else like it. So I really couldn't agree more.
And I think it's really what motivates I know my work and I'm sure your work and the Public Health Service's work and the administration's work as well to make sure we leave behind a profession for the next generation that continues to be joyous. And that's why we do this work to fight burnout and get those obstacles out of the way.
So thank you, Surgeon General, so much for your time, for your leadership, and using your platform to draw attention to this really important topic. To our audience, thank you for joining us. The conversation is really far from over. Please stay tuned for the second half of this discussion, where we're going to be joined by our panel of experts. Thanks again.
Dr. Murthy: Thanks so much.
Dr. Resneck: We're back. Thank you again to U.S. Surgeon General Dr. Murthy for his leadership and his insight in that last fantastic session. Now we're going to gather ideas, recommendations and proposed solutions related to burnout and mental health from our panel of physician leaders and medical experts. We'll talk about what wellness looks like in the health care space and what we must do to move closer to it.
Joining us are three physician leaders with significant experience in recognizing and solving physician burnout at the individual and system levels. It's my pleasure to introduce Anjalee Galion. Dr. Galion is a pediatric neurologist, physician wellness officer and president-elect of the medical staff at Children's Hospital of Orange County in California. She has a passion for wellness initiatives with a focus on system-wide operational solutions. She's a noted researcher through the National Institute for Neurological Disorders and Stroke and a consistent advocate for policies that support health and wellness. Welcome, Dr. Galion.
Dr. Galion: Thanks for having me.
Dr. Resneck: We're also delighted to have Christine Sinsky, MD, with us today. Dr. Sinsky is a board-certified internist and the AMA's vice president for professional satisfaction. She's the author of "The Quadruple Aim," "Joy in Practice," "Texting While Doctoring," and "Creating a Manageable Cockpit," contributions that continue to lead our national conversation on wholeness, wellness, and how physicians might achieve and maintain both. Welcome, Dr. Sinsky.
Dr. Sinsky: Thanks, Jack. Glad to be here.
Dr. Resneck: Rounding out our panel is Nigel Girgrah, and Dr. Girgrah is chief wellness officer and medical director of liver transplantation at Ochsner Health System in New Orleans. He's a recognized thought leader in workforce well-being with a degree in managing health care delivery from Harvard Business School. Ochsner Health System is the recipient of a $2.9 million grant to address workforce mental health and burnout. Welcome, Nigel.
Dr. Girgrah: Great to be here, Jack, and joining you all.
Dr. Resneck: It's wonderful to have all three of you with us today and we've got a lot to talk about. So I'm going to go ahead and jump in with some questions if that's OK. Anjalee, let me start with you. Can you talk a little bit about the importance of sleep and the impact of sleep deprivation based on your own research?
Dr. Galion: Thanks, Jack. Our knowledge about sleep and really the impacts of sleep deprivation have really, really increased in the last 30 to 40 years. The main concept is that your brain is actually doing very important work during sleep, and they're not just a bunch of hours from which you can steal to do other stuff.
A nice study in JAMA a couple years ago looked at hundreds of physicians and what they found was that one in three physicians screened were actually positive for a sleep disturbance. Even more interesting was that those who are positive for a sleep disturbance had higher rates of burnout and less professional fulfillment. Advances in sleep actually help us to understand the why.
There's two main concepts I wanted to bring up, and the first is the idea of connections. When you're awake, your brain is making all these connections. It gets stimulation, it's getting all this input, and the brain cells are actually connecting.
In sleep, we have now understood that the brain is actually getting rid of the connections that you don't need and helping strengthen the ones that you do. This makes sense. A lot of us remember in college they said, don't pull the all nighter. It's better to go to sleep and then wake up in the morning and study. We have better executive function, better cognitive performance when we've had good sleep.
The second is the idea of how sleep is related to chronic health conditions. A lot of people know that things like sleep apnea is related to cardiovascular stress. But the brain actually has important physiology that happens in sleep even without pathology. The brain actually activates an entire filtration system, the glymphatic system, during deep sleep. The glymphatic system filters out harmful things, like beta amyloid, which gets deposited in high amounts for people who have things like Alzheimer's.
Really to me, this is about that broader concept of the toll of constantly being on call, for the hospital, our patients, and those ever-present dings and pings and texts. Our brain isn't really getting the time to disconnect and do other work that it needs to do so we can perform optimally. We increasingly see athletes, high-performing people recognizing the importance of good sleep. And it's important that we take that same lens for our physicians, not just for our health and wellness and really to support our workforce, but really to provide great, safe patient care.
