Advertisement

Beyond Burnout: A Physician Wellness Hierarchy Designed to Prioritize Interventions at the Systems Level

Published:December 13, 2018DOI:https://doi.org/10.1016/j.amjmed.2018.11.028

      Abstract

      Burnout has been implicated in higher physician turnover, reduced patient satisfaction, and worsened safety, but understanding the degree of burnout in a given physician or team does not direct leaders to solutions. The model proposed integrates a long list of variables that may ameliorate burnout into a prioritized, easy-to-understand hierarchy. Modified from Maslow's hierarchy, the model directs leaders to address physicians’ basic physical and mental health needs first; patient and physician physical safety second; and then address higher-order needs, including respect from colleagues, patients, processes, and the electronic health record; appreciation and connection; and finally, time and resources to heal patients and contribute to the greater good. Assessments based on this model will help leaders prioritize interventions and improve physician wellness.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. National Academy of Medicine. Factors affecting clinician well-being and resilience. Available at: https://nam.edu/clinicianwellbeing/resources/a-journey-to-construct-an-all-encompassing-conceptual-model-of-factors-affecting-clinician-well-being-and-resilience/2018. Accessed October 1, 2018.

        • Shanafelt TD
        • Noseworthy JH
        Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
        Mayo Clin Proc. 2017; 92: 129-146
        • Maslow AH
        A theory of human motivation.
        Psychol Rev. 1943; 50: 370-396
        • Bucknill JD
        • Tuke DH
        A Manual of Psychological Medicine: Insanity.
        Blanchard and Lea, Philadelphia1858
        • Shanafelt TD
        • Boone S
        • Tan L
        • et al.
        Burnout and satisfaction with work-life balance among US physicians relative to the general US population.
        Arch Intern Med. 2012; 172: 1377-1385
        • Hawton K
        • Casanas ICC
        • Haw C
        • Saunders K
        Risk factors for suicide in individuals with depression: a systematic review.
        J Affect Disord. 2013; 147: 17-28
        • Center C
        • Davis M
        • Detre T
        • et al.
        Confronting depression and suicide in physicians: a consensus statement.
        JAMA. 2003; 289: 3161-3166
        • Yaghmour NA
        • Brigham TP
        • Richter T
        • et al.
        Causes of death of residents in ACGME-accredited programs 2000 through 2014: implications for the learning environment.
        Acad Med. 2017; 92: 976-983
        • Stack S
        Suicide risk among physicians: a multivariate analysis.
        Arch Suicide Res. 2004; 8: 287-292
        • Shanafelt TD
        • Balch CM
        • Dyrbye L
        • et al.
        Special report: suicidal ideation among American surgeons.
        Arch Surg. 2011; 146: 54-62
        • Oreskovich MR
        • Shanafelt T
        • Dyrbye LN
        • et al.
        The prevalence of substance use disorders in American physicians.
        Am J Addict. 2015; 24: 30-38
        • Oreskovich MR
        • Kaups KL
        • Balch CM
        • et al.
        Prevalence of alcohol use disorders among American surgeons.
        Arch Surg. 2012; 147: 168-174
        • Mahoney CR
        • Taylor HA
        • Kanarek RB
        The acute effects of meals on cognitive performance.
        in: Lieberman HR Kanarek RB Prasad C Nutritonal Neuroscience. Taylor and Francis Group, Boca Raton, FL2005: 73-91
        • Lemaire JB
        • Wallace JE
        • Dinsmore K
        • Roberts D
        Food for thought: an exploratory study of how physicians experience poor workplace nutrition.
        Nutr J. 2011; 10: 18
        • Lemaire JB
        • Wallace JE
