Clinician Burnout: Risks and Practical Workload Strategies

• Gastroenterology burnout was estimated at 45%–50%; a cited Reuters poll found 59% of health care workers planned to seek another job within 1 year, including 70% of Gen Z.
• Burnout risk factors included frequent call, ≥8 outpatient hours daily, high consult volume, low autonomy, ≥2 hours of after-hours work, EHR burden, work-home conflict, younger age, and female sex.
• Workload strategies included EHR templates, previsit surveys, scheduled messages, portal-response expectations, telehealth for complex questions, calendar blocking, and selectively declining commitments.

Dr Cross:

Welcome everyone to IBD Drive Time. I'm Raymond Cross of Mercy Medical Center in Baltimore, and I'm excited to have my friend Sara Horst from Vanderbilt back, and we're going to talk about burnout in medicine. This is going to be a little different than some of the podcasts I've done before where I have a script and a number of questions. I read a statistic the other day. I actually read my emails and I read the AGA Today in Medicine, and I saw a stat that was super troubling that estimates, it's a Reuters poll, that said that 59% of healthcare workers— this was not specific to GI—but are going to be looking for a new job in the next year. So I used OpenEvidence and I did a little research and I wanted to see what the rates of burnout were in GI in general.

And they're estimated to be about anywhere from 45 to 50%. And honestly, as I've gotten older, and Sara's mid-career, I'm later career I would say, and this is something that I think about pretty frequently, about what is it that's going to stop me doing what I love, which is taking care of IBD and education and making connections with people. What's going to keep me from doing that? What's going to make me want to stop doing this? And I think burnout is the thing that would do it. So Sara, what do you think about those numbers? Do you think that's right?

Dr Horst:

I think it's right. I think it's super scary to hear that, but I think it's correct. I think we all have seen this happen. We've all experienced it in different ways. I'm spending a lot of time and space thinking about this in ways that what can we do about it? What can we do about it now and how can we plan for this for the future? And especially young faculty members, I worry about their experience and what's going to happen to them over the next 10 to 20 years. I think we have opportunity, but these numbers are really scary right now.

Dr Cross:

And it's interesting you mentioned young because when I was digging a little deeper into the survey, it said that 70% of Gen Z is thinking about changing in the next year. And we're Gen X, you and I?

Dr Horst:

Yeah.

Dr Cross:

It's 50%.

Dr Horst:

Wow.

Dr Cross:

And if you go to the boomers, it's 31%, which is probably intuitive because they're close to retirement. But the younger generation's much more likely to be looking for another job. I don't know if that's just the generation where they're not necessarily, I don't want to say loyal because that's the wrong word, but I think you and I were willing to suffer for a longer period of time before thinking of changing perhaps in a younger generation that maybe doesn't have that. Loyalty's the wrong word. I'm struggling for the word, but you know what I mean.

Dr Horst:

Yeah. Honestly, I feel like this could be that they have less acceptance of some of the problems that are probably leading to burnout where they're saying, and I think more of us are saying this as well, that there's a call for action here. We need to help people who are taking care of patients, people who are doing research, people who are doing administrative work. Our hospital, our healthcare structure is often, I feel like what happens is a lot of it ends up on our shoulders as physicians or leads of clinical teams, and there's more and more of that happening. And so I think probably Gen Z is saying, "Huh, I'm going to take that anymore and I need to find a structure where we're going to be more supportive." So I could be wrong on that as well, but I think it's good.

Dr Cross:

I think you're right. And I think that probably we need to be a little bit more like them.

Dr Horst:

I agree.

Dr Cross:

And they need to be a little bit more like us. It probably needs to be somewhere in between. When you look at some of these risk factors, a lot of this is volume-based, like frequent call, eight hours or more of outpatient responsibilities in a day, number of consults. But there's a couple things, low autonomy, but there's a couple of things that I think are really important that we should talk about. You mentioned younger age. One is two hours or more of work after clinic, so pajama time, which has been published in IBD. The other is women are more likely than men, ER/EHR burden, and then work-home conflict. And I think those 4 we should focus on a little bit and talk about because to me, those are the— I can't speak to a perspective of a woman, although I support women, but you can talk to that. But we can talk about EHR, we can talk about work-home-life balance, and we can talk about this pajama time that we deal with.

