Addressing the 'public health crisis' of healthcare worker burnout

On weekdays, Dr. Matt Lambert is the chief medical officer at Curation Health, a health tech services company that helps providers transition to value-based care. On weekends and holidays, he's a practicing emergency department doctor at community hospitals in the mid-Atlantic region.

During the pandemic, he saw his hours and pay cut as the staffing firms he contracts with found ways to make up for the cost of lower volumes of patients in the EDs.

"I have even been pulled off the line and replaced by non-board-certified providers because they're less expensive," Lambert said.

Yet, he still faced the risks and pressures of being a front-line physician during a global pandemic and also had to deal with patients who increasingly distrusted him. It's a challenge he said he's never had to face before in his career, and it takes a toll. And he can see his colleagues struggling with the same mental, emotional and financial challenges.

Healthcare professionals like him who have shouldered so much stress and uncertainty during the pandemic "need more than days off;" they need legislation, policy changes and safeguards that address mental health and substance abuse challenges in medicine, Lambert said.

The pandemic didn't create staff burnout in healthcare workers; it exacerbated it. Significantly. In the Medscape National Physician Burnout & Suicide Report 2021, 79% of the more than 12,000 physicians who responded said their burnout began before the pandemic. During the pandemic, 93% of healthcare workers surveyed said they had experienced stress in the past three months, 86% reported anxiety, 77% reported frustration, 76% reported exhaustion and burnout, and 75% said they were overwhelmed, according to a survey by Mental Health America.

"The issue of burnout is certainly not one that's new to the healthcare environment in the best of times. These are stressful and demanding jobs, and the pandemic only made it more so," said Akin Demehin, director of policy for the American Hospital Association.

Across the country, healthcare providers and hospitals are trying to figure out how to reduce burnout in order to retain staff, reduce errors in patient care and improve performance, as healthcare workers start the process of recovering from the emotional and mental toll of the past year.

To start, those in the industry suggest giving clinicians more flexibility in their schedules and reducing their administrative burden. They recommend parity in payment for mental health services, and say health systems need to intensify efforts to eliminate the stigma around mental health issues—especially among providers.

Lambert said doctors often are wary to admit they need help because they fear having their privileges suspended at a hospital or their license suspended at the state level, which can often mean losing their source of income.

"Very rarely does financial stress, added on to other stresses in your life, make things better," Lambert said. "What you tend to see is providers present very late with mental health or substance abuse disorders."

Instead, Lambert would like to see protections for those who self-report, stipends for clinicians who seek treatment, and substitutes trained to help with the workload while colleagues recover.

Ultimately, Lambert said clinicians need fewer emails praising their work and "healthcare heroes" celebrations, and more concrete plans and resources offered to reduce burnout, prevent substance abuse and improve overall mental health.

"I think hospitals are starting to think more strategically about how they deploy efforts to address burnout and build resiliency among their staff," Demehin said. "I think, too, hospitals are thinking about how to build in the appropriate leadership for those initiatives."

The AHA for years has looked at the extent that regulations put additional strain on front-line healthcare workers and how those regulations can be changed to streamline documentation and limit the administrative burden, Demehin said.

"There's certainly an opportunity nationally to better understand and study approaches to burnout and how you scale them across the healthcare system," which would require funding for demonstration programs, Demehin said. "Improving the resiliency of our workforce and addressing burnout is something that is a prime area for collaboration, one that all hospitals have a stake in doing well."

Nancy Foster, vice president for quality and patient safety at the AHA, cited one teaching hospital that pairs residents with counselors to normalize addressing mental health. During the pandemic, that program was extended to additional front-line staff, particularly those in intensive-care units or COVID-19 units. Other systems have offered free laundry services for workers and mobile farmer's markets on site to make employees' lives easier. Some even opened up prayer lines for workers to offer counseling and support, added Demehin.

Dr. Tom Jenike, senior vice president and chief well-being officer at Novant Health in North Carolina, said burnout has "culturally and historically" been a challenge in healthcare, but he also said the pandemic accelerated it.

"The silver lining is it brought attention to a problem that's always been there. You almost couldn't ignore it anymore," Jenike said.

There's a mindset among healthcare professionals that those who care for others shouldn't need help, that they have to shoulder it all, he said.