        • Dinsmore K
        • Lewin AM
        • Ghali WA
        • Roberts D
        Physician nutrition and cognition during work hours: effect of a nutrition based intervention.
        BMC Health Serv Res. 2010; 10: 241
        • El-Sharkawy AM
        • Bragg D
        • Watson P
        • et al.
        Hydration amongst nurses and doctors on-call (the HANDS on prospective cohort study).
        Clin Nutr. 2016; 35: 935-942
        • Armstrong LE
        • Barquera S
        • Duhamel JF
        • Hardinsyah R
        • Haslam D
        • Lafontan M
        Recommendations for healthier hydration: addressing the public health issues of obesity and type 2 diabetes.
        Clin Obes. 2012; 2: 115-124
        • Harrson Y
        • Horne JA
        The impact of sleep deprivation on decision making: A review.
        J Exp Psychol Appl. 2000; 6: 236-249
        • Saadat H
        • Bissonnette B
        • Tumin D
        • et al.
        Effects of partial sleep deprivation on reaction time in anesthesiologists.
        Paediatr Anaesth. 2017; 27: 358-362
        • Maltese F
        • Adda M
        • Bablon A
        • et al.
        Night shift decreases cognitive performance of ICU physicians.
        Intensive Care Med. 2016; 42: 393-400
        • Mitra B
        • Cameron PA
        • Mele G
        • Archer P
        Rest during shift work in the emergency department.
        Aust Health Rev. 2008; 32: 246-251
        • Engelmann C
        • Schneider M
        • Grote G
        • et al.
        Work breaks during minimally invasive surgery in children: patient benefits and surgeon's perceptions.
        Eur J Pediatr Surg. 2012; 22: 439-444
        • Park AE
        • Zahiri HR
        • Hallbeck MS
        • et al.
        Intraoperative "micro breaks" with targeted stretching enhance surgeon physical function and mental focus: a multicenter cohort study.
        Ann Surg. 2017; 265: 340-346
        • Reicher J
        • Currie S
        • Birchall D
        Safety of working patterns among UK neuroradiologists: what can we learn from the aviation industry and cognitive science?.
        Br J Radiol. 2018; 9120170284
        • Bar S
        • Milanaik R
        • Adesman A
        Long-term neurodevelopmental benefits of breastfeeding.
        Curr Opin Pediatr. 2016; 28: 559-566
        • Nguyen B
        • Jin K
        • Ding D
        Breastfeeding and maternal cardiovascular risk factors and outcomes: a systematic review.
        PLoS One. 2017; 12e0187923
        • Victora CG
        • Bahl R
        • Barros AJ
        • et al.
        Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect.
        Lancet. 2016; 387: 475-490
        • Occupational Safety and Health Administration (OSHA)
        Workplace violence in healthcare: understanding the challenge.
        (Available at:)
        https://www.osha.gov/Publications/OSHA3826.pdf
        Date: 2015
        Date accessed: December 16, 2018
        • Occupational Safety and Health Administration (OSHA)
        Guidelines for preventing workplace violence for healthcare and social service workers.
        (Available at:)
        https://www.osha.gov/Publications/osha3148.pdf
        Date: 2015
        Date accessed: December 16, 2018
        • Trinkoff AM
        • Geiger-Brown JM
        • Caruso CC
        • et al.
        Personal safety for nurses.
        (ed)in: Hughes RG Patient Safety and Quality: An Evidence-Based Handbook for Nurses. 2008 (Rockville, MD)
        • Sundler AJ
        • Johansson E
        • Johansson L
        • Heden L
        Incidents reported by nurse anaesthetists in the operating room.
        J Interprof Care. 2018; 32: 699-705
      2. North Carolina Rural Health Research and Policy Analysis Center. Prediction of financial distress among rural hospitals. 2016. ruralhealthresearch.org/publications/998. Accessed December 16,2018.

