Physician Burnout - The Fatal Flaws in the Burnout Survey Industry
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.
In this article let me show you the massive flaws in the physician burnout survey industry - unproven theories, conflicts of interest, outright lies and more.
The Future of Physician Burnout Screening is a Big Deal
At the MACRO Level:
Look a short way into the future and you can see how physician burnout scores are very likely to become a quality indicator and a hurdle the government and insurance companies could require for payment. That is a healthy move if you think about it. What payor would NOT want a healthy population of doctors providing care to their members?
At Your Organization Level:
It is a short stride to your physician burnout score becoming a prerequisite to seeing patients at all inside your organization. You take the test every day or week and if you don't score above a certain threshold, you are not allowed to log into the system and see patients. The knock at your door from the Wellbeing Police is next. And again, this makes sense from an organizational level. You want to make sure your providers are up to the job - right?
But surveys are so flawed, that a "Chip in the Butt Cheek" would be a Massive Improvement
You know the Big Brother Fantasy I am talking about.
When you sign your employment contract they insert a small chip in your gluteus maximus - no bigger than a grain of rice - to measure burnout directly using something like real-time serum cortisol and epinephrine level. Your score is electronically beamed to the Wellness Databank in the office of the CMO. If you stray into the Yellow or Red bands of the Burnout Rangefinder ... BAM, you are logged out of the EMR and the Wellbeing Police are at your door again.
Don't get me wrong, that dystopian Chip in the Butt fantasy would actually be a Good Thing!
With a chip and a true physiologic measure for burnout in real time, 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 20,000 more physicians for 70 corporate clients to date.
1) A Survey is NOT a Burnout Prevention Strategy ... not by a LONG SHOTMeasurement 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 ... it is the principle that the health and wellbeing of your people are as equally as important as 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.
Last but not least, every dollar spent on surveys is a dollar not spent on an actual burnout prevention strategy.
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 entire universe of knowledge about physician burnout generated to date is based on:
a) Volunteer respondents
b) Answering surveys that were not sent out by their employer
Here's how it usually goes. One of the researchers who specialize in burnout prevalence studies finds another professional society or group to survey. They chug the same old Maslach Burnout Inventory or a derivative poll out to this new database. Then here is what happens:
Between 12% and 20% of the doctors answer the survey VOLUNTARILY. The response rates are reliably in the 20% or less 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 people who chose not to participate.
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.
4-Part Can Of Worms Alert
- Are the answers an accurate measure of burnout prevalence if your employer is the one asking the questions?
- Are the answers valid if your employer is the one asking the questions and you have to respond to quarterly surveys?
- Are the answers valid if your employer is the one asking the questions, the surveys come out quarterly and they are tracking 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 and all the physicians are loaded in and given access
- As an employee physician, you are asked to complete the survey by your boss or employer or both
- 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. And, of course, Mayo maintains that regular surveys are a pillar of a burnout prevention program.
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 "Beat Burnout. Renew Purpose. Transform the Approach to 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.
Academic and Institutional Medicine has supped the Mayo Koolaid via a Massive Conflict of Interest
Organizations like the National Academy of Medicine's Action Collaborative on Physician Wellbeing and Resistance actually allow Mayo to sell this program from the stage of their national meetings. Unbelievable!
Four Things I am Certain Of
1) I am certain that survey scores will improve over time for two 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) These improving burnout survey scores will have the leadership team slapping each other on the back in congratulations.
3) The improving scores are a Red Herring and simple consequence of employer administration of the surveys. 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.
4) Physicians and Patients will continue to die unnecessarily because the underlying burnout is unchanged.
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 butt" approach would be more accurate, since it would measure a physiologic metric of stress and burnout.
=> 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.
=> 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. 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.
Is that acceptable?
Burnout Surveys be Damned ... let's get to work.
Install the Quadruple Aim in your organization NOW
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?