Physician Well-Being¶

Chapter 9 | Part 1: The Profession of Medicine

KEY CLINICAL POINTS¶

Burnout is an occupational syndrome characterized by emotional exhaustion, depersonalization, and low personal achievement resulting from chronic workplace stress
63% of physicians reported burnout during the COVID-19 pandemic (2021), with crisis levels declared by NAM in 2019 even before the pandemic
One in five physicians has reported intent to leave medical practice due to burnout, contributing to projected shortfall of up to 86,000 physicians in the US by 2036
Addressing burnout requires a multipronged approach targeting societal, health care system, organizational, and workplace/learning environment factors
Core solutions include protection from harm, accessible mental health care, reduced administrative burdens, building connection and community, and fostering a culture of well-being

1. DEFINITION & OVERVIEW¶

Physician well-being has emerged as a critical focus in modern medicine, recognizing that the health of physicians is inextricably linked to patient safety and quality of care. The practice of medicine is often viewed as a calling and a way of life, but this dedication should not come at the expense of physician health. Burnout is defined as an occupational syndrome resulting from chronic workplace stress due to an imbalance between job demands and resources, along with organizational, societal, and cultural factors in health care. It is included in the ICD-11 classification.

1.1 Characteristics of Burnout¶

Burnout is characterized by three key components: - High degree of emotional exhaustion - Depersonalization (e.g., job cynicism) - Low sense of personal achievement at work

1.2 The Quadruple Aim¶

In 2014, the Institute for Healthcare Improvement advanced the Quadruple Aim, adding a fourth goal to improve health workforce well-being. This directly acknowledges that the existing goals in health care—enhancing patient experience, improving population health, and reducing costs—cannot be met without the health and well-being of our nation's healers.

2. HISTORICAL PERSPECTIVE¶

The evolution of physician well-being as a recognized concern has developed over more than a century, with significant policy changes driven by both educational reform and tragic events highlighting the consequences of physician fatigue.

2.1 Origins of Medical Residency¶

The term 'resident' originated from Dr. William Osler in 1890 when he established the first full-time, live-in medical residency training program at Johns Hopkins Hospital in Baltimore, Maryland. Residents lived in the administration building, and with training duration undefined, many stayed for years. Personal sacrifices came at the cost of professional expectations and norms.

2.2 Timeline of Medical Education Standards¶

1904: AMA formed the Council for Medical Education (CME)
1910: Flexner Report called for higher admission/graduation standards and adherence to mainstream science protocols
1912: Federation of State Medical Boards established
1933: American Board of Medical Specialties established
1972: Licensing Commission of Medical Education (LCME) established
1981: Accreditation Council of Graduate Medical Education (ACGME) established Notably, physician well-being was not prioritized in any of these early reforms.

2.3 Duty Hours Reform¶

Through much of the 20th century, residents were expected to work 36 hours every other night, often exceeding 100 hours per week. Key milestones in duty hour reform: - 1975: NYC medical residents went on strike calling for fewer hours - 1984: Death of Libby Zion linked to resident fatigue and inadequate supervision - 1989: New York became first state to regulate resident duty hours - 2001: Medical residents petitioned OSHA to nationally limit duty hours - 2003: ACGME established national standards limiting duty hours

2.4 New York Duty Hour Regulations (1989)¶

These pioneering regulations included: - Average of no more than 80 hours per week - No more than 24 hours of continuous duty - At least 24 hours free from clinical duties weekly

2.5 Institute of Medicine Report (2000)¶

The IOM landmark report 'To Err Is Human: Building a Safer Health System' shifted discourse from individual-level factors toward system-level changes needed to address patient safety concerns. This accelerated efforts to ensure patient safety and quality of care alongside physician well-being.

3. EPIDEMIOLOGY¶

Burnout has reached crisis levels among physicians and medical trainees, with the COVID-19 pandemic dramatically worsening an already concerning situation.

