By Dike Drummond MD, CEO and Founder TheHappyMD.com
The measurement of physician burnout is turning into a big business in the USA lately. Millions of dollars are changing hands for burnout, engagement and physician satisfaction surveys created and sold by some of the biggest medical groups and consulting organizations in the healthcare industry. Mayo, the Advisory Board, the MGMA come to mind immediately. This is totally understandable given recent evidence that over 50% of US physicians suffer from burnout on any given day and the new understanding of healthcare’s Quadruple Aim.
Look a short way into the future and you can see how physician burnout scores could easily be turned into a quality indicator and a hurdle the government and other payors could require for payment. It is a short stride to your physician burnout score becoming a prerequisite of logging onto the EMR system in your organization.
Let's face it ... if they could put a chip in your gluteus maximus to measure burnout directly and electronically beam it to the scorecard on your CMO's desktop computer ... THEY WOULD.
[SIDE NOTE: I actually think that would be a good thing , believe it or not. With a chip and a true physiologic measure for burnout, we could see who actually needs support and education and get it to them immediately - instead of waiting for the doctor to somehow overcome their Lone Ranger, Superhero, Perfectionist programming and actually ask for help. But that is a whole separate topic.]
This burgeoning physician burnout survey industry brings up two major concerns in my mind - concerns which arise directly from my 2000 hours of one-on-one coaching experience with burned out doctors and my experience training 10,000 more physicians for 48 corporate clients in 2016 alone.
1) A Survey is NOT a Solution
Measurement is NOT Treatment or Prevention
In fact, measurement can easily make things worse if you are not simultaneously doing something to actually prevent burnout and install the Quadruple Aim in your organization. There is nothing more demoralizing to a front line provider than filling out the physician burnout survey - in good faith - and then nothing happens. I have even seen organizations pay six figures for a survey and never report the results to the doctors. You can bet they were worse off than if they had never surveyed in the first place.
It is human nature to throw a tech solution at a dilemma that can only be addressed by a shift in culture. The Quadruple Aim does not encourage you to measure wellbeing. The Quadruple Aim is the principle that the underlying health and wellbeing of your people are of equal importance to the organization as the original Triple Aim of cost, quality and the patient experience.
To install the Quadruple Aim in your organization takes hard work ... not 13 clicks in an online form. This is the art and science of building a culture of support and engagement among a group of physicians and staff who must deal with sick, hurting, scared and dying people every day. To shift and maintain this culture, your leadership team must roll up their sleeves, get out of their meetings and offices and talk to the people.
No survey will ever prevent physician burnout by itself. However, a survey from an organization with a recognizable name -- is perfectly capable of checking the "we are doing something about burnout" box if your leadership doesn't actually understand or believe in the Quadruple Aim.
2) If the employer delivers repeated, mandatory surveys - the doctors will lie
This is not a character flaw in the physicians. We are not natural born liars. But it is normal human behavior to lie on a mandatory test that is a prerequisite of your employment. This is exactly like taking a person who smokes a couple cigarettes a day and giving them a life insurance questionnaire. When it comes to the question, "Do you use tobacco?" - we all know how they will answer.
And here is how airline pilots will hide their depression just to keep flying.
It is extremely important to have an historical context here ...
Everything We Know About Burnout Is Based On Volunteers
The studies we have all seen about physician burnout prevalence have been generated by surveys where the respondents are VOLUNTEERS.
Here's how it usually goes. One of the cadre of researchers who rest their laurels on doing endless physician burnout prevalence surveys, finds another professional society or group to survey. The same old Maslach Burnout Inventory or a derivative poll is sent to all the members. Then here is what happens:
About 20% of the doctors answer the survey VOLUNTARILY. The response rates are reliably in the 20% range over the entire span of 40 years burnout has been actively studied.
Every little scrap of what we know about physician burnout prevalence comes from this small slice of volunteers from each of the total "N" of the surveyed group.
What about the ones who didn't answer?
What we don't know is
- Why they didn't answer the survey.
- Whether or not they are more or less burned out than the individuals that did return the poll.
BECAUSE THEY DIDN'T ANSWER THE SURVEY (caps intended)
Here's what we do know:
They are a statistically valid sampling of the entire population we sent the survey to. This means the people who filled out and returned the survey were the same average age, gender mix, years in practice and yadda, yadda, yadda as the 80% who chose not to fill out and return the form.
So one of the consistent features of the entire universe of knowledge about physician burnout generated to date is this:
Everything we now know about physician burnout came from
a) Volunteer respondents
b) Answering surveys that were not sent out by their employer
What happens if the employer is sending you the survey - over and over again - and, heaven forbid, they make the survey mandatory?
That is the question going forward.
Can Of Worms Alert
- Are the answers a true measure of underlying burnout — if your employer is the one asking?
- Are the answers valid if your employer is the one asking and you have to respond to quarterly surveys?
- Are the answers valid if your employer is the one asking, the surveys come out quarterly and your boss is able to track your personal score?