Dr. Resneck: Anjalee, now I'm just worried about the damage that's already been done with my own sleep deprivation. But really important points. Thank you, thank you. I think as we design workflows of the future, this is really going to be important.
Chris, I want to turn to you for a second. A lot of the early work in physician wellness was focused on individual resilience, and it always felt to me a bit like that was sort of blaming the victim. In a recent interview, you said something like. "It's important for us to realize that while burnout manifests in individuals, it originates in systems." Can you elaborate a little bit on these ideas and how you think they fit into the discussion?
Dr. Sinsky: Sure. I'm happy to do that. I think we know that any time the majority of a group experiences something, then it has to be related to something other than individual weakness. So we know now that 63% of physicians are currently experiencing some sign of burnout. And that can't possibly be related to individual weakness on the part of physicians.
In fact, we from a study we published in 2020 that physicians as a group have a significantly higher level of resilience than the general population. We are a highly resilient profession and so I think, rather than focusing on fixing the worker, we need to focus on fixing the workplace. Just as Dr. Galion was saying, some of this manifests in individuals in the sleep disturbance, which then can contribute to burnout. But it's related to the system in which we are working, to all those pings, to all that call.
And so I think the work we need to do is to build better teamwork, better technology, better workflows, continue to work to reduce the administrative burden, and that's all happening in the work environment. Rather than trying to fix the individual worker with yoga and mindfulness and meditation, as helpful as those things may be, that's not where we should start because it's the environment, the system that's broken, not the people within.
Dr. Resneck: Great points, thanks. Nigel, I want to talk a little bit about the four-pronged approach to mental health that you've talked about. Can you tell us a little bit about how you came to those four elements and what changes you've really observed based on successes with that approach?
Dr. Girgrah: Sure, Jack. I think an approach to mental health or for that matter any organizational imperatives should be based on data, qualitative and quantitative data married with a little bit of intuition. So in our case at Ochsner, our quantitative data, we looked at surveys, both engagements and the AMA Well-Being Index. We were able to measure burnout, drivers of burnout, the state of mental health, both depression and PTSD, and also barriers or perceived barriers to seeking mental health support.
Another data point was we were seeing actually in the first year of the pandemic our EAP utilization going down, which was a little perplexing. But I think qualitative data can be more important. So by this, I mean the comments on the surveys, what I was hearing when rounding on the hardest-hit units during the waves of the pandemic, comments from focus groups and open forums.
Distilling this down to a voice, the customer, overall, I was hearing that while an EAP program is great, folks wanted to get a little bit more upstream, proactive versus reactive, a little bit more on demand.
So, very briefly, our four prongs are the first part would be just simply educating folks and raising awareness, secondly, measuring mental health, as I discussed earlier. Thirdly, destigmatizing or normalizing the conversation in a few ways but mainly through changing leadership behavioral norms and communication norms. And then lastly, experimenting with different support offerings and looking at things like utilization, net promoter score, scores with those offerings and scaling those things that seem to be working and sundowning those that aren't.
In terms of what I've observed compared to 2019, mental health and well-being is just much more part of our culture, our fabric. We're seeing this, Jack, with our executive communications, how our department meetings are run, one-on-one check-ins. We even have a mental health affinity group or resource group. That wouldn't have been the case in 2019. And it just seems like people, both front-line clinicians and leaders, are reaching out for help here at Ochsner.
Dr. Resneck: Nigel, I'm glad you mentioned leadership because I think we've seen in a lot of the data and in our AMA work with health systems that that is just such an enormous predictor of levels of burnout, the true level of engagement of leadership within a system or practice. Glad to hear that. Anjalee, I'd love to come back to you and sleep medicine for a second, and maybe even bring in a little bit of digital health, which I know you've thought about as well, and the role of advancements in those spaces to reduce physician burnout.
Dr. Galion: I think we all recognize that technology has had such an amazing effect on our lives. But as a society, we're still trying to find that balance of the benefits and the consequences. The pandemic really jumpstarted that with telehealth and all these new ways for us to be connecting with patients' families. But what we also see, that for physicians, it's not just about that connection but that feeling of being responsible all the time that can really perpetuate some of the burnout.
Just, again, to Nigel's point, I think organizations like the AMA are doing a really good job of helping us build awareness but also understanding of what goes into it. I want to recognize systems like my own at the Children's Hospital of Orange County, where they're actually using existing digital platforms to help understand this.
