Mitigating hospitalist burnout: A look at what works

Key takeaways:

• Appropriate staffing helps alleviate hospitalist burnout.
• Investing in leadership development, social community and mentorship also mitigates burnout.
• It helps to foster a culture in which clinicians are encouraged to identify problems and given mechanisms to escalate them to be solved.
• Large studies are now underway to help determine the right clinical workload and team design.

IRONICALLY, IT TOOK getting sick with covid in fall 2020 for O’Neil Pyke, MD, MBA, to acknowledge how much of a toll hospitalist burnout had taken on him.

Before the pandemic, Dr. Pyke had maintained a schedule where he worked eight clinical shifts a month while consulting full time. But when covid hit, “I stepped up and became a full-time clinical provider. That took me to a point clinically that being out of residency for almost 20 years had not before.”

The case of covid he contracted was so severe that “I was out of work for almost two months.” During what Dr. Pyke calls that “forced pause” while recuperating, he came to this realization: “I couldn’t do this level of clinical work anymore.”

Within months, he’d moved to Florida from the mid-Atlantic and taken the position—his first time in such a role—of chief medical officer for Jackson North Medical Center, part of the Jackson Health System in Miami. As such, says Dr. Pyke, he hasn’t worked a clinical shift in four years. He also now gets to see hospitalist burnout from the other side, as an administrator.

“We have to get to the point of saying, ‘No, Dr., you’ve already seen 16 patients today, take some time to spend on some other activity.’ “

O’Neil Pyke, MD, MBA
Jackson Health System

And what he sees is not encouraging. “There’s no end in sight,” he says. “The supply and demand do not meet, so we are always asking more of the current work group. They feel they need 30-hour days—and because those aren’t coming anytime soon, they don’t know what to do.”

Some become apathetic, Dr. Pyke adds, while others leave and still others just act out. “We have to get to the point of saying, ‘No, Dr., you’ve already seen 16 patients today, take some time to spend on some other activity,’ ” he says. “Until then, we’ll continue to address only the symptoms of hospitalist burnout and not the diagnosis.”

The pandemic may be over, but hospitalist burnout is certainly not a thing of the past. The Hospital Medicine Workforce Experience report, which the Society of Hospital Medicine issued last year, found that almost half—more than 45%—of the more than 900 hospitalists surveyed reported being burned out. Also sobering: Less than a quarter (24.3%) said they felt professionally fulfilled.

Such dismal numbers are a big reason why physicians like Dr. Pyke have turned their years of clinical experience into a new career. That leaves hospitals and health systems around the country trying to figure out what they need to do to address hospitalist burnout—and where they should invest—before their own physicians jump ship and seek out other options open to them beyond clinical work.

The impact of rightsizing staffing

Struggling with burnout and engagement. Since 2018, the hospital medicine program at Rochester Regional Health in Rochester, N.Y., has tracked hospitalist burnout through an annual survey. What department leaders were hearing going into 2023 wasn’t good.

“We were struggling mightily with burnout and engagement,” says Chris Reynolds, MD, hospitalist medical director at Rochester General Hospital, the health system’s tertiary/quaternary center. “That was primarily related to understaffing.”

As for how understaffed the group was, Anil Job, MD, a hospitalist who now heads up the health system’s Command Center, explains that the group had only 85 FTE physicians in the 2023-24 academic year.

“We were struggling mightily with burnout and engagement, primarily related to understaffing.”

Chris Reynolds, MD
Rochester Regional Health

“We were budgeted for 95, but we probably needed 105,” Dr. Job says. “We covered some of that gap with locums”—but those physicians, he admits, could be of varying quality. Plus, the heavy reliance on locums contributed to resentment among the hospitalist ranks and to subsequently higher levels of hospitalist burnout.

Bulking up recruiting. That was before what Dr. Job calls “an incredibly successful recruiting effort in late 2023,” due largely to a change in the health system’s ability to sponsor visas. “We were able to fill our proposed 2024 positions by October 2023, but we still had several applicants in the pipeline.” The hospitalists then proposed a new business case to increase its FTE count to 115, and they were able to fill those slots as well.

That 35% jump in staffing has made a significant difference. According to Dr. Job, hospitalists during the 2023-24 academic year were routinely over their goal census by as much as 25%. This year, in contrast, they are typically staying within their goal census range, exceeding it only once every seven days.

Per-diem overload contributed to hospitalist burnout. The group’s former degree of understaffing also required “an extremely high need” for per diem work from the employed hospitalists, according to Dr. Job. Because the group largely maintains a seven-on/seven-off schedule, doctors were working parts of their weeks off.

