October 3, 2018
The “NorthShore Way”—How Our System Addresses Physician Burnout
by Joseph Golbus, MD
Since 1998 I have served as President of NorthShore Medical Group, a nearly-1000 physician group that is part of a four-hospital integrated delivery system in Chicago and Northern Illinois. I’ve had the pleasure of overseeing its evolution from 150 physicians with little infrastructure and no clear culture to a large interdependent, multidisciplinary group with defined values, support structures, and strategic direction.
Over that time, we have seen tremendous alterations in both our internal and external environments. The changing nature of physician practice has been the greatest challenge, with shifting generational expectations and significant changes to practice requirements and operational workflows. And it’s the pace and degree of change that has led to a growing sense of unease among physicians, ranging from increased stress, fatigue and disillusionment to “burnout” and depression. Even with strong foundational culture and support for change management, we have seen rates of fatigue and burnout rising among our doctors, and have put in place a range of solutions—many of which are having a very positive, if early, impact.
We’ve had requests to share our learning with other systems, and in this series I’ll outline the NorthShore approach to sustainable practice. It reflects the evolution of our strategy, culture and infrastructure to manage pace of change, and is the essence of our value proposition to the physician members of our group.
Why we prefer to talk about “physician fatigue” rather than burnout
Physician burnout refers to the effect of internal and external stressors on the well-being of physicians, including emotional exhaustion, depersonalization and a diminished sense of personal accomplishment. The causes are multifactorial, complex, and very individualized. Nationally 50 percent or more of practicing physicians experience at least one symptom of burnout on a regular basis. A recent NorthShore member survey showed that 17 percent of our doctors (99/576 respondents) expressed at least one symptom of burnout daily, frequently (a few times per week), or occasionally (a few times a month).
While more favorable than the reported averages, 17 percent is still too high to ignore. Beyond that, I suspect virtually all of our members experience some degree of fatigue, stress, or concern over work-life balance, even if they don’t meet the definition of true burnout. While in no way trying to diminish the impact, the majority of physicians may not be burned out, but almost all are stressed from hurdles impeding their ability take great care of patients. That’s why I prefer the term “physician fatigue”.
I suspect virtually all of our members experience some degree of fatigue, stress, or concern over work-life balance, even if they don’t meet the definition of true burnout. That’s why I prefer the term “physician fatigue”
Unpacking the causes of physician fatigue
For the purpose of understanding the problem and suggesting tactical solutions, we break down physician fatigue into three categories:
- “Things that are done to us”. These “system issues” are estimated to be 70 to 80 percent of the problem for most doctors. It’s a long, familiar list: bureaucratic external mandates, regulatory and reporting requirements, health plan obligations, excessive workloads, and burgeoning technology. Electronic medical records (EMRs) have afforded great advantages, but nothing has brought more burden to physicians. Rising documentation and data entry demands lead to inefficiency in daily work flows, the stress of multi-tasking, communication break downs, and a perceived lack of resources. Taken together, these “things done to us” lessen one’s sense of control. Physicians historically have worked very long hours under stressful conditions. While we are surely seeing generational shifts in work expectations, the issue isn’t how much we are working, but the questionable value of some tasks and how we’ve had to restructure our practices to deal with external mandates.
- “Things we do to each other”. This second set of issues relates to a sense of lost autonomy, having a voice in decision-making, and respect amongst colleagues. A recent RAND/AMA study found greater physician autonomy and control over the pace and content of clinical work were both associated with higher professional satisfaction. Another key finding in the study, and one I’ve observed anecdotally at NorthShore: physician perceptions of collegiality, fairness, and respect were also key determinants of professional satisfaction. The rapid increase in size of many medical groups makes it more difficult to know each other on either a professional or personal level, exacerbating the difficulties of communication and relationship development.
- “Things we do to ourselves”. These are issues related to personal resilience and social isolation. Practicing medicine today can be a lonely endeavor. Increasing in-practice and outside obligations leave little time to attend meetings or work-related social events. Hospital rounding has declined, especially for primary care. Opportunities to support each other and empathize around the emotional toll of our roles have greatly diminished. As one’s community at work deteriorates, there can be feelings of isolation, disillusionment and a lack of trust in leadership.
NorthShore’s approach to improving practice sustainability
We designed a tactical approach to solutions based on these drivers of physician fatigue. Some issues, such as the EMR and practice inefficiency require a system-wide or top down approach. Other issues, such as how we treat each other, social isolation and personal resilience may respond better to a local or bottom up approach: tactics at a department, division, or practice level which can better reflect local practice dynamics, personalities, social connections and our individual abilities to adapt to change. Issues of autonomy and social isolation need solutions, but I believe some in the industry misperceive the root cause, tending to focus more on work-life balance solutions such as providing dinner or help at home, rather than focusing more intently on the work flow/operational issues that consume so much of a physician’s time and distract from the enormous rewards of patient care that lead most to the field. Here is an overview of our most promising work to date:
1. Systems and Processes: Given that the EMR is a shared tool and the focal point of our workflows, we must standardize to reduce the burden of interacting with the system. There are aspects of medicine that should remain individualized, but there are also many mundane activities that can be offloaded if we allow a degree of standardization through processes and automation. In doing so, we can focus on the more value-added intellectual and interpersonal aspects of care delivery. The solution to chaos is organization.
