Physician well-being is an issue that needs to be discussed, promoted, studied and funded. Physicians need to be at the front of the discussions and leaders in the field of well-being. As boots on the ground, we are force multipliers for change in this arena. We are the grassroots. Even the best grassroots efforts fail without money. In this age of limited healthcare resources, how do we convince our organizations to pay more than lip service to our well-being needs?
Over a decade ago I began to hear a lot of strange words and word combinations being thrown around in medical school that I had never heard before. Gastrulation of the blastula, intensity modulated radiation therapy, disseminated intravascular coagulation, menigomyleocoele, myelophthisic anemia, on and on and on to this day. These days, it seems like a few new words have entered the lexicon of medicine: physician well-being, physician burnout, physician wellness, work-life balance, chief wellness officer.
Burnout stories posted by physicians and guest physicians are common thanks to the epidemic of burnout. White Coat Investor has a few guest posts by Dike Drummond, MD, a physician leader in the area of burnout. The Happy Philosopher can experienced burnout himself and has good posts on the topic.
These stories only go so far, effort needs to be made a the institutional level to effect change. Physicians need to educated ourselves on the subject of well-being as we would anatomy, oncology, etc.
A leader in the field of physician well-being and Oncologist, Dr. Tait Shanafelt, has published an article on this topic titled: The Business Case for Investing in Physician Well-Being JAMA Inter Med 2017. The authors propose a continuum model of well-being and also a formula to calculate return on investment (ROI) from money invested in physician well-being. This information can be used in discussing funding with your organization.
Healthcare organization response to the physician burnout epidemic has been lackluster. There are 2 main reasons:
- Lack of awareness of the economic cost of burnout
- Uncertainty about whether anything can be done, ie, “We can only allocate x dollars to the issue, that doesn’t seem like enough to make a difference. “
Cost Associated with Turnover
Burnout is the one of the leading causes of physician turnover, with the 2 year turnover rate double among burnt out physicians. Turnover is expensive due to cost of recruitment, on-boarding and time for new physicians to reach optimum efficiency.
How expensive? Studies show the cost of physician replacement in 2-3 times the physician salary. Two studies have shown similar numbers at $990,000 and between $500,000 – $1,000,000. Subspecialtes will be higher and cost will rise as physician shortages in some fields manifest.
Turnover also affects patient care due to disruptions, can cause other members of the team to turnover (it’s contagious) and adversely affects the organization’s reputation.
Academic centers may think they are immune due to a pool of residents/fellows for employment. This assumes a newly trained physician can replace a mid-career faculty. This fails to recognize the mid-career physician excels in clinical productivity, grants, trial design, publications and influence. The mean age at first R01 grant is 44 years old indicating that this milestone of an independent investigator is reached in mid-career. Academics centers are not immune to the cost of turnover.
Costs Associated with Decreased Productivity
In a Mayo clinic study of 2,500 physicians, each 1-point increase in burnout on a 7-point scale or 1-point decrease in a professional satisfaction scale was associated with a 30-50% likelihood that physicians would reduce their work effort over the next 24 months as assessed by payroll records.
Due to the high fixed cost of many organization, a small change in physician productivity can have a large impact on the bottom line. Thus, only a small percent of physicians would need to have decreased productivity to affect the finances. For example, if 20% of physicians we burnt out (studies show it might be up to 50%) and those physicians cut back 30%, that translates into a 6% decreased in productivity. Assuming colleagues would pick up 50% of the workload, that is still a 3% productivity bottom line cut.
Effects of Well-Being on Quality, Safety and Patient Satisfaction
- There seems to be a dose-response relationship to burnout and quality with a 1-point increase in a 54-point emotional exhaustion or 30-point depersoould nalization scale correlating with a 3-10% increased likelihood of the physician reporting a medical error in the previous 3 months.
- Studying 54 ICUs in Switzerland, investigators that the aggregate mortality rate was associated with burnout level among physicians and nurses.