Because that coverage was patched together, care was often fragmented with patients being handed off several times in a week. Now, with increased staffing and stable capacity, that problem has largely been eliminated.

“We now have a markedly decreased need for per diem work,” Dr. Job says. “And I have people asking me about growth opportunities”—in research and leadership, committee participation and teaching/training—”that didn’t happen over the last two years.”

Social community

Burnout and turnover hotspot. Like Rochester Regional Health, Banner Health—with dozens of hospitals across six Western states—began surveying its physicians and advanced practice providers (APPs) about burnout in 2018. Like Rochester Regional, Banner’s hospitalist program a couple of years ago was considered understaffed by many of its hospitalists.

“We now have a markedly decreased need for per diem work.”

Anil Job, MD
Rochester Regional Health

 

“Hospital medicine was a significant hot spot with a lot of burnout and turnover,” says Carisa Bamford, Banner’s senior director of Clinician Experience & Physician/APP Development, who has held that position since 2018. Most of those problems, Ms. Bamford adds, were covid-related.

Now, high turnover is a thing of the past, thanks in part to successful recruiting. But it’s also thanks to an ambitious system-wide program that Ms. Bamford and her colleagues helped establish in 2019 called Cultivating Happiness in Medicine (CHIM).

Six health system “pillars.” That program contains six of what the health system calls “pillars”: design, leadership development, social community, individual wellness and wellbeing, second victims and “pebbles,” which Ms. Bamford explains are workflow irritants and inefficiencies.

How do those pillars work in practice? Nikhil Sood, MD, who has been a hospitalist at Banner Gateway Medical Center in Gilbert, Ariz., for the past nine years, explains how he’s used various facets of the CHIM program. Take social community, for example: The health system reimburses any physician or APP who organizes a social event for their colleagues, a standing offer that’s available to each individual twice a year.

Dr. Sood recently took about 15 members of his team to Top Golf. Before that, a clinician’s back-yard holiday party drew about 30 people from his hospital. Before that, it was a get-together in a bowling alley.

“You get to know each other outside of work,” says Dr. Sood. “You talk about things you don’t get around to discussing during work hours.”

Mechanisms to solve clinical problems

Finding solutions before burnout sets in. Dr. Sood points out that one major impact of the CHIM program is that it encourages clinicians to identify problems and inefficiencies (“pebbles”) and escalate them to find solutions before they lead to burnout.

That’s the idea behind the health system’s clinical high-reliability group (CHaRGe), a multidisciplinary committee that meets monthly.

“It’s a system-wide group and an open platform for you to pitch ideas that are taken seriously,” he points out. “Then informatics teams make those happen.” Dr. Sood has worked with CHaRGe to have unnecessary popups in the EHR removed. Through CHaRGe, he also partnered with the ED to generate a new pain management order set for sickle cell patients.

Rolling out new communication tools. Such initiatives also encourage individual efforts, Dr. Sood points out. For example, Banner Health introduced a new messaging app that became an essential communication tool. However, the lack of guidance for nurses on how and when to use it to contact hospitalists led to so many unnecessary pages and texts that nocturnists started refusing to take cross-cover calls.

“Academic writing has been my way out of burnout.”

Nikhil Sood, MD
Banner Health

 

Dr. Sood worked with both the hospitalist group and the nursing staff to create guidelines outlining expectations and streamlining communication for nurses and allied staff.

“The lack of guidance led to so much frustration,” he points out. “The initiative improved job satisfaction.”

Investing in wellbeing

One hospitalist discovers the power of writing. For Dr. Sood, hospitalist burnout was a type of stagnation that he believes is very common in the specialty.

“I was starting to feel like I had to move into a fellowship or transition into another type of job,” he says. Instead, he took advantage of mentorship opportunities within Banner that helped steer him toward something he really wanted to do: academic writing.

“It’s worked out well for me,” says Dr. Sood. “Academic writing has been my way out of burnout.” Through use of the mentorship program at Banner, some colleagues who are also mid-career hospitalists have started doing volunteer work, he adds, while others are doing advocacy or getting more involved with medical societies or doing consulting, in addition to their clinical work.

Beefing up physician mentorship. The CHIM program is now expanding physician mentorship. Only 25% of the system’s 300 hospitalists are academic, and the nonacademic hospitalists have typically not had as much access to mentors as their academic colleagues. But last month, says Ms. Bamford, the health system posted an opening for a full-time position to build out the health system’s physician and APP mentorship program.

