UPMC's Commitment to Physician Well-Being: The Wellness Initiative

March 30, 2020

Introduction

Resilience is a quality that is innate to physicians; however, in this era of "time poverty", “multiple hat” syndrome, and increasing expectations, this innate resilience is being challenged. In 1974, Herbert Freudenberger, a German-born American psychologist, described burnout as a state of fatigue or frustration that results from the failure of professional relationships to produce expected rewards. His writing goes on to state that burnout occurs more often in professionals who can be described as having stronger commitments and dedication to the work they do.1 These observations suggest that many physicians are at high risk for burnout.

Various definitions of burnout have been proposed since the introduction of the construct in the 1970s. Until recently, burnout had been called "stress syndrome." The World Health Organization includes burnout as an occupational phenomenon in the International Classification of Diseases-11 (ICD 11).2 According to the most widely endorsed of these definitions, burnout combines emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment, evolving from prolonged exposure to chronic interpersonal stressors in the workplace. The significance of this three-dimensional model is that it clearly places the individual’s experience with stress within a social context and involves a person’s conception of both self and others.3

There is increasing attention being paid to the experience of burnout among physicians. An estimated 300 to 400 physicians commit suicide each year with a rate of 28 to 40 per 100,000, which is more than double that of the general population.4 On a national scale, the conservative base-case model describes significant negative economic consequences associated with physician burnout. The majority of these costs, estimated at $7,600 per employed physician per year, are attributed to physician turnover and reductions in clinical hours.5 

Although the practice of endocrinology is often perceived as offering a good work-life balance to those physicians choosing this subspecialty, endocrinologists are highly susceptible to the experience of burnout. The 2020 Medscape National Physician Burnout and Suicide Report provides evidence that endocrinology is among the top five medical specialties affected by burnout.6 Almost half (46%) of all diabetologists and endocrinologists report symptoms consistent with burnout. Major contributors to physician burnout that have been described include excessive bureaucratic tasks (charting, paperwork, etc.), insufficient compensation or reimbursement for time spent with patients, and the increasing presence of computers with mandatory fields in electronic medical records.7 
An internal survey conducted among endocrinologists providing care in one of the UPMC outpatient clinical centers found a higher rate of career satisfaction and lower level of burnout than the national average. The focus of this survey was on how diabetes technology and clinic workflow affected provider well-being. Despite the favorable survey findings, a considerable number of providers reported fatigue with technology and workflow processes, describing that this interfered with the time spent with patients.

Creating a Culture of Physician Well-Being at UPMC

At UPMC, there is recognition of the fact that physicians are at risk for burnout, which has led to the development of structured training programs that support wellness initiatives and promote well-being. The UPMC Office of Graduate Medical Education has formed the Wellness, Environment, Learning, and Living (WELL) Committee that focuses on burnout among the community of residents and fellows. UPMC also collaborates with a national Physician Wellness Academic Consortium (PWAC) to monitor progress in this area with an annual wellness survey. Grant funding also is available for innovative approaches in this area. The UPMC Division of Endocrinology and Metabolism recently received funding from one such grant opportunity, the "UPMC Thrive Grants for Change."

UPMC hosted a Physician Thrive and Well-being Symposium in January 2020. This symposium was planned by physicians from throughout UPMC. The Physician Thrive and Well-being Symposium provided the opportunity for physicians to attend lectures on a range of topics, including diversity of all kinds, and its relationship to wellness. Tips and techniques for creating systemwide change also were presented. Workshops were conducted on guided meditations, healthy cooking, and personal financial planning to provide physicians with information related to well-being outside of their careers. Together, these workshops and presentations educated and encouraged physicians to create a culture of well-being both at work and at home. 

UPMC is one of 22 U.S. health care organizations honored by the American Medical Association (AMA) in 2019 for their commitment to physician well-being. The UPMC Physician Thrive Committee, formed in 2018, develops strategies to address workplace factors that promote well-being or contribute to burnout. Additional support resources for physicians dealing with stress management include The Physician Assistance Program; Physicians for Physicians; health coaches; and the UPMC Critical Incident Stress Manage-ment (CISM) ASAP (as soon as possible) Program. 

