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5-Tier Hierarchy Helps Prioritize Physician Burnout Interventions

Analysis  |  By Christopher Cheney  
   June 28, 2019

Researchers have adapted psychologist Abraham Maslow's Hierarchy to help healthcare organization leaders curb physician burnout.

A five-tier hierarchy has been proposed to help healthcare organizations prioritize interventions to address physician burnout.

Research published in September indicates that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout has also been linked to negative financial effects at physician practices and other healthcare organizations.

In an article published recently by The American Journal of Medicine, researchers adapted psychologist Abraham Maslow's Hierarchy into a five-tier physician burnout and wellness hierarchy.

"Unlike long lists of variables, this hierarchical model is practical. Using an assessment strategy tailored to the hierarchy will identify the greatest need at whatever organizational scale measured: individual life, work unit, department, institution, or networked system. Put simply, this tells leaders where to start," the researchers wrote.

In priority order, the five-tiers of the physician burnout and wellness hierarchy are physical and mental health, safety and security, respect, appreciation and interpersonal connections, and healing patients and contributing to the fullest of a clinician's ability.

Tier 1: Physical and mental health

The potentially severe impact of nutrition on cognition is well documented, and many clinicians have poor nutrition such as skipping meals and eating too fast. Clinicians also are at high risk for dehydration—a United Kingdom study found that 45% of physicians and nurses ended their shifts clinically dehydrated. Sleep deprivation is also common among clinicians.

Beginning with research conducted in the 1800s, physicians have been found to suffer from depression at higher rates than other professionals. When present with other behavioral health disorders such as anxiety and hopelessness, depression is a suicide risk. A 2003 study found that about 350 U.S. physicians commit suicide annually.

The American Journal of Medicine researchers propose two interventions to address physical and mental health problems among physicians:

  • Assess the mental health of clinicians and their willingness to seek help such as employee assistance programs. If access to psychological care is deficient, healthcare organizations should bring behavioral health services on-site.
  • For clinicians and nurses, ease access to good nutrition, promote adequate sleep such as ensuring on-site sleeping quarters are comfortable and clean, make water and other beverages accessible, provide private bathrooms, and install breastfeeding stations.

Tier 2: Safety and security

The federal Occupational Safety and Health Administration has found that severe workplace violence that requires time off for recuperation occurs four times more frequently in the healthcare sector compared to private industry. Healthcare professionals are more likely to be injured in workplace settings with inadequate staffing, poor communication, subpar leadership, and insufficient attention to safety.

The American Journal of Medicine researchers propose three interventions to address safety and security concerns:

  • Violence de-escalation training for healthcare staff and deploying security to high-risk settings such as emergency rooms
  • Increasing total security staff
  • Maintaining adequate healthcare professional staffing

Tier 3: Respect

To limit burnout, clinicians need respect from supervisors and administrators, colleagues, patients, and technology such as electronic health records (EHRs), the researchers say.

A study of more than 20,000 workers found that employees who feel respected by immediate supervisors reported 89% greater enjoyment and satisfaction with their jobs. A recent study on incivility in operating rooms found that exposure of anesthesiology residents to even "run of the mill" rudeness was associated with diminished performance in four metrics: vigilance, diagnosis, communication, and patient management.

"There is growing attention on the impact of patient disrespect on health professionals and healthcare trainees. We don't yet have evidence that working repeatedly with rude, discriminatory, or abusive patients causes burnout. This model, however, predicts that patient disrespect is relevant and, where possible, policy and procedures should protect health professionals as much as is ethically reasonable," the researchers wrote.

Earlier research published in The American Journal of Medicine found that EHRs contribute to three primary elements of physician burnout—lack of enthusiasm, lack of accomplishment, and cynicism.

Actions to address lack of respect for clinicians include three interventions:

  • Supervisors and administrators should respond to physician requests, even when the answer is "no"
  • Adopt patient rights and responsibilities charters that include provisions to ban patient abuse of healthcare staff
  • Initiate improvements to EHRs such as easing information management and communication between healthcare professionals

Tier 4: Appreciation and interpersonal connections

The researchers say their model predicts that healthcare professionals desire and deserve appreciation much like other professionals. Studies indicate that healthcare worker satisfaction is improved when leaders express appreciation. A trial at Mayo Clinic curbed burnout by connecting physicians socially through sponsored after-hours dinners.

The American Journal of Medicine researchers propose four interventions to boost appreciation and interpersonal connections:

  • Provide fair compensation for physicians
  • Promote individualized, specific, and frequent communication of appreciation
  • Publicize successes such as effective clinician responses to complex medical cases
  • Foster interpersonal connections through establishment of shared spaces such as physician lounges

Tier 5: Healing patients and contributing to fullest of abilities

"For those drawn to medicine and healthcare, improving lives by ameliorating suffering and healing the ill is a need," the researchers wrote. Meeting this need includes conducting research and mentoring other clinicians, they say.

Actions to address self-actualization among clinicians include three interventions:

  • Reducing conflicts between business imperatives and the daily practice of medicine
  • Fostering opportunities to conduct clinical research
  • Promoting mentorship

Christopher Cheney is the CMO editor at HealthLeaders.


A new hierarchical model for addressing physician burnout is designed to focus attention on primary drivers.

At most healthcare organizations, the top priority should be addressing the physical and mental health of clinicians.

Safety and security are considered the second most important focal point.

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