CHIM’s focus on leadership development has also helped, Ms. Bamford points out. Out of 9,000-plus doctors and APPs across the health system, more than 1,000 have graduated from health-system leadership development programs that are designed specifically for them.

“It is imperative that physician leaders be at the table helping drive strategy and business,” says Ms. Bamford. “We have to equip them to do just that.”

It’s that type of attention to clinician wellbeing that, in 2023, resulted in Banner’s lowest system-wide results on the Maslach Burnout Inventory survey since Ms. Bamford’s department started administering it in 2018: 7.6%. The health system in 2023 also saw improved physician retention and lower doctor and APP turnover, resulting in an estimated system-wide savings of $18 million.

The CHIM program that year cost $625,000, less than the estimated $800,000 the health system pays every time a doctor leaves and has to be replaced. “That represents,” says Ms. Bamford, “a monumental return on investment.”

Making clinical work sustainable

Academic medicine’s opportunities for diversification. Marisha Burden, MD, MBA, hospital medicine division head at the University of Colorado Anschutz Medical Campus in Aurora, Colo., points out that being in an academic center does provide opportunities for career flexibility and diversification. Those can in turn enhance professional fulfillment.

“It is imperative that physician leaders be at the table helping drive strategy and business.”

Carisa Bamford
Banner Health

“We have many different subspecialized services that can add to engagement and to building unique skill sets,” she says. One recent example of career diversification at the University of Colorado is the buildout of a virtual hospitalist program that provides remote coverage to surrounding rural hospitals.

But Dr. Burden also believes that a key factor in mitigating hospitalist burnout is figuring out the right clinical workload and team design, questions that have fueled her research career for the past 10 years. Trying to determine answers to work-design questions has led her and her research colleagues to tackle the impact of early discharges, administrative harms, comanagement models and leadership development.

Identifying clinical workloads. Is she any closer to knowing what an optimal workload and team model look like? Not yet, but “we’re about to hit a critical juncture where we can actually start to say, ‘Here’s what we think make for optimal workplace practices,’ ” she says. “We’re on the cusp of that, and a lot of work over the past many years has led up to it.”

That’s because Dr. Burden has now received funding to do what she calls “very large-scale studies”—across as many as 12 sites—on different care models, team structures, leadership practices, organizational decision-making and workloads. The goal will be to examine the impact of all those on many different outcomes, including burnout.

One study funded by National Institute of Occupational Safety and Health (NIOSH, part of the CDC) “will help us understand the costs of turnover for hospitalists and how work structure and environment contribute to important outcomes like burnout and worsening mental health.”

Another study funded by the American Medical Association will look at EHR use data—also known as audit logs or event logs—to see how workloads correlate to patient, clinician and organizational outcomes, including burnout and professional fulfillment. Still another study will enable Dr. Burden and her research colleagues to determine the best measures to track workload and work design.

“We’re trying to help organizational leaders understand the various trade-offs in work-design decisions.”

Marisha Burden, MD, MBA
University of Colorado Anschutz Medical Campus

“We aim to predict what work design models actively lead to harm and which do not,” says Dr. Burden. “We’re trying to help organizational leaders understand the various trade-offs in work-design decisions and how those choices affect important outcomes.”

A generational shift

Dr. Pyke in Miami takes the issue of “different trade-offs” seriously. He hopes that hospitals and health systems—in the midst of chasing ever-bigger mergers and a skewed reimbursement system that promotes procedures over preventive and primary care—will begin to make the investments needed for a healthier workforce.

In the meantime, he is encouraged by the fact that Gen Z physicians refuse to make their career their entire life.

“I think there’s been a generational shift,” says Dr. Pyke, who points out that his own daughter is getting ready to go to medical school. “They simply say ‘no.’ They say, ‘I’m a mom or a dad or this is time I spend for myself. I’m not coming in for that 7 a.m. meeting.’ ”

Physicians his age, he says, look at younger colleagues and think they may not have the right work ethic. “In fact, I’m jealous,” Dr. Pyke says. “The reality is, we shouldn’t be working all the time.”

Phyllis Maguire has been Executive Editor of Today’s Hospitalist since 2006. Based in Bucks County, Pa., her health care interests are hospital medicine and long-term care options. She also likes zydeco, hiking, and reading memoirs and romances.

Burnout, inadequate pay, and limited career growth are key reasons for healthcare workforce turnover, with 55% considering job changes. Survey.