Dr Horst:

There's so many factors for this, and this is where I spend a ton of time. I'm really passionate, especially about what we're doing on a daily basis in front of our computers, because that's where we are. That's how we're taking care of patients. We spend a lot of time talking about, thinking about advanced therapies and all this, and it's super important to talk about that in inflammatory bowel disease. But the thing that we may not be focusing on enough is what you're trying to do on the day-to-day basis. I think there's a lot of factors for this. When you talk about the EHR, several things started to occur in the early 2000s. One was that there was a push to try to get everyone on an electronic health record, and the goal was that we could all share information and everybody would know what was going on with the patient because we all had this beautiful shared electronic health record.

Dr Horst:

Unfortunately, a lot of people went on EHRs and we still have fragmented care because we all have individual EHRs and it's really hard to share

Dr Cross:

Information. Less fragmented. It's less fragmented.

Dr Horst:

Less fragmented, but still fragmented. And that pushed up administrative burden on us because we used to— I mean, I was in an age where I used to write a 4-line SOAP note about a patient in the hospital, and now our notes are extremely long. We're doing this for billing purposes, for trying to make sure we have everything documented correctly. And now our daily patient notes are 3 pages long, and so that has happened. I think what also has really -

Dr Cross:

And by the way, many of the notes are unreadable.

Dr Horst:

And you're trying to read through. You can't even find the information you need. And I think the third piece is that as this is all occurring, so we've got this electronic health record, we also have patients increasingly on patient portals. And I think the COVID pandemic actually surged that up really significantly. So there was one study that showed that in the pandemic, the number of people that started to go on patient portals doubled. It doubled in the span of 2 years. So now you have patients that are like, "Oh, I love this thing. I can get my care asynchronously. I don't wait anymore." We also have a culture where we can do everything on our phones, so we want our Amazon packages like yesterday. We are in a culture of instant access, and that has occurred in healthcare. All of these pressures, so those pressures that you're feeling, that your message basket has doubled in size, it's true. It's absolutely true.

I think it's good in some ways because patients can have better access to what's going on for them, and it has created ton of pressure. And remember what I just talked about, all of it filters up to the team lead, which is typically the physician at the end of the day. And so if there's a nurse question, if there's a pharmacy question, if there's a scheduling question, if there's the infrastructure that has been built is that it all filters up to you that you have to answer. So all of that stuff you're feeling is absolutely true.

And I think in medicine, we have been trained, we have been trained that our success lies on finishing all the jobs. So as a physician, I hear it every day. I see pictures on social media where somebody clears out their inbox and they're so proud of themselves, and it's great. It's a daily task that you feel like you've checked off your list, but it never stops. That never goes away. So our measure of success of clearing your inbox is creating incredible stress on clinicians who always want to take great care of our patients. And so all of this together, I don't have all the answers, but I think just laying that out there and helping people understand that your treadmill, if you clear the inbox, your treadmill will only turn up, the speed will only turn up because you're efficient and then that will happen.

Dr Cross:

Let's dig into them because I think there's 3 parts we can dig into.

And I forgot to mention that IBD Drive Time is the official podcast of the AIBD Network, and we're on Apple playlists and we're on Spotify, of course.

So let's talk about the documentation. So I changed jobs 2-plus years ago. I'm now in a private practice where it's a collection-based practice, so I'm paying myself. And so I see high volume in the office and high volume for endoscopy. Endoscopy's generally not that stressful, but office hours are stressful. And the way I combat that is, one, my HPIs aren't super long anymore. They're very brief and to the point, and I have templates and smart phrases where I can populate my note generally in less than 60 seconds, and then I'm just focused on the assessment and plan and updating it and modifying it. I can do a note in about 3 to 4 minutes. I don't use AI because I don't like how my notes look with AI, but I do a lot of previsit surveys to patients that come back to me, templates, smart phrases, the buttons, all those things.

