Physician Wellness, Resiliency

and Burnout
Robert Sidman, MD

This much we know from academic journals, the news media, and our own experience: the practice environment is
more challenging than it used to be and professional satisfaction is not what it used to be. The quality and safety of
our hospitals and practices depend on physicians functioning at a high level. Yet there is an extraordinarily high and
increasing prevalence of physician burnout, and it has become a national problem.

Professionally fulfilled physicians (defined as those who experience happiness, self-worth, self-efficacy and satisfaction)
are better equipped not only to practice the art and science of medicine, but also able to lead the effort to identify
and implement much-needed improvements to our health system.

Professional wellness can be categorized into three components: efficiency of practice, a culture of wellness and
developing personal resilience. Like a three-legged stool, all should be addressed for stability and success. While no
member of the care team is immune, the focus needs to be on physician well-being for two reasons. First, physicians
have been hard-hit by the organizational transformation of the health delivery system resulting in an epidemic
of burnout and declining professional fulfillment. We have suffered from a reduction in professional autonomy,
experienced significant increase in clerical duties (e.g. EHR), and are required to report on an ever increasing number
of quality metrics. Second, medical training has traditionally inferred that physicians sacrifice self-care in the service
of others. It is now insufficient to just ask “physician heal thyself ” through resiliency training while the practice
environment continues to deteriorate. Yet the majority of interventions and research related to physician wellness
has focused on personal resilience (e.g. mindfulness), while organizational interventions (efficiency of practice
and developing a culture of wellness) are only beginning to emerge. Health systems have a responsibility to build
an efficient practice environment and foster a culture of wellness while supporting physicians’ efforts to improve
their own resilience. The obligation of the health system does not relieve us of our obligation to focus on personal
resilience. In fact, it is essential that the physician play a key role in improving the efficiency of practice and
building a culture of wellness in the hospital.

Efficiency of practice is improvement through continuously identifying administrative problem points, removing
administrative barriers and devising solutions to epitomize workflow. As physicians, we have an intrinsic desire
to provide optimal care for our patients. Excessive time pressures and a chaotic work environment impair these
efforts and contribute to burnout. Strategies that help us efficiently deliver high-quality care, by re-engineering and
continuously improving care process and clinical workflows, will improve well-being. Taking a page from industry and
incorporating sound Lean Management methodology is a path to operational efficiency. Key targets for improvement
include streamlining the usability of our electronic medical record, appropriate staffing (allowing physicians to
spend more time doing work for which they are uniquely trained), reducing regulatory and documentation burdens,
improving user-friendly decision support, and facilitating reliable care coordination. Efficiency of practice impacts
the other two domains in that those who practice in an efficient clinical setting have more capacity to improve their
personal resilience and help foster a culture of wellness.

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A culture of wellness is defined as a set of values, attitudes, and behaviors that promote self-care, personal and
professional growth, and compassion for colleagues, patients, and self. Healthcare organizations that recognize
physician well-being as an important quality indicator will support it with appropriate attention and resources.
Clinical leaders should reject the historic “iron doc” culture and encourage physicians to extend compassion and care
to their overburdened colleagues. It is essential to build a culture of appreciation, support, and compassion. Examples
include forming a peer support program to provide emotional support to colleagues. They have been shown to be
effective in preventing harmful stress while contributing to a culture of compassion and a sense of community. Care
teams can reduce harmful stress by ensuring all members feel safe when pointing out problems (as is taught in High
Reliability Training), rather than fearing negative feedback. Like improving the efficiency of practice, a culture of
wellness exerts a positive effect on the other two domains. Physicians who feel supported by the organization tend
to contribute more to improvement efforts that increase the efficiency of their practices. We are also more likely to
attend to our own personal resilience, and this is supported by a culture which values and encourages this behavior.