In our Primary Care Physician Task Force, physician-led subcommittees are charged with inbox “debulking”, tackling issues like automation of prescription refills and medical prior authorizations, elimination of unnecessary alerts, improved processes for standard letter requests, home health certificates, referral protocols, and standardized nurse triage. Here are two of their success stories:
- “Let the EMR work for you”: We strive to automate as many of our workflows as possible. One big win: we automated large portions of the Medicare Annual Wellness Exam, electronically identifying and notifying eligible patients, aggregating completed portions of the exam and data, and simplifying compliance with Medicare requirements without further physician involvement. In the first 18 months, we have more than doubled the number of Medicare annual wellness visits from 30 to over 60 percent of eligible patients with significant time savings for our physicians. It has been a big win for all: we’ve improved preventative services and quality of care for our patients, taken work off the plates of our primary care physicians, and allowed them to get paid for their efforts.
- The “Home for Dinner” Project: We are helping physicians improve their own gaps in the use of the EMR, providing efficiency reports and physicians trainers, or “super users”, who can help our physicians accomplish tasks quicker, easier (less “clicks”) or more effectively through better use of the tools available. Deemed the “home for dinner” project, we are monitoring the frequency and duration of time spent on Epic after hours as one metric of success.
Given that the EMR is a shared tool and the focal point of our workflows, we must standardize to reduce the burden of interacting with the system
2. Autonomy, respect and voice: There is abundant evidence demonstrating that the leadership behaviors of physician supervisors play a critical role in the well-being of the physicians they lead. The degree of difficulty has increased as our group has grown—we simply need more leaders. We have created new physician leadership positions where they are most impactful, such as in our primary care practices, which are geographically dispersed and in great need of two-way communication vehicles. To give physicians the tools to lead, we have created the Medical Group Leadership Institute (MGLI) to provide offerings for everyone within our group. In addition to the core curriculum for titled leaders, we have in-person and online courses for any interested physician and hold quarterly forums to both inform and engage our members on our issues, and have twice yearly “State of Our Union” events to provide information and seek feedback.
- Primary Care Practice Network (PCPN): We created the PCPN as a platform to “elevate” primary care at NorthShore, creating a comprehensive, integrated approach to primary care services, with a key objective of creating both a better patient and physician experience. A key element is the creation of primary care “leads” in each practice, and physician director positions to expand primary care physicians in leadership roles, two-way communication, and decision-making—something that had been largely missing for office-based PCPs. Through those leaders we are assessing our practice structure, staffing ratios, and processes to advance teamwork.
- Understanding a changing physician workforce: Several years ago we formed a Women in Leadership Task Force aimed at helping us address barriers to involving more women in our activities and leadership, and developing actionable steps to improve. While there is room for further improvement, women now make up 40 percent of our membership, compared to 33 percent nationwide, and there has been a similar increase of women in our leadership ranks. Building on this success, we recently launched a Millennial Task Force to better understand the needs and perspectives of millennial physicians to continue to attract and retain the brightest doctors. We’ve already identified a number of parameters, including our benefits, flexibility in hours for physicians at all stages of their career, desire for service opportunities, and mentoring systems to help all cope and adapt.
3. Personal resilience and social isolation: At the other end of the spectrum lie the very personal issues of resilience and social isolation. We have group meetings both to review what is going on within our group and to serve as an opportunity to interact with colleagues. Forums have already been held on subjects such as mentorship, work-life balance and personal resilience. We promote collegial interactions by tying those meetings to social events designed to be convenient and attractive to a changing workforce. While these system-level efforts have been helpful, I think this is where all physician leaders can provide great support at the local level by listening to concerns, providing support, and reinforcing our shared purpose.
Where do we go next?
We are finding that deliberate, sustained and comprehensive efforts can make a real difference in reducing physician fatigue and burnout, but we’re just getting started. We hope to share what we are learning to benefit other groups, start a conversation, and solicit further ideas from you about what we at NorthShore Medical Group and our colleagues across the country can do to better adapt to the realities of healthcare in the years to come. What else can we do to simplify the workflows of our practices? How can we better reduce social isolation? And how can we better leverage the resources of large medical groups to help our organizations, our physicians and staff, and most of all, the patients and communities we serve?
I look forward to your comments and suggestions—let’s have a conversation to share ideas, and identify both successful solutions and needs for further support.