Burnout looms as growing crisis that could cripple hands-on care
Documentation and patient loads, technology that doesn’t support care and financial pressures are exacerbating woes that are causing shortages among doctors and nurses.
That workloads and operational stresses have resulted in clinician burnout is undeniable. Federal agencies and private research organizations alike have produced a stream of survey results and reports, increasingly warning that doctors and nurses are leaving the workforce or filling their roles and suffering inwardly.
In late January 2023, the overwhelming sense of the challenge was encapsulated by the title of new survey-based report published in Medscape - “I Cry but No One Cares.”
“The impact of persistent burnout and depression continues to build among doctors,” a synopsis of the report states. “Frustration, sadness and anger are widespread.” The COVID-19 pandemic was a watershed event that whipsawed emotions during the crisis, and it continues to impact the industry with massive ripple effects now.
Information technology has been identified as one of the factors that has aggravated clinicians’ stress levels, and challenges with usability and some related consequences of its use do indeed increase clinician dissatisfaction. But technology often is the most visible aspect of other problems affecting the industry, such as documentation requirements, billing pressures, workflow processes, historical care team hierarchies, and organizations’ financial shortfalls and resulting calls on clinicians for higher efficiency and heavier workloads.
No matter the cause, more clinicians are looking to leave the field, even as the aging of the workforce is depleting caregivers’ ranks.
“It’s the worst I’ve seen it,” says Subha Airan-Javia, MD, associate professor at Penn Medicine and founder and CEO of CareAlign. “Some of my colleagues for the past 20 years say they’re done, and they’re looking for opportunities outside of medicine. “There’s a gigantic cognitive burden that it’s always on your shoulders to get it all done – there’s all this pressure on yourself.”
Clinician shortages and burnout
There’s wide recognition of current shortages of clinicians, and they’re expected to grow in the coming years. A recent report from the Association of American Medical Colleges projects a shortage of 37,800 to 124,000 physicians within the next 11 years. It predicts a shortfall of 17,800 to 48,000 primary care physicians, as well as a shortage of 21,000 to 77,100 non-primary care physicians.
Shortages in specialties such as primary care and psychiatry are already affecting access to care, according to data from the Health Resources and Services Administration.
Gaps in staffing are also evident among nurse ranks, the front-line caregivers at most organizations. Current data suggest that the U.S. healthcare industry may have 200,000 to 450,000 nursing vacancies by 2025, but those estimates may be understated because of disillusionment with the profession, noted panelists at HLTH in Las Vegas on in November 2022. Trauma related to the COVID-19 pandemic resulted in 100,000 nurses leaving the workforce in 2021, and annual turnover in 2022 stood at 27 percent. Younger nurses are becoming disillusioned with caregiving workloads, and 57 percent of new nurses leave the profession after two years, data at the HLTH session indicated.
A study by Qualtrics underscored staff retention issues and its impact on patient care. Exacerbated by burnout and attrition in the wake of the pandemic, the percentage of healthcare employees who said they intend to stay in their jobs fell to 61 percent in 2022, down four percentage points from the previous year.
Burnout is clinically described in the 11th Revision of the International Classification of Diseases as “resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job; and reduced professional efficacy.”
“What it boils down to is people want to feel valued; it should be a free thing to give out. There are some places that have done it – they will do whatever it takes to keep the workforce. On our side, we need any tool available to do the energy-draining, soul-sucking work.”
- • Eve Bloomgarden, MD
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Affirming that trend, a poll by the Medical Group Management Association in October 2021 found that 33 percent of clinical physicians reported that they plan to retire early because of burnout, says Andrew Hajde, its director of content and consulting. And ongoing research by the American Medical Association, the Mayo Clinic and Stanford Medicine released in September 2022 indicated that nearly two-thirds (62.8 percent) of U.S. physicians were experiencing work-induced burnout.
The AMA and other industry organizations have highlighed documentation on electronic health records as a key burden for clinicians. Research in the Annals of Internal Medicine in 2016 estimates that physicians spend two hours on EHR systems for every hour of direct patient care, while nurses spend as much as 41 percent of their time on EHRs and documentation.
More data and statistics describing the surge in burnout among clinicians can be found here.
Technology’s role in burnout
Clinician shortages have been accelerating in recent years, with losses of staff being increasingly attributed to burnout. An advisory issued in mid-2022 by the U.S. Surgeon General acknowledged burnout among clinicians, which it attributes a range of “societal, cultural, structural and organizational factors … Some examples include excessive workloads, administrative burdens, limited say in scheduling, and lack of organizational support.”
Technology plays a role in burnout because it enables additional work to be piled on clinicians – for example, by eating up larger percentages of their workday with computer documentation, providing more channels for communication with patients or extending charting back into the home after work hours, says Conner Bice, a product line owner for KLAS Research’s Arch Collaborative, which has been tracking technology-related burnout for the past five years.
Bice says his organization’s studies have found that the top three predictors of burnout include clinicians working more than six hours a week after work hours; lack of control over the clinician’s workload; and a perceived loss of control over in-basket communications.
The surgeon general’s report lists multiple areas in which improvements are needed to reduce clinician burnout, specifically offering suggestions for information technology as one of the many factors required to reduce clinician burnout. Experts in the linkage between burnout and the use of technology in caregiving acknowledge the need for improvements and supportive technology to assist clinicians. But they also note that technology gets blamed for many systemic problems that need to be addressed within healthcare organizations and, more broadly, by the many players in the industry.
In terms of information technology, the advisory suggests:
- • Designing technology to serve the needs of health workers, care teams and patients, particularly in designing and improving electronic health records and supporting telemedicine and virtual care programs.