So with our email system, things like Outlook and the Microsoft Calendar, they actually track how much meeting burden is, how many administrative tasks we have. And we get information about how much people are on email, how quickly they're responding or feel that they need to respond. It's really powerful data in your own email system to see how many people are doing tasks after 8 p.m. and sometimes after midnight.
The other thing is that the electronic health record has had so many benefits for our patients— documentation, clear orders, standardized order sets. But what if we used it in a different way? What if we thought about the EHR as a tool to look at physician burnout?
Our health care system is one that's actually trying to do that, seeing how many clicks does it take you to get through a patient chart? How much time are people spending charting after hours or efficiently? What is really interesting is that if we think about the existing digital platforms as not just tools to help the patients but as a mirror to see what's going on in our own organization, it's really powerful.
The other thing it does is it allows us to use existing measures to see if interventions make sense. I loved Christine's point that asking physicians to do more yoga is not the answer. But if a system is going to change, we have to have measurable ways to see that the intervention makes a difference.
And so can we use existing technology to do that? Again, we've recognized how this is important for trainees. But I wonder what it would be like if hospitals said, if you're not on call, maybe you don't need access to the EHR. Maybe you shouldn't be expected to do extra things. Would it actually shift our expectation of what can actually be done in a workday if the workday wasn't 24 hours?
So leveraging existing technology, I think, can be a powerful tool, and we don't always have to look for something new. Helping us understand the scope and breadth of this issue and how to make a difference can be really powerful.
Dr. Resneck: So glad to hear about leveraging all these data that we actually do have in these tools that we're using. Do you have an example, maybe, of—so once you've found out that a certain subset of physicians are spending a lot of time at 11 at night, we even hear from our patients sometimes, I can't believe you're answering my message at 11 p.m., an intervention that in response to those data a health system can undertake?
Dr. Galion: So one of the things is when you engage your leadership and you change the expectation of response time. The Microsoft system will actually say, hey, do you need to send this email now? Why don't you wait until business hours?
There's also this idea of just highlighting what's going on so we verbally recognize and acknowledge, you don't have to respond 24 hours a day. You don't need to on Saturday night, at 1:00 p.m., be doing all of this. So these ideas of engaging leadership and then having gentle prompts, which don't feel too onerous, to say, hey, do we really need to do this now, can be really helpful for the system.
Dr. Resneck: Chris, I've heard you cite some data in the past around specific costs to the health care system of burnout. And I know that when we talk to health systems, we often utilize these data if they need a bit of a wake-up call as to how big of a problem this is. And I've heard the number, $4.6 billion, just based on the turnover and reduced hours that occur due to burnout, not even including many of the other costs. Can you say a bit about how the AMA is responding to this crisis, how it's maybe different than some other things that we've faced as an organization?
Dr. Sinsky: Sure, happy to do that. So first, I think we're raising awareness about how costly burnout is to various stakeholders. So it does cost us, at the tip of the iceberg, as a health system $4.6 billion a year. Individual health systems also bear a cost. If you're a system that has 1,000 physicians and average rates of burnout, you are already investing over $13 million every single year just replacing those physicians who leave your organization not for a better job, not for career advancement, but who leave just because of burnout.
And so our message is, invest a fraction of that upstream on the activities that will reduce burnout and you'll have a positive ROI. Many of the things, Anjalee, that you were talking about, all that work outside of work or pajama time that's happening at night, is driving burnout. We know that if you've got higher rates of work outside of work, you have much higher rates of burnout than if you are in the lower quintile of work outside of work.
So we've been doing a lot. The AMA has invested many millions of dollars every year on removing obstacles from the physician in their care of patients and reducing burnout. So we do research. We sponsor 8 to 10 research projects every year that are using EHR audit log data, all that data that's already being collected, and looking at things like time on inbox, and how does that relate to burnout? And how can we reduce time on inbox with greater teamwork?
We help organizations measure both the rates of burnout in their organization and the precursors of that burnout and the consequences. So we have what's called an organizational assessment, our Organizational Biopsy®. And, Nigel, your group was our initial group to do that in a pilot fashion and we now have national benchmarks. We do that at no cost to organizations so they can have a better sense of what's happening and use local data to communicate among the leadership about the issue at hand.
We have a recognition program where we recognize organizations that are really doing exceptionally well in terms of addressing health professional well-being. And this also serves as a roadmap. So organizations who are at the beginning of their journey and are saying, I know we've got a problem but we really don't know where to start, we don't know what to do, have been using this recognition program and the criteria and using that as a strategic roadmap as they map out the next three to five years of their efforts to reduce burnout.
