Clinical Faceoff: Physician Burnout—Fact, Fantasy, or the Fourth Component of the Triple Aim?

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One of the buzzwords frequently mentioned in discussions on healthcare transformation is the “triple aim.” The triple aim suggests a redesign of delivery systems so as to: (1) Improve patient outcomes, (2) increase patient satisfaction, and (3) decrease overall cost. Whether we can or will achieve the triple aim is a topic for another day; rather, here, I would like to add a fourth component to the triple aim: Provider well-being.
As the delivery system continues to change, how can we ensure the deliverers themselves remain mindful of their own physical, emotional, and professional health? This consideration has been lost in many of the discussions pertaining to healthcare transformation. Often, the improvement plans and transformational activities focus merely upon system improvement. This is necessary but insufficient. In fact, the most crucial cog in the transforming machine is the practitioner, without whom the delivery of care is impossible. Unfortunately, while consultants, efficiency experts, systems analysts, and software engineers have been feverishly working to improve efficiency, the effect of such efforts on the human beings charged with actually delivering this “enhanced” care has been largely ignored.
Is the electronic medical record optimized for our clinical practices? Do the increased reporting and documentation burdens imposed upon practitioners actually improve care? If the system is transforming for the better, why are we faced with an epidemic of early physician retirements, career changes, and burnout [10, 12, 17, 21, 22]?
Recognizing the importance of these issues, I have solicited the opinions of two experts in this field, Drs. Michael J. Goldberg and John D. Kelly, IV.
Dr. Goldberg, a Professor in Orthopaedics at the University of Washington School of Medicine, is also the Director of the Skeletal Health Program at Seattle Children's Hospital. While recognized as a leader in the diagnosis and treatment of children with complex syndromes, birth defects, and skeletal dysplasia, his thought leadership in caregiver well-being is the expertise we will take advantage of here. He is the first Scholar-in-Residence at The Schwartz Center for Compassionate Healthcare in Boston, MA—a national nonprofit whose mission is to advance compassionate healthcare and provider well-being (
Dr. Kelly is a Professor in the Department of Orthopedic Surgery and Director of the Sports/Shoulder Service at the University of Pennsylvania. He is a regular columnist in Clinical Orthopaedics and Related Research® on topics of mindfulness, physician well-being, and personal/professional growth and introspection. His thoughts on “Holistic Orthopedics,” and his columns on topics from Tolstoy to stress reduction are widely read because they provide a humanistic insight into medical and surgical practice.
Thomas K. Wuest MD, MMM: How have you or any of your colleagues dealt with issues related to physician burnout?
Michael J. Goldberg MD: As a first step, we have tried to have hospital leadership recognize that burnout is a mental state characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. It is not whining by highly paid professionals, nor should it be stigmatized. Because burnout affects all caregivers—anyone who touches a patient—a successful program addressing workforce well-being must be comprehensive and organization-wide, similar to successful patient safety, continuous process improvement, and Lean Six Sigma initiatives.
We have proposed a program model to address the interrelationships between the individual provider, the unit/team, and organizational leadership. A brief sampling that we and others have employed include: (1) Programs that build individual resilience such as mindfulness, meditation, verbal and nonverbal communication skills, and attentive listening, (2) events that nourish caregiver-to-caregiver compassion by scheduling time for open and honest discussion of social and emotional issues that arise in caring for patients, and (3) organization-wide initiatives that support workforce well-being.
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