Burnout Prevalence Trends Among Physicians¶

Year	Burnout Rate	Context
2017	44%	Pre-pandemic baseline

Year	Burnout Rate	Context
2019	35-54%	NAM declared crisis levels
2020	38%	Early pandemic
2021	63%	Peak pandemic period

3.1 Prevalence of Burnout¶

Pre-pandemic (2019) crisis levels documented by NAM: - 35-54% of nurses and physicians experienced burnout - 45-60% of medical students and residents experienced burnout Pandemic-era trends: - 38% burnout rate in 2020 - 44% burnout rate in 2017 - 63% burnout rate in 2021 (during pandemic)

3.2 Intent to Leave Medicine¶

One in every five physicians has reported intent to leave medical practice due to burnout, contributing to a projected shortfall of up to 86,000 physicians in the United States by 2036.

3.3 Suicide Risk¶

In the 2023 Physicians Foundation Survey of America's Current and Future Physicians, more than half of physicians (increased since 2021) reported knowing of a physician who has ever considered, attempted, or died by suicide.

3.4 Demographic Disparities¶

Surveys have found widening gender and racial gaps, especially among: - Female physicians - Groups underrepresented in medicine

3.5 Workforce Trends¶

According to Federation for State Medical Boards data, the U.S. physician workforce is 20% larger than it was over a decade ago. However, health care needs will continue to increase due to: - Ongoing mental health crises - Growing and aging population - Climate change impacts on health

4. ETIOLOGY & CONTRIBUTING FACTORS¶

Burnout results from a complex interplay of factors at multiple levels. The Surgeon General's Advisory on Addressing Health Worker Burnout identifies four major domains of contributing factors.

Factors Associated with Burnout Among Health Workers¶

Domain	Contributing Factors
Societal and Cultural	Politicization of science; Structural racism; Health misinformation; Mental health stigma; Unrealistic expectations

Domain	Contributing Factors
Health Care System	Regulatory limitations; Misaligned reimbursement; Administrative burdens; Poor care coordination; Non-human-centered technology
Organizational	Lack of leadership support; Values disconnect; Excessive workload; Discrimination; Mental health care barriers
Workplace/Learning Environment	Limited flexibility/autonomy; Lack of collaboration culture; Limited patient/colleague time; Harassment/violence

4.1 Societal and Cultural Factors¶

Politicization of science and public health
Structural racism and health inequities
Health misinformation
Mental health stigma
Unrealistic expectations of health workers

4.2 Health Care System Factors¶

Limitations from national and state regulation
Misaligned reimbursement policies
Burdensome administrative paperwork
Poor care coordination
Lack of human-centered technology

4.3 Organizational Factors¶

Lack of leadership support
Disconnect between values and key decisions
Excessive workload and work hours
Biased and discriminatory structures and practices
Barriers to mental health and substance use care

4.4 Workplace and Learning Environment Factors¶

Limited flexibility, autonomy, and voice
Lack of culture of collaboration and vulnerability
Limited time with patients and colleagues
Absence of focus on health worker well-being
Harassment, violence, and discrimination

4.5 COVID-19 Pandemic Impact¶

The pandemic highlighted specific stressors including: - Moral distress and moral injury - Compassion fatigue - Forced choices between caring for patients and keeping families safe - Witnessing countless patients suffer and die without family present - Helplessly rationing inadequate supplies, beds, or treatment

5. CLINICAL FEATURES & HEALTH CONSEQUENCES¶

Chronic work stress and burnout have well-documented harmful effects on physician health and well-being across multiple domains.

