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NAM offers recommendations to fight clinician burnout


The practice of medicine needs a major reset to address the stresses that lead to clinician burnout, a condition now estimated to affect a third to a half of clinicians in the United States, according to a report from an influential federal panel.

The National Academy of Medicine (NAM) on Oct. 23 released a report, “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.” The report calls for a broad and unified approach to tackling the root causes of burnout.

There must be a concerted effort by leaders of many fields of health care to create less stressful workplaces for clinicians, Pascale Carayon, PhD, cochair of the NAM committee that produced the report, said during the NAM press event.

“This is not an easy process,” said Dr. Carayon, a researcher into patient safety issues at the University of Wisconsin–Madison. “There is no single solution.”

The NAM report assigns specific tasks to many different participants in health care through a six-goal approach, as described below.

–Create positive workplaces. Leaders of health care systems should consider how their business and management decisions will affect clinicians’ jobs, taking into account the potential to add to their levels of burnout. Executives need to continuously monitor and evaluate the extent of burnout in their organizations, and report on this at least annually.

–Address burnout in training and in clinicians’ early years. Medical, nursing, and pharmacy schools should consider steps such as monitoring workload, implementing pass-fail grading, improving access to scholarships and affordable loans, and creating new loan repayment systems.

–Reduce administrative burden. Federal and state bodies and organizations such as the National Quality Forum should reconsider how their regulations and recommendations contribute to burnout. Organizations should seek to eliminate tasks that do not improve the care of patients.

–Improve usability and relevance of health information technology (IT). Medical organizations should develop and buy systems that are as user-friendly and easy to operate as possible. They also should look to use IT to reduce documentation demands and automate nonessential tasks.

–Reduce stigma and improve burnout recovery services. State officials and legislative bodies should make it easier for clinicians to use employee assistance programs, peer support programs, and mental health providers without the information being admissible in malpractice litigation. The report notes the recommendations from the Federation of State Medical Boards, American Medical Association, and the American Psychiatric Association on limiting inquiries in licensing applications about a clinician’s mental health. Questions should focus on current impairment rather than reach well into a clinician’s past.

–Create a national research agenda on clinician well-being. By the end of 2020, federal agencies – including the Agency for Healthcare Research and Quality, the National Institute for Occupational Safety and Health, the Health Resources and Services Administration, and the U.S. Department of Veterans Affairs – should develop a coordinated research agenda on clinician burnout, the report said.

In casting a wide net and assigning specific tasks, the NAM report seeks to establish efforts to address clinician burnout as a broad and shared responsibility. It would be too easy for different medical organizations to depict addressing burnout as being outside of their responsibilities, Christine K. Cassel, MD, the cochair of the NAM committee that produced the report, said during the press event.

Dr. Christine K. Cassel, former chief executive officer of the National Quality Forum

Dr. Christine K. Cassel

“Nothing could be farther from the truth. Everyone is necessary to solve this problem,” said Dr. Cassel, who is a former chief executive officer of the National Quality Forum.

Darrell G. Kirch, MD, chief executive of the Association of American Medical Colleges, described the report as a “call to action” at the press event.

Previously published research has found between 35% and 54% of nurses and physicians in the United States have substantial symptoms of burnout, with the prevalence of burnout ranging between 45% and 60% for medical students and residents, the NAM report said.

Leaders of health organizations must consider how the policies they set will add stress for clinicians and make them less effective in caring for patients, said Vindell Washington, MD, chief medical officer of Blue Cross Blue Shield of Louisiana and a member of the NAM committee that wrote the report.

Dr. Vindell Washington, chief medical officer of Blue Cross Blue Shield of Louisiana

Dr. Vindell Washington

“Those linkages should be incentives and motivations for boards and leaders more broadly to act on the problem,” Dr. Washington said at the NAM event.

Dr. Kirch said he experienced burnout as a first-year medical student. He said a “brilliant aspect” of the NAM report is its emphasis on burnout as a response to the conditions under which medicine is practiced. In the past, burnout has been viewed as being the fault of the physician or nurse experiencing it, with the response then being to try to “fix” this individual, Dr. Kirch said at the event.

The NAM report instead defines burnout as a “work-related phenomenon studied since at least the 1970s,” in which an individual may experience exhaustion and detachment. Depression and other mental health issues such as anxiety disorders and addiction can follow burnout, he said. “That involves a real human toll.”

Joe Rotella, MD, MBA, chief medical officer at American Academy of Hospice and Palliative Medicine, said in an interview that this NAM paper has the potential to spark the kind of transformation that its earlier research did for the quality of care. Then called the Institute of Medicine(IOM), NAM in 1999 issued a report, “To Err Is Human,” which is broadly seen as a key catalyst in efforts in the ensuing decades to improve the quality of care. IOM then followed up with a 2001 report, “Crossing the Quality Chasm.”

“Those papers over a period of time really did change the way we do health care,” said Dr. Rotella, who was not involved with the NAM report.

In Dr. Rotella’s view, the NAM report provides a solid framework for what remains a daunting task, addressing the many factors involved in burnout.

“The most exciting thing about this is that they don’t have 500 recommendations. They had six and that’s something people can organize around,” he said. “They are not small goals. I’m not saying they are simple.”

The NAM report delves into the factors that contribute to burnout. These include a maze of government and commercial insurance plans that create “a confusing and onerous environment for clinicians,” with many of them juggling “multiple payment systems with complex rules, processes, metrics, and incentives that may frequently change.”

Clinicians face a growing field of measurements intended to judge the quality of their performance. While some of these are useful, others are duplicative and some are not relevant to patient care, the NAM report said.

The report also noted that many clinicians describe electronic health records (EHRs) as taking a toll on their work and private lives. Previously published research has found that for every hour spent with a patient, physicians spend an additional 1-2 hours on the EHR at work, with additional time needed to complete this data entry at home after work hours, the report said.

In an interview, Cynda Rushton, RN, PhD, a Johns Hopkins University researcher and a member of the NAM committee that produced the report, said this new publication will support efforts to overhaul many aspects of current medical practice. She said she hopes it will be a “catalyst for bold and fundamental reform.

“It’s taking a deep dive into the evidence to see how we can begin to dismantle the system’s contributions to burnout,” she said. “No longer can we put Band-Aids on a gaping wound.”

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