We have an enormous wealth of resources in what we call our STEPS Forward® Academy. We have had over 1.8 million unique users of our STEPS Forward® toolkits. We have webinars. We have podcasts. Thank you, Dr. Girgrah, for being a frequent podcaster with us on that.
One of the things that's part of our STEPS Forward® is a Deimplementation Checklist. So it's a guide that organizations can use to look through and see, are there opportunities for us to remove policies that at one point made sense but are no longer necessary or relevant? And we sent that checklist to The Joint Commission, who reviewed it, made a few comments and we edited it accordingly. So we now know that this is aligned with The Joint Commission standards, which means it's also aligned with CMS requirements.
One organization, Kaiser of Southern California, had looked at that list and saw that one of the things we recommend is to remove unnecessary password burdens. So they looked it over and decided they no longer needed to require password revalidation at the time of putting in an order. So they turned that off. That provided relief for 1.5 billion, with a b, orders every week in their system. And other systems have done that as well, and talk about the relief that just rises up from within their organization by removing that really frequent pebble in the shoe.
Then, just as another example, we have an Inbox Reduction Checklist that will be published in the next few months. That is available now individually, but it goes through some of the things that other organizations have done to reduce the volume of inbox work, which is what is causing physicians to spend hours every day after hours. And, really, physicians aren't leaving their jobs, they are leaving their inboxes when they choose to leave their clinical position.
So, I think we're really fortunate that the AMA has invested a lot of resources to help address these issues. And I'm optimistic because there's so much good that can be done.
Dr. Resneck: Chris, the term "deimplementation checklist" just brings a smile to my face every time I hear it, and I think about some of the wasteful things that we've all built into our systems that we can take back away, particularly as we keep adding new things.
I've also really been pleased with your group's work and the rest of AMA's work around as we take this from the individual level up to the system level and we think both about all these great examples you've given about helping practices and health care systems to reduce friction and take some of those burdens away, but also as our advocacy team and the rest of the organization thinks about trying to take some of those burdens down at the big health system, insurer, or government level like prior auth and all those other things that have grown out of control that actually contribute to this. So, keep up the good work.
Nigel, you wrote a letter to 34,000 coworkers sharing some personal reflections on self-care and mental health. I'd love it if you could share with our audience today a little bit about that and about the reflection, a reaction that you heard from your colleagues.
Dr. Girgrah: Happy to. So I, like many of us, was really struggling in the summer of 2020, the first year of the pandemic. Summer's often a tough time for me. It represents the anniversary many years ago of my son, Bennett, and then his death the following year. Usually I'm able to recognize the symptoms and compensate. I usually plan a vacation up to Canada to spend time with family and friends, visit the grave.
Exercise is important. That summer I ruptured my quadriceps tendon and had surgery, so I wasn't exercising. And things just seemed to be getting worse. I called it languishing, but it was probably a euphemism. I think I was anxious and depressed.
So eventually I reached out for help and certainly got on the right track quickly. And I guess an epiphany of sorts for me was that many of us, if not all of us, have some version of that story but are timid to reach out for help essentially because of the stigma around the conversation, particularly in health care.
So in September 2020, I composed an open letter. I have a quarterly open letter but my previous ones would be the kind of sterile, sort of report out some of what we were doing. In this one, I told the story. I told that story that I just shared with you. Then I talked more broadly about what I thought was the stigma that exists around mental health in health care. This part just talked about intuition and data, this was all intuition.
I'd run it by a few executives and they were supportive, but I was extremely nervous sending that out. But it was pretty overwhelming. Most executive letters that go out or executive emails may elicit two or four responses. I had hundreds of people reach out sharing their stories, some of them calling it a call for action to seek help. I talked earlier about changing leadership communication norms, and I think it's a fairly important step within our organization.
I've seen many communications by other executives, not just at this organization. I'm not saying that my letter was the reason for that, cause and effect, but I think executive emails have gotten a little more conversational, a little more personal rather than just data reports, if that make sense.
Dr. Resneck: Thank you for being vulnerable and willing to share that. As we have seen so many physicians due to stigma not get the help that they need when they are in crisis, I think we just can't say enough about the power of having a respected senior colleague share their own stories as we work to destigmatize that. So I really appreciate that.
Chris, how do we get back to this work? At the end of the day, we want to reduce burnout because it gets in the way of doing what brought us all to medicine in the first place, that love of actually providing care to our patients. How do we shift the framework and get back to that?
