Transcript Physician Satisfaction and Worklife

Preventing Burnout in
Academic Physicians
Mark Linzer MD
and the MEMO investigators
Hennepin County Medical Center
Minneapolis, MN; Madison, WI;
Milwaukee, WI; Chicago, IL; NYC, NY
No conflicts of interest
No financial support for this talk –
research supported by Agency for
Health Care Research & Quality
Objectives
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List factors predicting clinician job
satisfaction
Describe ways to prevent burnout
Explain associations between work
conditions, physician reactions and patient
care quality
New York Times, 6-17-08
“It will take real structural change in the
work environment for physician
satisfaction to improve. Fortunately, the
data show physicians are willing to put
up with a lot before giving up.”
Mark Linzer, Madison, WI
Job satisfaction: the business case
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Harvard Business School: stock prices rose
147% when employee satisfaction rose
Meta-analysis 7900 businesses: productivity
and income tied to employee satisfaction
Sears: employee satisfaction up 4% = $200
million increased sales, rise in customer
satisfaction
(Brown & Gunderman. Acad Med 2006;81:577-82)
Setting the dollars aside…
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“…we need to feel that we have made a
real difference in the lives of others.”
(Brown & Gunderman. Acad Med 2006;81:577-82)
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Anything that can facilitate our feeling this
way will increase satisfaction, loyalty,
longevity and, potentially, quality of care.
Outcomes of dissatisfaction
Burnout
Linzer et al. Am J Med
2001;111:170-75.
Turnover: $250,000/departing physician
Buchbinder et al. Am J
Manag Care 1999;5:1431-8
Instability (larger patient load for
remaining providers)
Brown & Gunderman. Acad
Med 2006;81:577-82
Reduced patient:
1) access to care,
2) satisfaction,
3) medication adherence
Linn et al. Med Care 1985;
23:1171-78; DiMatteo.
Health Psychol 1993;12:
93-102
Increased patient disenrollment
Brown & Gunderman. Acad
Med 2006;81:577-82
Newer factors in physician satisfaction
MEMO (Minimizing Error, Maximizing
Outcome) Study (2002-2006)
Funded by AHRQ
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422 primary care physicians, 119 practices
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Key variables:
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Time pressure (ratio time allotted/time needed)
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Work control
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Work pace (chaos)
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Organizational culture
Pace of work (chaos)
“Describe the atmosphere in your office...”
CALM
1
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BUSY,
HECTIC,
BUT
REASONABLE
2
3
CHAOTIC
4
5
Chaos is prevalent: 40% of primary care practices
Chaos ratings similar between physicians and their
clinic managers (r=0.30, p<.001)
Chaos and physician outcomes
100%
80%
87%*
79%*
67%
60%
44%
41%*
35%*
40%
14%
20%
0%
Satisfaction
Stress
Chaotic
Burnout
Not Chaotic
20%
Leave
Practice
Question:
“Think of a time when you
felt especially good about
your job… why did you
feel that way?”
(Brown & Gunderman. Acad Med 2006; 81:577-82)
Burnout: long-term stress reaction
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Prevalent (20-30%) in practicing physicians (Linzer M.
Am J Med. 2001;111:170-75) and medical students (Dyrbe L. Ann
Intern Med 2008;149:334-41). Learning environment matters
Associated with perceived errors by medical
housestaff (West C. JAMA. 2009;296:1071-78)
1.6 x higher in women physicians
Mediated by home support, work control, and workhome balance (Linzer et al. Am J Med 2001;111:170-5)
Demand-control model of job stress
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Demands are balanced by control
Stress increases if demands rise or control
diminishes
Support can facilitate the impact of control:
more support, less stress
Bottom line… support and work control
prevent stress
Demands
(Karasek et al. Am J Public
Health 1981;71:694-705)
Control
Support
Why more burnout in women
physicians?
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Work hours: Netherlands experience
(Linzer et al. J Am Med Women’s Assoc 2002;57:191-3)
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Gendered expectations for more listening
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Faster pace
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Less alignment of values with leadership
(Horner-Ibler et al. J Gen Intern Med 2005; 20(s1):194)
Importance of Values Alignment*
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Men – regardless of values alignment,
high workload=exhaustion
Women – high level of values
alignment=high sense of efficacy
regardless of workload
Thus, values alignment can be
protective of burnout for women.