Health Consequences of Chronic Work Stress and Burnout¶

Domain	Consequences
Physical	Impaired cognition, cardiovascular disease, type 2 diabetes, fertility issues, sleep disruptions
Mental	Anxiety, depression, suicidal ideation
Social/Relational	Isolation, relationship conflict, substance use/misuse
Professional	Reduced hours, intent to leave, leaving medicine
Patient Care	Access delays, quality issues, safety concerns

5.1 Physical Health Effects¶

Chronic work stress is associated with: - Impaired cognitive function - Increased risk of cardiovascular disease - Type 2 diabetes - Fertility issues - Sleep disruptions

5.2 Mental Health Effects¶

Burnout is associated with: - Anxiety - Depression - Suicidal ideation

Isolation
Relationship conflict
Risk for substance use and misuse

5.4 Professional Consequences¶

Physicians and other health workers who report burnout are more likely to: - Reduce working hours - Report intent to leave jobs or medical school - Leave medicine altogether

5.5 Patient Care Impact¶

Workforce shortages resulting from burnout can negatively impact: - Timely access to care - Quality of care - Patient safety These shortages compound the vicious cycle of increasing physician work demands that lead to more burnout.

6. CORE ELEMENTS FOR BUILDING A THRIVING PHYSICIAN WORKFORCE¶

A thriving physician workforce requires a dynamic, multipronged, and collective approach to solve the complex array of institutional, structural, cultural, and societal factors that impact physician health and well-being. Fundamental change in the organizational environment, including the systems and cultures where all physicians learn, train, and work, is the necessary first step.

7. PROTECTION FROM HARM¶

Strengthening physician protections from physical and psychological harms in the clinical learning and work environment is essential.

7.1 Physical Protection Measures¶

Ensuring adequate personal protective equipment during and outside of public health emergencies
Sufficient staffing
Shift coverage and rest
Clearly communicated policies protecting physicians from threats and acts of harassment, intimidation, and violence at work and in communities

7.2 The Joint Commission Standards¶

The Joint Commission released workplace violence prevention standards in 2021 to guide leaders with implementation.

7.3 Equity and Inclusion¶

Health care organizations must explicitly support inclusion and equitable access to policies and programs (e.g., paid leave, career advancement) that comprehensively address diversity and accessibility. This addresses microaggressions, implicit bias, discrimination, and racism that many physicians face.

7.4 Mental Health Care Access¶

Increase access to quality mental health care for all physicians, including residents and students. Services can be offered: - On-site - Via telehealth options - Peer support groups - Confidential physician health programs - Employee assistance program (EAP) services (counseling, referrals, caregiver support) Most importantly, ensure access is convenient, meeting unique needs and work schedules.

7.5 Suicide Prevention¶

A proactive, evidence-based approach to suicide prevention must incorporate: - Voluntary, anonymous screening - Tailored referrals - Follow-up care

7.6 Ending Barriers to Mental Health Care¶

Many physicians may be reluctant to seek care due to concerns about potential repercussions on: - License - Hospital credentials - Careers - Credibility Health care organizations, academic institutions, and policymakers should review and remove intrusive, stigmatizing questions on all applications and forms, ensuring alignment with national recommendations set by The Joint Commission in 2020.

8. REDUCING ADMINISTRATIVE BURDENS¶

Administrative burdens must be reduced to give physicians more time for what matters—their patients. A rapidly changing health care ecosystem has contributed to loss of physician autonomy and significant reduction in time for patient care.

8.1 Contributing Factors to Administrative Burden¶

New payment options
Market consolidation
Insurance and regulatory requirements
Advances in health information technology
Corporate privatization of practices

8.2 Workflow Improvement Strategies¶

Improve and streamline workflow processes including: - Documentation requirements - Inbox notifications - Prior authorizations Example: Documentation guidelines for outpatient E/M visit codes were updated in 2021 to better align with current medical practice and patient care.

8.3 Available Tools and Resources¶

Health professional associations offer practical tools: - AMA Saving Time Playbook - Electronic Health Records (EHR) Playbook - 'Getting Rid of Stupid Stuff' (GROSS) model - showing measurable reductions in unnecessary daily documentation tasks

8.4 Prior Authorization Reform¶

In 2022, 94% of physicians surveyed reported that prior authorizations from insurers delayed access to necessary care. Many reported treatment abandonment by patients due to delays. Solutions include exempting clinicians from prior authorization requirements if they meet specific performance measures.