        • Porath C
        Half of employees don't feel respected by their bosses.
        Harv Bus Rev. 2014 (Available at)
        • Shanafelt TD
        • Gorringe G
        • Menaker R
        • et al.
        Impact of organizational leadership on physician burnout and satisfaction.
        Mayo Clin Proc. 2015; 90: 432-440
        • Grissinger M
        Unresolved disrespectful behavior in healthcare: practitioners speak up (again)-part 1.
        P T. 2017; 42: 432-440
        • Riskin A
        • Eriz A
        • Foulk TA
        • et al.
        The impact of rudeness on medical team performance: a randomized trial.
        Pediatrics. 2015; 136: 487-495
        • Cooper WO
        • Guillamondegui O
        • Hines OJ
        • et al.
        Use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications.
        JAMA Surg. 2017; 152: 522-529
        • Hickson GB
        • Entman SS
        Physician practice behavior and litigation risk: evidence and opportunity.
        Clin Obstet Gynecol. 2008; 51: 688-699
        • Martinez W
        • Etchegaray JM
        • Thomas EJ
        • et al.
        'Speaking up' about patient safety concerns and unprofessional behaviour among residents: validation of two scales.
        BMJ Qual Saf. 2015; 24: 671-680
        • Martinez W
        • Lehmann LS
        • Thomas EJ
        • et al.
        Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.
        BMJ Qual Saf. 2017; 26: 869-880
        • Martinez W
        • Pichert JW
        • Hickson GB
        • Cooper WO
        Programs for promoting professionalism: questions to guide next steps.
        Jt Comm J Qual Patient Saf. 2014; 40: 159-160
        • Pichert JW
        • Moore IN
        • Hickson GB
        Professionals promoting professionalism.
        Jt Comm J Qual Patient Saf. 2011; 37: 446
        • Pichert JW
        • Moore IN
        • Karrass J
        • et al.
        An intervention model that promotes accountability: peer messengers and patient/family complaints.
        Jt Comm J Qual Patient Saf. 2013; 39: 435-446
        • Fontana N
        Ethical moment: how can I handle a rude patient?.
        J Am Dent Assoc. 2005; 136: 1739-1740
        • Giesen P
        • Mokkink H
        • Hensing M
        • van den Bosch W
        • Grol R
        Rude or aggressive patient behaviour during out-of-hours GP care: challenges in communication with patients.
        Patient Educ Couns. 2008; 73: 205-208
        • Dick T
        Apologies. Do we have to tolerate disrespect from the public?.
        EMS World. 2013; 42: 26
        • Miedema B
        • Easley J
        • Fortin P
        • Hamilton R
        • Tatemichi S
        Disrespect, harassment, and abuse: all in a day's work for family physicians.
        Can Fam Physician. 2009; 55: 279-285
        • Whitgob EE
        • Blankenburg RL
        • Bogetz AL
        The discriminatory patient and family: strategies to address discrimination towards trainees.
        Acad Med. 2016; 91: S64-S69
        • Peckham C
        Medscape national physician burnout and depression report 2018.
        (Available at:)
        • Sinsky C
        • Colligan L
        • Li L
        • et al.
        Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties.
        Ann Intern Med. 2016; 165: 753-760
        • Young RA
        • Burge SK
        • Kumar KA
        • Wilson JM
        • Ortiz DF
        A time-motion study of primary care physicians' work in the electronic health record era.
        Fam Med. 2018; 50: 91-99
        • Casalino LP
        • Nicholson S
        • Gans DN
        • et al.
        What does it cost physician practices to interact with health insurance plans?.
        Health Aff (Millwood). 2009; 28: w533-w543
        • Arndt BG
        • Beasley JW
        • Watkinson MD
        • et al.
        Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations.
        Ann Fam Med. 2017; 15: 419-426
        • Shanafelt TD
        • Hasan O
        • Dyrbye LN
        • et al.
        Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
        Mayo Clin Proc. 2015; 90: 1600-1613
        • Smith R
        Why are doctors so unhappy? There are probably many causes, some of them deep.
        BMJ. 2001; 322: 1073-1074
        • Grant AM
        • Gino F
        A little thanks goes a long way: explaining why gratitude expressions motivate prosocial behavior.
        J Pers Soc Psychol. 2010; 98: 946-955
        • Stegen A
        • Wankier J
        Generating gratitude in the workplace to improve faculty job satisfaction.
        J Nurs Educ. 2018; 57: 375-378
        • West CP
        • Dyrbye LN
        • Rabatin JT
        • et al.
        Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.
        JAMA Intern Med. 2014; 174: 527-533
        • Goitein L
        Physician well-being: addressing downstream effects, but looking upstream.
        JAMA Intern Med. 2014; 174: 533-534