(*Leiter M. Can Fam Phys 2009;55:1224-25)
How can we prevent burnout?
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Flexible/part-time work
(Linzer et al. Acad Med 2009;84:1395-1400)
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Leaders model work-home balance; value
well-being (Saleh et al. Clin Orthop Relat Res 2009;467:558-65;
Dunn et al. J Gen Intern Med 2007;22:1544-52)
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Understand and promote work control
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Alter our “culture of endurance”
(Viviers et al. Can J Ophthalmol 2008;43:535-46)
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Articulate and align values
MEMO study (Minimizing Error
Maximizing Outcome)
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Funded by AHRQ; 2002-2006
119 PC clinics; 422 MDs; 1785 patients.
Determine relationships between work
conditions, physician reactions (stress
and burnout) and patient care (quality
and errors)
Linzer M, et al. Ann Intern Med 2009;151:28-036.
MEMO Study conceptual model
Workplace
Characteristics
Structure
Culture
Workflow
Policies, processes
Patient demands
Physician
Reactions
Patient
Outcomes
Satisfaction
Satisfaction
Stress
Trust
Burnout
Intent to leave
Quality of care
Medical errors
Measuring quality
Up to 6 patients per primary care
physician with diabetes, HTN, and/or CHF
Assess:
 Patient satisfaction
 Quality of life
 Disease management
Patient Survey
Chart review
Determining Errors
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Confidential chart reviews for errors in processes
of care (e.g., wrong medications, missed preventive
activities)
MEMO Results: physician outcomes
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49% said jobs were stressful
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50% need more time for visits
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27% burning out or burned out
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30% moderately or more likely to leave job
within 2 years
Strong relationships between work conditions
(time pressure, work control, chaos,
organizational culture) and physician reactions
(satisfaction, stress, burnout, intent to leave)
MEMO Results: patient care
Variable
Outcome
p-value
Moderate to high
work control
Higher diabetes care
quality
<0.05
Time pressure
Lower overall quality
<0.05
Poorer care for HTN
patients
<0.05
Linzer et al. Ann Intern Med 2009
MEMO Results: patient care
Variable
Outcome
p-value
Information and Higher overall quality
communication Better HTN quality care
emphasis
<0.05
Values
alignment
<0.001
Better diabetes care
quality
<0.01
Fewer prevention errors <0.01
Linzer et al. Ann Intern Med 2009
Findings from MEMO
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Work conditions of profound importance to us
Some work conditions related to patient care,
but effects are inconsistent
Physician stress and burnout were not related to
quality and errors
Which leads to the following hypothesis…
Doctors as buffers
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We act as buffers between adverse work
conditions and patient care
Adverse effects are felt by us, perhaps our
families, coworkers?
Because adverse work conditions strongly
associated with intent to leave, patient care
could suffer due to lack of continuity
WL
The OWL and its surveys provide a
snapshot of a clinic. We provide
comparison data from MEMO clinics.
Office & Work Life Feedback
Clinician/staff data:
Your clinic
MEMO clinics
Organization data:
Your clinic
MEMO clinics
Patient survey data:
Your clinic
MEMO clinics
Chart audit data:
Your clinic
MEMO clinics
Satisfaction, stress, burnout,
intent to leave, orgn’l culture, etc.
Staffing ratio, patient mix,
resources, procedures, etc.
Satisfaction, trust, quality of
life, literacy, med adherence, etc.
Errors and quality in management
of chronic diseases & prevention
New AHRQ grant:
Creating Healthy Workplaces
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Randomized trial of QI interventions to
improve work conditions
Rural WI; Chicago; NYC
Use OWL to measure work environment
and patient outcomes at baseline and
after one-yr follow up
Stanford Data
Areas of dissatisfaction:
1. work hours
2. administrative time
3. value placed on teaching
4. control over schedule
Areas to Consider
1.
2.
3.
4.
5.
6.
part-time
work control
work-home balance
values alignment
adjusting for patient gender
wellness emphasis
Satisfaction and Work Life
In summary…
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Satisfaction is important; burnout can
be prevented
Healthy workplaces can be created
and nurtured
It has been a privilege to share our
work with you