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As hospital medicine grows, so do the challenges of avoiding burnout
With some practices reporting double-digit turnover, strategies to avoid depleting the workforce remain a hot topic
by Bonnie Darves



Published in the June 2005 issue of Today's Hospitalist.

Just minutes before the start of a presentation on burnout at the Society of Hospital Medicine’s annual meeting in Chicago, at the Society of Hospital Medicine’s annual meeting in Chicago, two young physicians eyed each other, gathered their things things and prepared to leave the room. As the pair made their and prepared to leave the room. As the pair made their way out of the room, one muttered something to his colleague just way out of the room, one muttered something to his colleague just loud enough for those within earshot
One practice tries to limit burnout by making sure its physicians work no more than 18 days a month.

to hear: “I think we already know more than we want to know about burnout, don’t you?” know more than we want to know about burnout, don’t you?”

Whether the presentation might have helped those two hospitalists is hard to say. But in their hasty departure, they unwittingly exemplified the growing dilemma facing hospital medicine: coping with rapid growth and ever-increasing demands without depleting the forces.

“When we started out, we were going to be the key to hospital cost control, then we took on quality and safety,” said presenter Tosha Wetterneck, MD. “Now we’re taking over care of medical subspecialists’ patients and, with the resident work hour restrictions, some of that duty as well. The question is: Are we going to be able to be all things to all people?”

Not without incurring the risk of broad-scale burnout in the specialty, replied Dr. Wetterneck, assistant professor of medicine and a practicing hospitalist at the University of Wisconsin- Madison.

The prevalence of burnout

The burnout rate among hospitalists hasn’t been formally studied since the Society of Hospital Medicine’s 1999 survey, which found a 13 percent rate among hospitalist respondents. At least some in the specialty, however, think evidence suggests that the rate may be much higher today.

Co-presenter Mark-Anthony Williams, MD, president of Inpatient Services PC in Denver, said that he has heard hospitalist programs report double-digit turnover every year. He has even heard anecdotal evidence of turnover rates as high as 40 percent.

And perhaps just as importantly, burnout—even if that exact term isn’t always used—remains a frequent topic of discussion among hospitalists. Dr. Wetterneck, for example, said the following scenario is common on the Society of Hospital Medicine’s online chat area: “Our program is growing, and I’m working myself to the bone. I’m burning out. What can I do?”

She has also heard program directors weigh in, she noted, with an increasingly common plea: “How can I make my program one that doesn’t burn out physicians?”

Drs. Williams and Wetterneck agreed that some burnout is inevitable in any rapidly growing field undergoing constant change. Dr. Wetterneck noted that in the early days of emergency medicine and critical care medicine, self-reported burnout rates got as high as 50 percent.

Dr. Wetterneck said that hospitalist programs would do well to take a page from their site-based colleagues to address burnout.

Both emergency and critical care medicine, for example, orchestrated efforts to establish fixed work hours, and to make sure that physicians had ample time away from work. Group leaders and executives in those fields also devised ways to let their physicians know their work was valued.

The importance of workloads

Hospital medicine isn’t likely to get any easier in the next few years, as the specialty defines its role amidst pressing demands. With that reality in mind, how can hospitalists try to ward off burnout, and how can program directors identify its signs in their programs—and head it off at the pass?

For one, it’s important to understand that physicians’ perception of workload—in addition to actual workload as measured by patient load, shift duration or number of hours worked per week—can lead to stress. If that stress is sustained over a long enough time, burnout can be one result.

Hospitalists who feel like they don’t have enough time to do their job are at risk for burnout, regardless of how their productivity stacks up to others’ or the group’s expectations.

That’s probably why qualitative issues are so important in burnout. Those issues include role ambiguity, environments in which physicians have little control and support, and the sense that resources, including backup clinicians, are inadequate.

“People who have a sense of an effort-reward imbalance are at high risk,” Dr. Wetterneck added,” because when we don’t get back from the job what we expected, it’s a stressor.”

In attempting to mediate burnout in the hospitalist group, Dr. Williams suggested, the best approach is to start by tackling issues that can be controlled. Adhering to the group’s stated values is critical, as is allowing for as much autonomy and control as possible. In addition, try to inject stability and predictability into physicians’ schedules and expectations wherever possible. That simple step can go a long way to counter the effects of the field’s currently “fluid” state.

It’s also important to provide additional resources for overworked hospitalists in the form of efficiency-enhancing tools and non-physician support staff—even if those supports don’t actually reduce physicians’ work hours. And honestly recognizing hospitalists’ frustrations—and making frequent mention of their contributions to the group and patient care—can also stem burnout.

“You can say, ‘I can’t give you less of a workload, but I can give you more resources and try to make the situation more fair—and I can try to respect your values more,’ ” Dr. Wetterneck said.

Scheduling strategies

In Dr. Williams’ group, which has achieved what he described as an “unplanned turnover” rate of 9 percent in the past six years, the value of ensuring an attractive lifestyle is reinforced by the group’s scheduling practices.

No hospitalist, for example, is allowed to work more than 18 days a month, and some work as few as 12. In addition, hospitalists are assured that if they block out vacation days on the monthly calendar, that time off will be granted.

“What that does is give people that control back,” he said. “Even if they don’t have the stability of an exact, replicating schedule, they know they can get that time off.” On a daily basis, the hospitalists are not allowed to care for more than 20 patients, yet the group aims for 15. “We can’t have people who are wildly off the scale,” Dr. Williams said.

The group also strives to include hospitalists in decision-making, even when the decision that prevails isn’t necessarily to their liking—or is handed down by an entity outside the group. In that regard, frequent, open communication becomes critical.

“This is a huge issue, because if you feel you can’t change anything, that’s difficult,” Dr. Williams said. “The hospitalists can’t necessarily change who’s in charge, but they need to know who is making the decisions.”

To that end, setting clear lines of communication so that hospitalists can at least air their grievances can help deter burnout, Dr. Williams maintains.

“I think it’s possible to keep your physicians and to keep them happy,” he said. “You don’t need to have 30 percent to 40 percent annual turnover.”

Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.


What is burnout? A definition of a common problem

While burnout in hospitalists resembles the problem in other professions, there is an added—and unsettling—dimension: the risk that sions, there is an added—and unsettling—dimension: the risk that hospitalists in distress will compromise patient safety.

Simply defined as an “erosion of engagement with the job,” burnout presents as emotional exhaustion that comes on slowly and becomes chronic in nature. As the condition worsens, physicians experience depersonalization, which often translates into job cynicism that translates into dysfunctional attitudes and behaviors toward patients. Ultimately, burnout can lead to professional inefficacy and a sense of reduced personal accomplishment.

While the exact appearance of burnout varies, it’s often associated with the intent to leave the job or work fewer hours, higher rates of absenteeism and a self-reported lower quality of care.

Tosha Wetterneck, MD, assistant professor of medicine and a practicing hospitalist at the University of Wisconsin-Madison, said that while burnout is often thought to be associated with or caused by depression, that’s usually not the case. While people with depression have been found to be more prone to developing burnout, she said, burnout is specific to the work environment, although it may affect home life as well.

Burnout tends to affect younger doctors more than middle-aged or older individuals, Dr. Wetterneck explained, and it is more common in single people than physicians with spouses or partners. In addition, women with burnout tend to have higher emotional exhaustion scores than their male counterparts.

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