- • Creating tech platforms “with the goal of interoperability at the outset,” which will help support communication and coordination among care teams.
- • Strengthening integration of data across platforms and health sectors, providing a more comprehensive view of patients’ health and ensuring coordinated care.
- • Improving the seamless storage of and access to health data, requiring a standard format for storing and exchanging health data.
Several initiatives are working on these and other technology factors that add to clinician burden, says William Hayes, MD, chief medical officer for Mobile, Ala.-based CPSI and vice chair of the HIMSS Electronic Health Records Association, but he agrees that technology is a cause of physician stress.
“There’s no doubt in my mind that, in the perception of physicians, they view a lot of EHRs as data collection devices,” Hayes says. “You have to tease out the reasons why. If you give someone a functionality that doesn’t work well, you’re just compounding a problem, primarily because of the burden.”
More blame to share
But technology is often the most visible aspect of many factors that are causing burnout, Hayes and other researchers note.
“A lot goes back to poor implementation and education,” Hayes says. “Clinicians are also dealing with the documentation burden, the volume of inbox messages, negative perceptions of the EHR and its functionality and usability, and too much after hours work.”
“Burnout is multi-factorial,” agrees Josh Holzbauer, director of physician well-being at Verona, Wis.-based Epic, a records system vendor. “For the part that does involve the EHR, trainers shadowing clinicians and helping them learn how to use it better is important. “Personalization is also important. If an organization is able to take a little time and tailor workflows, from research it shows that physicians are a lot more satisfied and feel a lot better about their work.”
EHRs also have enabled the documentation process, often resulting in needless overwriting – typically called note bloat. “And it’s not just about doing documentation — it's also about reading documentation,” Airan-Javia says. “The average patient chart has over 15,000 words. To give you a comparison, Shakespeare’s longest work, which is Hamlet, has 30,000 words.”
In addition, data from Epic indicates that U.S. physicians write notes that are about four times longer than international colleagues, adds Sam Butler, MD, a physician working at Epic who works with clients to utilize its Signal resources, a UserWeb program available to Epic customers that provides efficiency data of all ambulatory Epic users.
Some cross-industry efforts are underway to reduce documentation requirements and reduce note burdens for clinicians, but it’s often hard to change ingrained habits, Holzbauer notes. For example, requirements for evaluation and management charges were changed to give physicians and other qualified health care professionals more flexibility, enabling them to reduce documentation. But physicians have been slow to change old patterns, he says. “We have to seek out those myths that drive excessive documentation.”
For example, the Office for the National Coordinator for Health Information Technology (ONC) is looking to leverage data collection from audit logs and other sources of data to better assess EHR burden. ONC detailed its plans in a blog published in February 2023. ONC says it’s aiming to use audit log information that reveals comprehensive details of clinicians’ EHR use to better support an initiative by the Department of Health and Human Services to reduce regulatory and administrative burden related to the use of healthcare IT. ONC aims to find insights that will enable it to create actionable steps to improve clinical workflow, monitor performance and reduce documentation burdens.
Can technology assist?
Even as information technology vendors are working to improve the user interface and experience, there’s growing hope that emerging technologies can lighten caregivers’ workloads.
For example, ambient listening technology enables clinical notes to be extracted during physician-patient interactions. The technology already is in use and available from technology vendors – in one case, University of Michigan Health - West is using ambient listening technology with its Epic systems to draft physicians’ notes, capturing documentation and improving the exam room experience and saving physicians several minutes per day.
Other technical capabilities early in development include using artificial intelligence to extract the most needful information from electronic records. More advanced computing capabilities need to be employed to make clinicians’ jobs easier, says Eve Bloomgarden, MD, an endocrinologist and thyroid subspecialist at NorthShore University HealthSystem, and co-founder of IMPACT4HC, a coalition of physicians in Illinois.
“It’s possible to have chatbots go into a patient’s chart and get the information we need,” she says. “Why aren’t we using this technology to make our jobs easier? It’s a waste of resources.”
Clinicians also need more training to know how to manage the length of their notes or use macros or other shortcuts within records systems to streamline the process or reduce entries down to just the essentials that need to be preserved and passed on to others.
Wider patient access to clinicians through portals, texting or other in-basket communication also needs to be constrained, with these limitations communicated to patients, who have been conditioned to expect 24-by-7 access during the pandemic, experts say.
Beyond that, care delivery processes need to be redesigned to take the pressure off any one person, which typically leads to bottlenecks and pressures that lead to burnout. Many of those interviewed believe that team-based care can provide relief, enabling clinicians to have a variety of individuals support patient care and allowing them to practice “at the top of their license.”
Other emerging capabilities will include technology to support training manual processes, particularly prior authorization dialogues between providers and payers. The Centers for Medicare & Medicaid Services issued a draft regulation in December 2022 requiring certain payers to work with providers to automate the process of requesting and receiving prior authorizations for treatment by implementing HL7’s Fast Healthcare Interoperability Resources (FHIR) standard application programming interface (API).
Making a dent in burnout statistics, though, will require a variety of initiatives. Technology alone cannot solve this one, says Holzbauer of Epic.
“A big part of it is that organizations need good processes and good people working as a team,” he says. “Technology is not going to get the job done. You need team-based care, everyone in a clinical setting working to top of their licensure. As we look at our data, (the biggest impact) has nothing to do with technology but with operations.”
Immediate action is necessary, says Bloomgarden. “What it boils down to is people want to feel valued; it should be a free thing to give out. There are some places that have done it – they will do whatever it takes to keep the workforce. On our side, we need any tool available to do the energy-draining, soul-sucking work.”