Building Upon a Culture of Wellness

Although the rates of burnout and career satisfaction were better at UPMC than the national average, faculty leaders in the UPMC Division of Endocrinology and Metabolism recognize the adverse impact burnout can have on physicians when it is not recognized or addressed. To expand on the current UPMC wellness initiative, the UPMC Division of Endocrinology and Metabolism has proposed a Wellness Initiative with an aim to create an organizational work environment that promotes values and behaviors to encourage self-care, personal and professional growth, and compassion for our colleagues, patients, and ourselves.

This Wellness Initiative is inspired by the Steps-Forward program sponsored by the AMA, and the Collaborative for Healing and Renewal in Medicine (CHARM), sponsored by the Alliance for Academic Internal Medicine (AAIM). With the support of divisional and departmental leadership, Diana Pinkhasova, MD, clinical assistant professor of medicine, is serving as the Endocrine Division Wellness Representative. Vrushali Shah, MD, one of the current chief clinical fellows, is serving as the Endocrine Fellowship Wellness Representative. These Endocrine Division Wellness leaders have joined other wellness leaders across all of the divisions and departments at UPMC to promote change that works toward the goal of a culture of wellness throughout the UPMC health system and beyond. 

The "UPMC Thrive Grants for Change" awarded to the Division of Endocrinology is being used to support system changes that will improve efficiency and workflow in the clinical centers. One example has been the successful installation of Tidepool®, a software that allows clinic staff to download more than 40 different devices (e.g., insulin pumps, glucometers, sensors) used for the patient population with diabetes. Tidepool encourages patients to take a proactive role in their health care by uploading diabetes-related data before their scheduled appointment in the UPMC Center for Diabetes and Endocrinology. Having the data available for review affords additional time for physicians and patients to discuss their clinical care and concerns. 

The Wellness Initiative also is designed to meet the needs of fellows and faculty, embracing them in the culture of facilitating well-being within their place of work. The clinical fellowship program in the UPMC Division of Endocrinology and Metabolism is one of the largest programs in the country, with five clinical fellows per year. In 2019, the Division decided to assign chief fellows to serve not only as a liaison between the fellows and the faculty but to serve as an initial point of contact and buffer to enhance efficiency and sensitivity in addressing fellow concerns. Each incoming fellow is paired with a senior fellow and faculty advisor to help adjust to new work and home environments in the scope of professional wellness.

The engagement of certified registered nurse practitioners (CRNP) on the inpatient endocrine weekend rounding schedule has led to a reduction in the number of weekend hours for fellows during their inpatient rotations. This has led to improved occupational and social well-being among the fellows in training. The introduction of flexibility in the timing of conference presentations for fellows also has contributed to an improved sense of well-being as they now can plan their preparation time when it fits best within their overall academic and clinical responsibilities. 

To monitor the progress of the Wellness Initiative, we plan to conduct annual internal surveys regarding the implemented changes. The annual UPMC Physician Well-being Survey will aid in monitoring the progress of the initiative. While several changes have been put in place, the goal of the Wellness Initiative is to continuously improve upon these interventions as we identify additional opportunities for improvement. 

With continued commitment and dedication, the mission of the Wellness Initiative is to deliberately and thoughtfully prevent and reduce the level of burnout, achieve a well-integrated work-life model, and enhance the overall wellness and satisfaction of all employees.

References

1 Freudenberger H. Staff Burn-Out. Journal of Social Issues. 1974; (30)1: 159-165.

2 World Health Organization. Mental Health in the Workplace. May 2019. https://www.who.int/mental_health/in_the_workplace/en/

3 Maslach C. Understanding the Burnout Experience: Recent Research and Its Implications for Psychiatry. World Psychiatry. 2016; 15(2): 103-111.

4 Data at American Psychiatry Association, May 2018.

5 Han S, et al. Estimating the Attributable Cost of Physician Burnout in the United States. Ann Intern Med. 2019; 170(11): 784-790.

6 Medscape National Physician Burnout & Suicide Report 2020: The Generational Divide.

7 Medscape Endocrinologist Lifestyle, Happiness & Burnout Report 2019.