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• W2991439853 abstract "FOR RELATED ARTICLE, SEE PAGE 1001Have you had days when your emotional, physical, and mental fuel tanks are depleted to fumes and it is impacting your work? Physicians in general, and perhaps intensivists in particular, are accustomed to working hard, managing stress, and even thriving in chaotic circumstances. Nevertheless, burnout rates for intensivists remain distressingly high—often exceeding 50%. In the quest to mitigate burnout, emphasis has often been placed on enhancing an individual’s ability to cope with workplace stress, such as through boosting one’s resilience. In this issue of CHEST, Lilly et al1Lilly C. Cucchi E. Marshall N. Katz A. Battling intensivist burnout: a role for workload management.Chest. 2019; 156: 1001-1007Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar correctly redirect our attention to the importance of managing key drivers of work dissatisfaction and burnout; they focus on workload. FOR RELATED ARTICLE, SEE PAGE 1001 The syndrome of burnout has been recognized for decades and is described by the World Health Organization2World Health OrganizationBurn-out an “occupational phenomenon”: International Classification of Diseases.https://www.who.int/mental_health/evidence/burn-out/en/Google Scholar as an occupational phenomenon resulting from chronic workplace stress that has not been successfully managed. Burnout is characterized by feelings of energy depletion or exhaustion, increased feelings of negativism or cynicism related to one’s job, and reduced professional efficacy.2World Health OrganizationBurn-out an “occupational phenomenon”: International Classification of Diseases.https://www.who.int/mental_health/evidence/burn-out/en/Google Scholar Burnout is often triggered by imbalance between job demands and a worker’s expectations and ability to meet those demands.3Moss M. Good V.S. Gozal D. Kleinpell R. Sessler C.N. Burnout syndrome in critical care health care professionals: a call for action.Chest. 2016; 150: 17-26Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar Burnout is associated with potential harm to the worker, including physical manifestations of stress, insomnia, and higher rates of depression, substance abuse, and suicide.3Moss M. Good V.S. Gozal D. Kleinpell R. Sessler C.N. Burnout syndrome in critical care health care professionals: a call for action.Chest. 2016; 150: 17-26Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar Not surprisingly, there is a strong association between burnout and intent to leave the profession or reduce hours of work. Experts conservatively estimate nearly $5 billion in costs is attributable to burnout-associated reduced productivity each year in the United States alone.4Han S. Shanafelt T.D. Sinsky C.A. et al.Estimating the attributable cost of physician burnout in the United States.Ann Intern Med. 2019; 170: 784-790Crossref PubMed Scopus (320) Google Scholar Burnout harms not only individual health-care workers (HCWs) and the health-care system but is associated with harm to patients. A large survey of US physicians, in which 54% of physicians reported symptoms of burnout, demonstrated independent associations of worker burnout and fatigue with major medical errors.5Tawfik D.S. Profit J. Morgenthaler T.I. et al.Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors.Mayo Clin Proc. 2018; 93: 1571-1580Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar Burnout is substantially more common among physicians than the general working population: 40% vs 28%, respectively, in a sizable US survey.6Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017 [published online ahead of print February 13, 2019]. Mayo Clin Proc. https://doi.org/10.1016/j.mayocp.2018.10.023.Google Scholar Among physicians, front-line workers such as those in critical care medicine, emergency medicine, obstetrics and gynecology, family medicine, internal medicine, and neurology tend to have the highest proportion of workers reporting burnout.3Moss M. Good V.S. Gozal D. Kleinpell R. Sessler C.N. Burnout syndrome in critical care health care professionals: a call for action.Chest. 2016; 150: 17-26Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar, 6Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017 [published online ahead of print February 13, 2019]. Mayo Clin Proc. https://doi.org/10.1016/j.mayocp.2018.10.023.Google Scholar What factors explain this excessive burnout? In a framework for addressing burnout and engagement, Shanafelt and Noseworthy7Shanafelt T.D. Noseworthy J.H. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.Mayo Clin Proc. 2017; 92: 129-146Abstract Full Text Full Text PDF PubMed Scopus (754) Google Scholar highlight seven drivers including (1) meaning in work, (2) workload and job demands, (3) efficiency and resources, (4) control and flexibility, (5) organizational culture and values, (6) social support and community at work, and (7) work-life integration. One can argue that the nature of the work itself—both the quantity and the nature or quality of the work—is of utmost importance, especially in the ICU. To start, physicians work, on average, 30% more hours per week than the general US working population,6Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017 [published online ahead of print February 13, 2019]. Mayo Clin Proc. https://doi.org/10.1016/j.mayocp.2018.10.023.Google Scholar and intensivists typically work among the longest hours. Hours worked per week does not, however, tell the full workload story. Other factors that can have an impact on HCW exhaustion and impaired recovery include consecutive hours worked in a day or shift, number of consecutive working days without a break, working on weekends, and working at night—either physical in-hospital work or answering sleep-disrupting pages and phone calls. Additionally, physicians often bring work home, including spending evenings or weekends completing documentation or on other tasks. Intensivists typically work long shifts, numerous consecutive shifts, and disproportionately more weekends and nights than many other physicians—raising the risk for burnout. Indeed, the number of nights worked, consecutive work days, and days since last nonworking week have been identified as independent risk factors for intensivist burnout, and taking a weekend off between working weeks is protective.8Pastores S.M. Kvetan V. Coopersmith C.M. et al.Workforce, workload, and burnout among intensivists and advanced practice providers: a narrative review.Crit Care Med. 2019; 47: 550-557Crossref PubMed Scopus (63) Google Scholar Finally, workload in a typical ICU is not static—there are frequent surges in activity, so-called strain, in which human and physical resources may be inadequate to meet the demands of spikes in acuity from new admissions and patients who are unstable. Strain contributes to stress and burnout. It is instructive to dissect the quantity and nature of the work by exploring a typical workday. Lilly et al1Lilly C. Cucchi E. Marshall N. Katz A. Battling intensivist burnout: a role for workload management.Chest. 2019; 156: 1001-1007Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar identified mandatory ICU tasks and estimated the average time to complete these tasks. When compared with the number of scheduled work hours, they determined that 86% of work hours were required to perform mandatory tasks such as direct patient care, ICU procedures, interprofessional rounds, documentation, and writing orders, leaving little time for other basic necessities. Their findings are similar to those of a hospitalist time-motion study in which personal and professional development time accounted for only 12% of the time of all observed activities.9Tipping M.D. Forth V.E. O’Leary K.J. et al.Where did the day go? – a time-motion study of hospitalists.J Hosp Med. 2010; 5: 323-328Crossref PubMed Scopus (75) Google Scholar These examples of a packed workday can be defended as efficient with considerable work performed in a limited time, but raise concerns about the cost in terms of stress and burnout and leaving inadequate time for personal needs, teamwork, and teaching. These studies also help us to examine the importance of the nature of the work as we consider workload. For example, the hospitalists devoted only 17% of their time to direct patient care, but spent 34% of time working with the electronic medical record (EMR).9Tipping M.D. Forth V.E. O’Leary K.J. et al.Where did the day go? – a time-motion study of hospitalists.J Hosp Med. 2010; 5: 323-328Crossref PubMed Scopus (75) Google Scholar EMR documentation is an important example of unrewarding menial work that crowds out the meaningful work of direct patient care and is a highly cited driver of burnout among virtually all HCWs.7Shanafelt T.D. Noseworthy J.H. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.Mayo Clin Proc. 2017; 92: 129-146Abstract Full Text Full Text PDF PubMed Scopus (754) Google Scholar Lilly et al1Lilly C. Cucchi E. Marshall N. Katz A. Battling intensivist burnout: a role for workload management.Chest. 2019; 156: 1001-1007Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar offer additional support for targeting EMR documentation because they demonstrated a striking relationship between increases in documentation burden after introduction of EMR and increases in burnout, by specialty. Shanafelt and Noseworthy7Shanafelt T.D. Noseworthy J.H. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.Mayo Clin Proc. 2017; 92: 129-146Abstract Full Text Full Text PDF PubMed Scopus (754) Google Scholar identify “meaning in work” as a core driver of engagement and burnout mitigation. Meaningful work gives us satisfaction, whereas performing menial work, such as excessive documentation, builds frustration and contributes to burnout. One might argue, however, that the nature or quality of the work is more multifaceted. Clinical events that are negative and destructive (eg, work accompanied by moral distress, incivility, and conflict among HCWs; violence in the workplace) are important drivers of burnout. Poor relationships and conflict among physicians, nurses, supervisors, and patients and families have been identified as among the most important risk factors for burnout for both ICU nurses and intensivists.8Pastores S.M. Kvetan V. Coopersmith C.M. et al.Workforce, workload, and burnout among intensivists and advanced practice providers: a narrative review.Crit Care Med. 2019; 47: 550-557Crossref PubMed Scopus (63) Google Scholar Medical errors are tied to burnout in a bidirectional fashion because physicians who commit medical errors often develop burnout and physician disengagement associated with burnout can contribute to medical errors.5Tawfik D.S. Profit J. Morgenthaler T.I. et al.Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors.Mayo Clin Proc. 2018; 93: 1571-1580Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar I would argue that these and other toxic events can gash a devastating hole in our emotional fuel tanks. Fortunately, health-care professionals experience many rewarding and uplifting events (eg, witnessing a great clinical outcome for a patient who is profoundly ill, participating in flawless teamwork, feeling the gratitude and love of the patients and their families). These and other events that exemplify positive and meaningful aspects of the quality of our work help to refill our emotional fuel tanks and are important reasons why we do the work we do. Lilly et al1Lilly C. Cucchi E. Marshall N. Katz A. Battling intensivist burnout: a role for workload management.Chest. 2019; 156: 1001-1007Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar highlight the relationship between ICU physician workload and burnout, and offer practical goals of measuring our work, eliminating low-value work, enhancing efficiency of workflow, and optimizing roles and interplay of team members. Published literature, physician experiences, and expert advice can help to identify potential remedies for burnout including those addressing workload.3Moss M. Good V.S. Gozal D. Kleinpell R. Sessler C.N. Burnout syndrome in critical care health care professionals: a call for action.Chest. 2016; 150: 17-26Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar, 7Shanafelt T.D. Noseworthy J.H. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.Mayo Clin Proc. 2017; 92: 129-146Abstract Full Text Full Text PDF PubMed Scopus (754) Google Scholar, 8Pastores S.M. Kvetan V. Coopersmith C.M. et al.Workforce, workload, and burnout among intensivists and advanced practice providers: a narrative review.Crit Care Med. 2019; 47: 550-557Crossref PubMed Scopus (63) Google Scholar, 10National Academy of Medicine: Action Collaborative on Clinician Well-Being and ResilienceClinician well-being is essential for safe, high-quality patient care.https://nam.edu/initiatives/clinician-resilience-and-well-being/Google Scholar, 11Panagioti M. Panagopoulou E. Bower P. et al.Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis.JAMA Intern Med. 2017; 177: 195-205Crossref PubMed Scopus (606) Google Scholar, 12Kleinpell R, Moss M, Good VS, Gozal D, Sessler CN. The critical nature of addressing burnout prevention: results from the Critical Care Societies Collaborative’s National Summit and survey on prevention and management of burnout in the ICU. Crit Care Med. In press.Google Scholar As we continue to strive to eliminate burnout, it is important that we focus on the actual work we perform—both the quantity and the nature or quality of the work—as perhaps the core drivers of physician satisfaction and burnout. /cms/asset/063751fb-c5b3-427a-b081-98252847c5bf/mmc1.mp3Loading ... Download .mp3 (37.2 MB) Help with .mp3 files Audio Battling Intensivist Burnout: A Role for Workload ManagementCHESTVol. 156Issue 5PreviewBurnout syndrome is an increasingly common phenomenon that threatens our critical care workforce and the well-being of its members. Burnout syndrome can be conceived of as a workforce manifestation of chronic workload and workforce capacity imbalance. This study explores the role of workload management tools that can address workload as a complement to the resilience-based countermeasures that seek to increase worker capacity. We were able to use step-wise increments in the volume of documentation-related tasks that occurred at the time of electronic health record (EHR) implementation to investigate the relation of workload and burnout. Full-Text PDF" @default.
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