- Are the answers valid if your employer is the one asking, the surveys come out quarterly, they are able to track your personal score — and if you score below "X", they won't let you see patients???
Enter the Mayo Well-Being Index
The Mayo Clinic is ground zero for the physician burnout prevalence research community. Mayo has now developed their own 9 item, validated and proprietary Well-Being Index and has hired an independent sales organization (Med+Ed Web Solutions) to promote it to healthcare organizations nationwide. I spoke to one of the salespeople and apparently the system is flying off the shelves.
[BTW, the Mayo CEO, Dr. John Noseworthy is on record recommending that patients fire their doctor if they suspect burnout and he knows the Mayo internal burnout rate in their physicians is 40% -- but that is a whole different story]
Here's the setup:
- Your employer buys the Mayo Well-Being Index (because they are Mayo after all)
- It is installed in your company intranet. All the physicians are loaded in and given access to the survey
- As an employee physician, you are asked to complete the survey by your employer
- You are shown your score - as is your CMO, though Mayo says the system is anonymous and all they can see is group averages.
- You are shown how you stack up against Mayo's own expanding and proprietary database of physicians in your specialty
- If you don't like your score and want some help -- you could reach out to your CMO and ask - not likely for the average physician. The Index also contains an anemic set of digital resources purported to help you become less stressed. I have checked these out and they are strange collection of random resources that will be ineffective in helping a truly burned out physician IMHO. Remember that Mayo's forte is burnout surveys, not prevention tools and training.
- Then the organization is equipped to ask you to repeat your Well-Being Index at whatever interval they wish.
Here is what Mayo says about this system ...
Mayo has the audacity to claim up front ... with no proof of accuracy ... that this system will "Improve Your Organization Wellbeing". That is the actual tag line of their sales page here. Click the link and check it out for yourself. BTW, if you want to ask a question to the people at this website ... they will be salespeople, not a physician and certainly not a burnout expert.
Three Things I am Certain Of
1) I am certain that this system will improve the scores on their index for three simple reasons:
- It is being requested by your employer
- It is being requested over and over again
- In situations like this - professionals will lie on the survey to be able to continue practice.
Just look at airline pilots for example - The numbers will be even more universally positive if the survey becomes mandatory and your CMO can actually see your personal score. These are two developments I expect to take place in the near future.
2) I am also certain that the increasing scores will reassure the leadership team in your organization that they are doing something about physician burnout and it is working.
3) I am also certain that the improving scores are a red herring. Physician burnout will continue to ravage 30 - 60% of the physicians in any organization that thinks this survey is the solution to burnout.
We already know - from this Mayo study - that 54% of physicians screen positive for depression and 7.2% have thought about suicide in the last year - if they are allowed to answer a survey anonymously ... a survey that was not sent to them by their employer.
Will physicians answer honestly when screened repeatedly by their employer?
What do you think? I know what I believe.
=> I know that Mayo must prove that improving scores actually reflect improvement in the underlying condition BEFORE they can legitimately make that claim. This is where I think the "chip in the buttock" approach would be more accurate, since it would measure a physiologic metric of stress and burnout - something you can’t lie about.
=> I know that Mayo will make a lot of money here. It's Mayo and it is a tech solution to a culture and leadership issue. It will sell like hotcakes, yet it will be years before customers realize it is just rearranging the deck chairs.
=> Leaders will check their Burnout Box. This allows leaders who don't care about their people to install software, push a button and get back to their next time-wasting meeting ... thinking all the while they have done something about burnout. So many leaders are simply looking to check the burnout box without getting their hands dirty in the hard work it takes to change an organizations' culture. If you are a leader who cares and want to know how to avoid all this running in circles, you will want to check this out.
I know - from my one-on-one work with hundreds of burned out physicians - that a survey is not a solution here. You can survey the docs with any test and as often as you want, but the lowest burnout prevalence I have ever seen is 25% and the historical average before the days of the ACA is one in three. If your survey showed a burnout prevalence of 33% in your doctors, would you relax and stop efforts to take better care of your people and de-stress the workplace?
Is a background burnout rate of 25 - 30 - 40% acceptable?
Burnout Surveys be Damned ... let's get to work.
- Work your prevention strategies now - Build your culture now - De-stress the work flow now - Care about your people now - Install the Quadruple Aim in your organization NOW Surveys be damned, full speed ahead.
What do you think?
PLEASE LEAVE A COMMENT:
- Have you been screened for physician burnout by your employer?
- Did you answer honestly?
- What effect do you think repeated testing by your employer will have on response rates and the legitimacy of the results?
Dike Drummond MD is CEO and Founder of TheHappyMD.com. His coaching, training and consulting organization is focused on the prevention of physician burnout and creation of true Quadruple Aim leaders and organizations. He is the author of “Stop Physician Burnout” with over 25,000 copies in print and delivered live burnout prevention training to over 10,000 physicians in 2016 alone.