"She or he who does the most with the least amount of sleep and doesn't complain about it wins," Jenike said.

Novant Health for years has tried to combat that mindset by promoting personal well-being and self-care, he said. To support that work, the system last year launched a platform called "Thriving Together" that combines all of the internal resources available to employees to thrive in their personal lives and at work. Tools for financial, emotional, social and physical health and professional growth are all bundled together as part of the package.

"It doesn't isolate out our emotional or mental health to a dark room. It's all part of growth; it's all part of thriving," Jenike said. "Within our company, we're just messaging that the path to high performance, both individually and collectively, the path to taking better care of our patients and our communities is by taking care of yourself."

The idea, he explained, is to normalize seeking help and protecting their mental health, to make wellness part of the culture.

After conducing a survey on the mental health of its workforce last summer, Novant launched a voluntary six-week emotional health advocate training program. Three hundred employees were trained on how to become more empathic listeners and to serve as peer supports. Within that group, another 75 became on-call "super users" with whom other employees could be connected if they needed someone to talk to. And another round of emotional health advocate training is set to be offered soon.

"We just try to make it as normal as possible, knowing there's a long way to go to reducing emotional heath stigma," Jenike said. "I think a lot of it comes from how we model behavior. Senior leaders and senior physicians are talking about their own challenges and their own struggles."

To help reduce the stigma, the system removed any questions about having a mental health diagnosis from its recertification applications for physicians.

"It's just a message to say, 'We're not going to ask you because we expect that's part of life and we don't want to put a stigma on that,' " Jenike said.

By creating a culture in which people want to work, the system is better able to attract and retain staff and help reduce burnout, Jenike said. The cost of replacing one physician, which can be two to three times their salary, likely pays for the investment, he said.

Dr. Cole Edmonson, chief experience and clinical officer at staffing company AMN Healthcare, said burnout and mental health struggles in the industry should be treated as "a public health crisis."

"We know that the health and the wellness of our healthcare workforce is tied directly to the health and wellness of society," Edmonson said.

As such, he sees a need for additional dedicated federal funding for mental health services, especially for students training to enter healthcare professions, to help them establish healthy habits early on. And there should be parity in payment for mental health.

AHA's Demehin adds that there need to be more Medicare-funded residency spots to address the long-term physician shortage and improve residency training. The Association of American Medical Colleges predicts the U.S. could see a shortage of 54,100 to 139,000 physicians by 2033.

At Ohio State University Wexner Medical Center in Columbus, well-being is embedded into the culture of the system and into the curriculum of students at the teaching hospital. That involves incorporating more breaks, or pauses, into the day for clinicians, offering more flexible work schedules and giving clinicians meeting-free time. And in January 2020, the system expanded the Buckeye Paws certified therapy dog program it uses to reduce stress, pain, anxiety and depression in patients to its employees as well.

Dr. Harold Paz, Wexner's CEO and chancellor of health affairs at Ohio State University, sees technology, namely artificial intelligence and machine learning, as one way to reduce the burden on clinicians by automating tedious tasks like data entry. He wants to find ways to reduce stress by maximizing technology, especially when it comes to electronic health records.

"We don't want highly trained clinicians to become data-entry clerks. What can we do to use technology to automate these things?" Paz said.

Michelle Davey, founder and CEO of Wheel, which matches clinicians with telehealth companies and helps businesses launch their own virtual-care programs, sees telehealth as a way to improve doctors' work-life balance, if done correctly. With the right tools and training, clinicians can use virtual care to bring more flexibility to their schedules, she said.

"I think the pandemic did a lot for workforces across the U.S. How do we enable that remote work environment for clinicians as well?" Davey said.

That will involve reducing the administrative burden put on clinicians by not using "antiquated systems with 16 click-throughs" and designing systems with input from doctors, Davey said.

"Most people think to get a clinician's opinion primarily when (it involves) clinical outcomes or clinical protocol development. The other piece is making technology that works for them, not against them," Davey said.

And it will involve training, as early as residency, on telehealth and other rapidly expanding technologies, she said.

"Healthcare in the future is going to be digitally enabled across the board. At this point, there's no fighting that. … How do we create an environment to move forward that's healthy and not just bringing the broken system online?" Davey said.