Personal resilience is being able to adapt well in the face of adversity or significant sources of stress. It is
“bouncing back” from difficult experiences. The importance of this in our profession is under appreciated and, as
previously mentioned, not addressed in our medical training. When the hospital and practice promote self-care this
will improve practice efficiency, and strengthen personal resilience. There are several self-help strategies that
promote personal resilience, including good nutrition, exercise and adequate sleep. These strategies can improve
general well-being and reduce the risk of burnout, and improve cognitive performance. Techniques to engage in self-
awareness and stress reduction are also proven approaches to enhance resilience.

It is increasingly clear that the growing threat to physicians’ well-being directly impacts the quality of care
delivered, as well as the effectiveness of the hospital and/or practice that we work within. Organizations such as
Hartford HealthCare are taking responsibility for developing programs to address the crisis of physician burnout.
We need comprehensive, systematic, and sustained efforts to improve physician well-being. These efforts will be most
effective when they address drivers of physician well-being from each of the three domains of practice efficiency, a
culture of wellness, and personal resilience. A balanced approach is necessary to build a stable platform that will
drive sustained improvements in physician well-being and the performance of our health care systems. g

Adapted in part from an article that appeared in NEJM Catalyst on April 26, 2017

Editor’s Note on page 4

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Editor’s Note:
Burnout, characterized by emotional exhaustion, depersonalization, and diminished sense of personal accomplishment, is plaguing
medicine. One of every three physicians experiences burnout at any given time, a rate higher than any other profession. In a
study by Dyrbye, et al, published in the Mayo Clinic Proceedings (2013; 88:1358), 27,276 physicians responded to an e-mail
questionnaire about burnout and 7,288 physicians participated in the final survey. The demographics accurately reflected the
814,022 US physicians listed in the AMA Physician Master file. Early career (1583 physicians, 27.2%), middle career (1634
physicians, 27.9%) and late career (3006 physicians, 54.8%) physicians were defined as practicing medicine for less than or
equal to 10 years, 11-20 years, or greater than or equal to 21 years and the median ages were 38, 49, and 61 years, respectively.
Approximately 25% were surgeons, 22% primary care physicians, 17% medical or pediatric specialists, and 35% other (industry,
administration, etc.). The average hours worked per week were 52, 54, and 50 hours for early, middle, and late career physicians.
Early career physicians had the lowest satisfaction in career choice (37.6%) and middle career physicians had the lowest
satisfaction with specialty choice (33.7%) and the highest burnout rate (53.9%). Overall career satisfaction tended to be lower and
burnout higher in private practice.4.8%, 12.3%, and 5.2% of early, middle, and late career physicians planned to leave the
practice of medicine within 2 years for reasons other than retirement.

Dr. Robert Sidman, the East Region Director of the Hartford HealthCare Network, succinctly summarized the underlying factors
associated with burnout and emphasized the commitment of Hartford HealthCare to address this problem. Dr. Sidman knows
well the organizational costs for replacing physicians ($500,000.00 - $1,000,000.00 per physician depending on specialty)
and the disruptions of patient care and the threat to public health in The William W. Backus Hospital and Windham Hospital
communities associated with physician retirement and physician flight over the past few years. The problem of recruiting and
retaining physicians in eastern Connecticut is manifold – poverty, tax burden, public school image, distance from an urban center,
to mention a few – but stress and burnout should be very low on the list. Small hospitals and small communities have the distinct
advantage of a close knit medical staff with intimate relationships to each other and to the public it serves, a powerful incentive to
practice here. As Dr. Sidman proposes, we physicians must support and care for each other, just as we care for our patients. The
exact formula for addressing physician wellness and resilience at Backus Hospital needs to be defined and physician leadership will
be essential, but recognizing the problem is the right start.
– Dennis E. Slater, MD

Addendum: A brief questionnaire by Dr. Sidaman regarding physician burnout has been e-mailed to every medical staff member
in order to better understand the exact triggers of stress at the Backus Hospital. Please complete the survey and mail it back to the
medical staff office.

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