8.5 Technology Implementation¶

Organizations can harness, adopt, and implement technology in a physician- and patient-centered way. Opportunities to leverage AI, machine learning, and digital automation tools include: - Previsit planning - Encounter documentation - Prior authorizations - Follow-up communication AI companies must ensure platforms: - Safeguard patient safety and privacy - Mitigate risk of clinical harm - Measurably improve quality of care

8.6 EHR Optimization¶

EHR companies must strengthen platforms to: - Focus on key features needed for patient care - Design systems meeting clinician needs - Optimize usability as clinical decision support tools - Ensure accessible, meaningful, and unbiased processes and data - Avoid adding more burden onto the health care team

9. BUILDING CONNECTION AND COMMUNITY¶

Opportunities for strengthening social connection and community in medical education, clinical training programs, and all health care work environments should be integrated into systems. The value of workplace connection and social support cannot be overstated, especially in an era of widespread societal loneliness and social isolation.

9.1 Recognizing the Problem¶

Acknowledging that loneliness and isolation can be felt at all stages of medical education and throughout a career in medicine is a necessary and important first step. Physicians may have fewer routine opportunities to connect meaningfully with colleagues and identify new mentors, particularly when new to the community.

9.2 Strategies for Building Connection¶

Peers, faculty, and leaders can model and foster opportunities for social connection through: - Applying teamwork and team-based care models - Establishing peer support groups and informal learning networks - Reviving the modern-day doctors' lounge - Investing in mentoring and coaching programs

These efforts must be operationalized with: - Protected time built into core working hours - Infrastructure built into the physical environment - Time to pause and reflect on challenging circumstances and morally distressing dilemmas - Opportunities to build trusting relationships - Time and space to reinforce connection through shared purpose, professional fulfillment, and celebration of collective achievements

10. BOLSTERING THE HEALTH WORKFORCE¶

Investments that bolster the health workforce need to be expanded. Health workforce shortages across all specialties and settings can negatively impact timely access, quality, and patient safety.

10.1 Workforce Development Solutions¶

Hopeful signs and solutions include: - New medical schools and postgraduate training programs being developed at unprecedented rates - Renewed efforts to increase and diversify the workforce - Efforts to ensure culturally appropriate care - Encouraging practice in shortage specialties and underserved communities

10.2 Support Mechanisms¶

Equitable pathways via scholarships and tuition support
Career advancement programs
Faculty salary support
Apprenticeship training programs to retain instructors, preceptors, and mentors

Sustain and increase investments for addressing unmet underlying social needs: - Housing - Food - Transportation Social determinants of health are estimated to account for 80-90% of modifiable factors in health outcomes. In 2022, 61% of physicians felt they had little to no time to effectively address patients' social determinants of health.

11. FOSTERING A CULTURE OF PHYSICIAN WELL-BEING¶

The culture of medicine must be transformed to center on physician health and well-being.

Key Stakeholders in Addressing Health Worker Burnout¶

Stakeholder Group	Role
Federal, State, Local, Tribal Governments	Policy and regulation
Health Insurers and Payers	Reimbursement and authorization reform
Health Care Organizations	Organizational culture and systems
Academic Institutions	Training and education
Licensing and Accreditation Bodies	Standards and credentialing
Researchers	Evidence generation
Family Members, Friends, and Communities	Social support

11.1 Addressing the Hidden Curriculum¶

The hidden curriculum refers to unwritten and unofficial values, and unintended lessons, that students learn by observing a teacher's actions, which may be at odds with the formalized curriculum. The American College of Physicians reported that more than half of medical students experienced disconnect between what they were explicitly taught and what they perceived from faculty behaviors in practice. The ACP 2018 position paper provides recommendations for fostering values of respect, honesty, empathy, inquiry, and ethics while promoting clinician wellness.