- There is a relationship between burnout and failure to discuss treatment options and answer patient questions.
- Post-discharge recovery time is longer among burnout physician patients and patients adhered less to physician recommendations.
A Suggestion on the Organization Approach to the Problem
Historically, organizations have invested in interventions shown to improve patient safety and care quality. There are moral, ethical and organizational viability reasons for these, often large, investments. The argument has been made to invest similarly in physician well-being.
Interventions to enhance well-being:
- Prioritization by leadership
- Organizational learning
- Open Communication
- Promoting a culture of wellness
A model is proposed spanning the organizational stages of novice, beginner, competent, proficient and expert. Here are metrics of the novice level:
- Aware of the issue
- Wellness committee
- Individual level interventions – mindfulness training, resources for exercise/nutrition
Here is the Expert level:
- Physician well-being influences key operations decisions such as strategy, priorities, resource allocation, new initiatives
- Shared accountability for well-being among leaders
- Chief well-being officer on executive leadership
- Endowed program generates knowledge applicable to other organizations
- Strategic investment to promote physician well-being
- Culture of wellness
There is an ocean of difference between these stages. Years of work and funding. I’ve worked at several organizations and have yet to see one move past the novice stage.
Where do we start?
Commitment from executive leadership is the prerequisite, assessment the first step…
Assessment: Organizations should understand the factors that govern physician well-being. These factors can be organized into driver dimensions:
- culture and values
- work-life integration
- work community
- meaning at work
Limited investment can be made with great change in flexibility/control, efficiency, community and meaning. However, even limited investments cost money. What kind of money are we talking about?
Determining The Appropriate Initial Level of Investment
You need a dollar amount to ask to promote well-being. Getting to this number starts with determining the cost of physician burnout. There is a nice simple formula in Figure 2 of the paper, but you can look it up if needed. Chances are if you’re reading this, you’re not meeting with leadership tomorrow but painting with broad strokes so an example will suffice.
- Number of physicians at center
- Rate of burnout at center. National mean 54%
- Turnover rate per year. National mean 7-7.5%.
- Cost of turnover per physician. Mean cost $500,000-$1,000,000.
Example: 450 physicians, 50% burnout, 7.5% turnover, $500,000 cost per physician = $5,625,000 cost of physician turnover annually.
Ok, so now you have a number to start with. This isn’t the amount needed to combat the problem. However, lets say the organization (with your help) identified an intervention costing $1,000,000 that would lower the burnout from 50% to 40%. That’s a relative reduction of 20% and is consistent with or greater than that of multiple interventions shown to reduce burnout.
With 50% burnout rates turnover is 7.5%. Data shows that burnout physicians are twice as likely to turnover. Therefore, 50% (the burnout half) of physicians have a turnover rate of 10% and the other 50% have a 5% turnover rate for a final 7.5% turnover for a total of 2.5% attributable to burnout. If your intervention lowers the burnout rate by 20% as mentioned above, that is a 0.5% reduction in turnover. Taking the cost of burnout above of 5.625 million and cutting 20% due to the intervention saves 1.125 million.
Return on investment (ROI) = (Savings – Cost) / Cost = 12.5% ROI. That is a tremendous ROI, and should get the door open to at least start the awareness part of the novice continuum. A worksheet for ROI is available in the paper.
This is probably conservation because it doesn’t account for lost productivity of burnout physicians who don’t turnover, cost of reduced patient satisfaction, quality, safety, reputation and litigation costs.
Coffee beans in Kauai, HI. Invest in well-being and it will bear fruit.
Physician well-being is not a problem that will disappear without intervention. Awareness of the problem and that change can be made are first steps. Meaningful progress requires organizational monetary investment. As with interventions aimed at improving patient safety and quality of care, providing these funds is not only the ethical responsibility of the organization but interventions have a positive return on investment. Thus, it is also fiscally responsible for organizations to invest in physician well-being.
What is your experience with the business side of physician well-being? Is your organization invested?