Dr. Sinsky: Right, right. Well, first of all, I just want to underline what Nigel just said because I think leadership modeling getting help, avoiding the iron doc stereotype is really important, and it's a way of being human and a way of having relationships. You were human and developed a relationship with the other people within your organization by sharing that letter.
So how do we get back to doing the work that really matters? I think there are a couple of key concepts. One of those is that we have evolved to a very transactional notion of what health care is and yet I believe at its core, our work is relational. And when we build the infrastructures and the processes within our organization and we support that with the policies and the physical space and the technology that supports relationships with our patients and supports relationships with each other, we will have better outcomes.
I think, stepping back again, over the last several decades, when the EHR was implemented, I noticed that there was this great work transfer, that work that previously was done by receptionists, pharmacists, medical records clerks, by transcriptionists suddenly became the work responsibility of the physician. And because of that iron doc mentality and because we always step up to the plate and take on what needs to be done, we kept taking on and kept taking on until it started to break us. I think it's come to the breaking point when we have two hours of EHR and desk work for every one hour of direct face time with our patients.
And I think what's happened is we recognize that we are spending our days doing the wrong work for our patients. We are spending our days doing transactional activities and we are not doing the healing work of deep thinking, the deep work of doctoring and of strengthening the relationships.
So there's a framework that I came upon that I think has really been helpful in my own thinking and I hope it's helpful for others. It comes from the Harvard Business School and Clay Christensen, who had been at the Harvard Business School. It's the idea of solution shop versus production line work, that in most industries, the highest-trained professional, their time is reserved for solution shop work, which has meant the solving of unstructured problems. And I'd modify that in health care to mean the solving of unstructured problems and the development of relationships.
And production line work can also be very important, but that's more the standardized, predictable work of the practice, some of that work that previously was done by the receptionist and the transcriptionist and the medical records clerk that got pushed to the physician. I think we need to start looking at work distribution and saying, are we making the best use of the training, the investment that society has made in physicians by having our physicians work as transcriptionists, by having our physicians do every order entry, by having our physicians spend more time on data processing than knowledge work, than adding value to the knowledge?
So for me, that thought about looking at solution shop versus production line work and have we thoughtfully distributed that work according to training and ability is really helpful and gets at one of the core problems, again, that our physicians are spending our—we know we're just spending our days doing the wrong work for our patients.
We're not available to see them on the same day they need to be seen. We can't focus on the three things that they brought to us because we're so busy typing the notes and going through the dropdown boxes to enter the orders and all of those things and doing the prior auth, all of those things that take us away from the core meaningful work of health care.
Dr. Resneck: I think that's really going to resonate with our audience because it aligns so closely with what I hear from physicians and their frustrations about. I think the electronic health record has made it easier for a lot of those tasks to roll uphill to the physician and away from others in the practice and it doesn't have to be that way. So thank you for giving voice to that.
We're nearly out of time but I wanted to open it up a little bit. Does anybody have anything that they think is missing from this discussion or things we need to pay attention to in the next phase of this work and in the next several years that have not really made the priority list yet?
Dr. Girgrah: I'd just to echo what Chris said. At least at Ochsner, it seems like a bit like back to the future. Obviously, in the last two years, two and a half years, we spent a lot of time doing important work around resilience and mental health.
But in the surveys that we're conducting now, I'm hearing loud and clear, get back to blocking and tackling, practice efficiency, advanced team-based care, automation, leadership development. So these were areas of focus prepandemic. I think we got a little distracted, for good reason, during the pandemic. But I think we have to certainly reboot those efforts around those areas.
Dr. Resneck: Well, seeing the burnout numbers soaring and the data of the last couple of years during the pandemic, knowing what our colleagues have been through as they took care of this country over these last three difficult years, piling fighting disinformation and misinformation on top of all these other burdens that we've been talking about, I think it's not surprising. And I think we have a workforce that's somewhat tired but wants to find ways to fall in love with their work again and to experience the joy of medicine.
So, I'm just so appreciative of the work that the three of you are doing. You're bringing data to the work. You're bringing inspiration to the work. And I want to extend my gratitude to each of our panelists, to the U.S. Surgeon General for contributing to this really important session.
To the members of our virtual audience, thank you for joining us. Thank you for participating. On behalf of the American Medical Association, we look forward to continuing our discussions around the most important issues of health care. So thank you very much for joining us and have a great day.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
