A Penn State College of Medicine vice dean who also works as a clinical psychiatrist shares his perspectives on medical staff burnout.
The stakes are high for physicians when it comes to burnout—it is estimated that a doctor commits suicide every day. Research indicates that nearly half of physicians nationwide are experiencing burnout symptoms. A study published in October 2018 found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.
"Organizations should be moving forward in a systemized way on burnout. We know enough to recognize that burnout is corrosive. It's time to act," says Dan Shapiro, PhD, vice dean for faculty and administrative affairs at Penn State College of Medicine in Hershey, Pennsylvania.
Shapiro and several colleagues recently published a journal article about a five-tier hierarchy that they developed to help healthcare administrators prioritize interventions that address medical staff burnout. He has been involved in initiatives to ease burnout among Penn State Health's clinicians and nurses for nearly two years.
HealthLeaders recently spoke with Shapiro to get his perspective on efforts to address medical staff burnout. Following is a lightly edited transcript of that conversation.
HealthLeaders: Why are you interested in the topic of staff burnout in the medical setting?
Shapiro: I'm a clinical psychologist, and I saw my first physician as a patient in 1995.
I started noticing patterns. Physicians would come much later to treatment than other people—I realized that we had acculturated them to deny their own needs.
One of the first things we do with medical students is introduce them to the cadaver. What's happening in their heads and their hearts is, "Oh my god! Oh my god!" But they learn not to show emotion and to be professional. They hide what is going on inside of them. They learn to put their forehead down and grind it out in the service of their patients. We need doctors and nurses who can do that, but that means they look for help way later than the average person.
I was recruited to be a chair at Penn State's medical school and became a vice dean. That's when I became interested in efficient ways of measuring and impacting the pervasive burnout problem among my colleagues—both the physicians and the nurses.
HL: A recent article in JAMA Psychiatry warns of the danger associated with confusing medical staff burnout with major depressive disorder. How have these varying diagnoses played out in your psychiatric practice?
Shapiro: I have data because we are using depression screening inventories along with burnout inventories, and the ratio is about 5-to-1. I have five burned out folks to at least one who screens positively for depression. And in all the work that I do, I also look for suicidal ideation.
The reason we use the burnout hierarchy is that it prioritizes interventions for administrators, and the first level is this exact topic—"Do you have an adequate mental health safety net? Do you know the percentage of your folks who have screened positive for major depression, suicidal ideation, and binge drinking or other substance use?"
When a physician, a nurse, or another health professional filling out our surveys indicates they have had any suicidal ideation, the first thing that pops up is a list of resources. Then, if there has been more than one episode of suicidal ideation in the past year, we break confidentiality and personally reach out to the patient.
HL: How does the five-tier hierarchy that you helped develop aid healthcare leaders in prioritizing burnout interventions?
Shapiro: The hierarchy is based on Maslow's Hierarchy, so it has some inherent logic for administrators. One of the issues they face is that there are more than 80 factors that have been associated with burnout. That's overwhelming.
I compare a physician who is showing signs of burnout to a pilot who sees a warning light that an engine has failed. The pilot has a systematic way of responding to the warning light: checking the speed and heading; determining how much time there is to make a decision; finding out whether there is fuel, air, and spark getting to the engine; and contacting air traffic control.
The advantage of having a prioritized hierarchy for burnout is it starts with interventions that make a major difference such as physiological basics and mental health basics. For physiological basics, you determine whether staff members are eating, sleeping, and hydrating. The percentage of healthcare professionals who are dehydrated at any given time can be more than 40%. We know that dehydration impacts cognition and mood.
HL: For senior healthcare administrators, what are the primary elements of their role in addressing burnout?
Shapiro: First, you must assess the problem, preferably with brief surveys that the physicians will fill out. Then, you need to start systematically addressing a prioritized plan. Our hierarchy produces a dashboard that has ratings on each of the five levels.
Just like the patient safety movement, which started in the late 1990s, it's going to take us a while to address burnout and make real traction. So, we need to have realistic expectations. We also need to be prioritized in how we approach interventions. Engagement surveys can result in thousands of action plans at a health system, and our approach is the exact opposite. We want to pick a few interventions for each healthcare professional group, resource those interventions, have accountability, put action teams together from across several disciplines, and make substantive progress.
HL: What has Penn State done to address burnout?
Shapiro: The No. 1 thing that came out of our assessment was people feeling disrespected by the bureaucracy. So, we created a bureaucracy reduction team. We have systematically reduced the amount of email and automatic trainings. We're letting some people test out of compliance programs. We're thinking through nitty gritty details such as who can send an email to everyone in our organization, who can call a program mandatory, and which policies ought to be mandatory.
Second, we recruited and hired a physician mental health professional with a PhD, and we established a wellness office. Third, we are working to optimize the EMR. Fourth, we are looking at compensation.
Fifth, we are actively recruiting leaders with greater emotional intelligence. Our chair candidates now must go through a simulation, where they interact with a mock disgruntled faculty member. We want leaders who can help faculty navigate the common challenges they face.
We are in the first iteration of our responses to burnout. We are viewing this as a long-term process.
HL: What data are you collecting?
We want to see a 2.5% reduction in burnout.
It's hard for me to believe that we are wasting anybody's time. If you are instituting better security in your emergency department, where 85% of your nurses have been assaulted in the past year, it's hard to think you are wasting your time regardless of the ultimate burnout score. There are a lot of interventions like that. Getting food and water to all the nurses in the ICUs just seems valid.
I'm very interested in what our turnover numbers are going to be. Some of these interventions are going to help health systems and hospitals to keep workers in greater percentages. The turnover rate among nurses is very high—young nurses leave about 16% to 17% of the time over the course of a year. That's enormously high. If you can keep half of that number, the intellectual firepower you are retaining is significant.
I'm interested in the perception of staff about the safety of their organization. We are looking at patient satisfaction data—there's a pretty strong relationship between staff burnout and your patient satisfaction scores.
Dan Shapiro can be reached via email at firstname.lastname@example.org.
Christopher Cheney is the senior clinical care editor at HealthLeaders.
Dan Shapiro, PhD, of Penn State College of Medicine, has been treating physicians for symptoms of burnout for more than two decades.
Shapiro and several colleagues developed a five-tier hierarchy to help healthcare administrators prioritize burnout interventions at their facilities.
Penn State Health has been taking a systematized approach to addressing burnout for nearly two years.