Addressing Physician Burnout

Strategies to Manage Burnout in Nephrology

Managing patients with complex chronic and acute illnesses is not the only source of stress for nephrologists; it stems from multiple factors, including personal characteristics, workload and environment, and the burden of regulatory expectations (Figure 1). Nephrologists should be resilient to stresses created by managing to quality metrics, pay for performance, and bundled care: we have been doing this for years. As these rules expand and spread from dialysis to all aspects of practice, are we approaching a tipping point? Improving patient outcomes is paramount, but without reliable, efficient systems for data gathering and reporting, the administrative burden can become overwhelming. Plus, being responsible for analyzing outcomes defined by these metrics and developing and implementing appropriate interventions can add stress, particularly if lacking needed skills or resources. Knowing regulatory agency intrusiveness and lack of autonomy and input into practice design can lead to burnout; highly protocol-driven environments limiting flexibility, such as may occur in dialysis organizations, can increase burnout risk. As we gain experience with the ESRD Seamless Care Organization (ESCO) model, we must monitor for and address burnout. The ESCO’s multidisciplinary teams and focus on improving efficiencies and outcomes should decrease stress but must be balanced with unanticipated consequences, such as less autonomy and expanded nephrologist duties, possibly trading meaningful work for administrative and clerical tasks. Additionally, the squeeze on clinical and scholarly time can create anxiety over meeting competing expectations, particularly if performance metrics determining payment and reputation are negatively affected.

Do personality traits of nephrologists predispose to burnout? Attributes linked to coping, problem solving, and a balanced drive to success are protective, whereas difficulties managing failure and worrying about poor performance are associated with burnout (5,6). Moreover, younger physicians (age <55 years) are more likely to experience burnout due to lack of resiliency (5). With 59% of nephrologists younger than 55 years old and projections of higher numbers entering fellowship than retiring, burnout prevalence may increase (4). Additionally, although maintaining competency is important, the financial and time demands of maintenance of certification and high-stakes examination anxiety may decrease wellbeing, especially for those with poor coping skills.

Physician burnout is worldwide, but the drivers may differ. In a meta-analysis of 65 studies from various regions and specialties, work-life balance more strongly correlated with physician burnout in America than in Europe (7). These findings could be explained by the older physician population representing Europe, but understanding contributors to improved work-life balance in Europe may help address burdens in other regions. It does suggest a burnout risk for international medical graduates transitioning into United States medical systems, where workload expectations and cultural norms differ from their previous environment.

Interventions to address physician burnout have been identified, but individual physicians cannot tackle burnout alone: health care systems, academic institutions, and organizations, including dialysis organizations, must improve work environments, influence policy, and support physicians’ wellbeing at all career stages (Figure 1). Not surprisingly, leadership qualities correlate with physician wellbeing (Figure 1) (8–10). Leaders must create a culture that supports values aligned with the organization’s mission and continuously address factors that erode culture. Careful recruitment and expectation setting are essential for career fulfillment, success, and longevity. Individuals must be aligned with institutional goals, values, and mission, and their career goals, talents, and passions should match with job expectations (6,9,10).

Keeping physicians engaged throughout their career will decrease burnout and facilitate organizational success. Involving physicians in process redesign focusing on efficiency, autonomy, flexibility, and highly functioning teams as well as creating a culture that eliminates fears of seeking help for mental and physical illnesses are effective approaches to ensure engagement (2,6). These and other tactics addressing excessive workhours and clerical duties along with creating a community at work will bolster job-related gratification and resiliency. Systems improvements are not enough; the culture around expectations of physicians must also be addressed. The legacy of rewarding those who push themselves to undefined limits no longer supports sustainable careers. It is time to recognize the importance of physicians’ mental and physical health; we owe this to our patients, families, colleagues, and society. Health care organizations must promote the wellbeing of their most valuable players—physicians. An important role of professional organizations is to lobby on behalf of the nephrology workforce and patients, starting with addressing the burdens of regulation. Organizations should prioritize burnout in strategic plans and offer enhanced faculty development that includes mental and physical wellbeing, resiliency, self-awareness, mindfulness, career fit, and balance throughout careers. Leadership development courses must include how to prevent, recognize, and treat burnout. A measure of staff burnout should be part of institutional balanced scorecards, leadership evaluations, and everyone’s annual review.

Health care organizations and individual nephrologists must reflect on burnout vulnerabilities and defenses. Physicians cannot solve the problem without organizations addressing culture and value alignment, inefficiencies, and appropriate resource allocation. Although it requires resetting, we all need time to reevaluate what we find fulfilling, realign our professional roles, and participate in creating environments that support safety and participation in meaningful work and balance.

Disclosures

None.