11.2 Leadership Responsibilities¶

Concrete steps for leadership include: - Operationalizing well-being as an organizational value - Integrating well-being into strategic plans, performance indicators, and training - Establishing a chief well-being officer role with dedicated resources and decision-making authority - Collaborating with leadership in health care administration, HR, finances, health IT, and equity - Proactively engaging physician and other health worker representatives

11.3 Assessment and Monitoring¶

Leaders must regularly: - Assess the work environment for factors contributing to chronic work stress and burnout - Evaluate changes in policies and programs impacting physician well-being - Use validated tools for engaging staff and measuring well-being - Benchmark success NAM's Action Collaborative offers a compendium of resources with validated tools.

11.4 Normalizing Mental Health Conversations¶

All health care leaders must model and create environments where conversations about physical and mental health are normalized. Physicians should be able to talk openly about work stressors and mental health without stigma or fear of repercussions on licensing, credentialing, or careers. This includes: - Encouraging open, honest conversations about mental health challenges - Offering support and validation - Beginning these efforts early in medical training - Implementing periodic physician well-being support and awareness campaigns

12. SOLUTIONS FRAMEWORK: THRIVING TOGETHER¶

The approach to addressing burnout must shift from a 'me' problem to a 'we' problem, requiring coordinated action across multiple stakeholders and domains.

Solutions to Health Worker Burnout - Key Domains¶

Domain	Key Elements
Leadership	Commitment and organizational values alignment
Workforce	Diverse and empowered health workforce
Administrative	Reduced burdens and streamlined processes
Mental Health	Accessible care without stigma or barriers
Environment	Safe and inclusive workplaces
Culture	Healing, community, and connection
Technology	Human-centered design and implementation
Partnerships	Community collaboration and trust

12.1 Core Solution Domains¶

Leadership commitment and organizational values
Diverse and empowered health workforce
Reduced administrative burdens
Accessible mental health and substance use care
Safe and inclusive environments
Culture of healing, community, and connection
Human-centered technology
Community partnership
Trust

13. THE FUTURE OF PHYSICIAN WELL-BEING¶

Medicine remains a calling, yet one that should be built on, not at the expense of, the well-being of our nation's healers. Failing to value and center their health and well-being at the core of our health care system puts us all at risk. When physicians look ahead, they should see a future where their dedication is not taken for granted, but one where their health, safety, and well-being are as much a priority as the well-being of the people and communities in their care.

14. KEY POINTS & CLINICAL PEARLS¶

Essential takeaways for understanding and addressing physician well-being.

14.1 Understanding Burnout¶

Burnout is an occupational syndrome, not a personal failing
The most important drivers are workplace systems, not individual-level factors alone
Burnout affects patient safety, quality of care, and physician health equally
Crisis levels existed before the pandemic and have worsened since

14.2 Addressing Burnout¶

Individual wellness programs alone are insufficient without systemic change
Leadership commitment is critical for cultural transformation
Mental health care access must be destigmatized and barriers removed
Administrative burden reduction directly improves well-being and patient care time
Social connection and community are protective factors

14.3 Action Items for Organizations¶

Establish chief well-being officer with resources and authority
Regularly assess workplace factors contributing to stress
Remove stigmatizing questions from applications and forms
Implement the GROSS model to eliminate unnecessary documentation
Create protected time for social connection and reflection
Leverage technology to reduce burden, not add to it

15. RESOURCES¶

Key resources for further reading and implementation.

15.1 Key Documents¶

The Complexities of Physician Supply and Demand: Projections From 2021 to 2036 (AAMC)
To Err Is Human: Building a Safer Health System (IOM, 2000)
US Surgeon General's Advisory on Building a Thriving Health Workforce (2022)
National Plan for Health Workforce Well-Being (NAM)
ACP Position Paper on Hidden Curricula, Ethics, and Professionalism (2018)

15.2 Websites¶

American Medical Association: www.ama-assn.org
Physicians Foundation: www.physiciansfoundation.org
National Institute for Occupational Safety and Health
NAM Clinician Well-Being Action Collaborative

15.3 Practical Tools¶

AMA Saving Time Playbook
AMA Electronic Health Records (EHR) Playbook
NAM validated tools for measuring physician well-being
The Joint Commission workplace violence prevention standards