And to me, that is a way that I decrease stress. It's by doing previsit surveys, and so it's not horrible for me. What do you do differently at Vanderbilt? And you're an EHR expert.

Dr Horst:

Yeah, so this is a space where I think when I was talking earlier about we need better tools, I think we need to be spending more time talking about this. So I'm so glad we're having space to do this today because a lot of us are on different EHRs, but many people are probably on Epic. And so Epic has in some ways been great because it keeps a lot of the information in one place for us to evaluate. And there's also probably 6 different ways to do the same thing. So while it's great, there are people that are clicking, there's so many button clicks, and so I think we need to be spending more time talking about how to make that increase your efficiency. And I'm not saying this is going to -

Dr Cross:

Not necessarily to see more patients. It’s to give you more time.

Dr Horst:

It's to give you more time. And so Jamie Kinnucan, who is at Mayo Jacksonville, she and I both have leadership roles within our institutions around health IT management, and we've been spending years and years thinking about this, and it's great, but we're doing it very siloed at our own institution. So one of the things that we're trying to do is get the word out. We've formed a nonprofit called Gastro Digital Health. We've got a website, and I have tried to put a lot of information on how to become more efficient in a way that you can do it on your own time. So when you and I talk about this, you build it, but you've done that. You've got to spend probably 20 minutes to build easy do-it-yourself things. You've got to build a smart phrase. You need to build an order panel for yourself. So you can click one button instead of clicking the 7 buttons you see.

Dr Cross:

You have to work with your IT people to send out your pre-visit surveys.

Dr Horst:

Yeah, you've got to talk. You have to do some of this, and some of it you can do-—in fact, a lot of it you can do yourself. And we've also given strategies, which I think is as important as how to talk to your health IT team, because I also hear a lot of frustration from that. I want to do this thing that you talked about, but I can't get health IT to do it. So on the website, there's also frameworks of how to talk to your health IT team, and a lot of times it's a different language. I've learned a different language when I talk to health IT and having to be in that world in that space. A lot of times they need very defined strategies coming back from the operational teams about how to do this. So I call it an SBAR, situation background assessment and recommendation.

They love for something to come to them like that. So we've put that on the website on if you're going to do something where your health IT team is going to need you to get help from them. And I think setting expectations for you and your team, a lot of times these builds take, if they're bigger, they can take 3 to 6 months, and it's frustrating. You want it done yesterday. You feel like this thing should be really facile. It's complex. You have to make sure you're not breaking anything else in the records, and you get put on a list of priorities. So sometimes it is going to take a little while if you're going to ask for a health IT team build, but a lot of this you can do yourself.

And I think the other key about this is that when it comes down to it, when you're talking about EHR efficiencies, it is actually behavior change. So think about it, if you're driving to work, you may take the road that is 15 minutes longer just because that's what you've done every day for the past 15 years. And suddenly I'm like, "Ray, you got to go the other direction." You have behavior. That's a big behavior change. You got to turn the wheel left instead of right, and we have to do behavior change for you to get more comfortable in your EHR. I think it takes about 5 times to do something new.

Dr Cross:

Again, it's to help you, not to help your administrator be more efficient so we can put in a couple patients. Now that can be a goal, but the goal here, particularly in fields like IBD and liver and functional— I'm not supposed to say functional, disorders of brain gut interaction—where there's a high volume of out of office work and messaging that you need time to address that 2 hours. You need some of that back, and these tools do that.

The other thing, Sara and I are actually at IBD 101, which is fun. I heard Corey Siegel say, "Just remember that with these complex patients, you can't get everything done in that 20-minute slot or 30-minute slot, whatever you're given, and you may have to leave the vitamin D behind and address it to next visit. You make a note and you move on.” You can't do everything. And as you get experienced, I think you learn that you just move on and you'll get it to next visit.

Let's talk a little bit about afterhours. So one of my approaches is that when I try to get my work done before I leave, and when I come home, I want that to be my time, and I want my phone face down.  I'm not on Epic. I don't try to go back to the computer. Now, I also don't have young kids where I have to be home at a certain time, where then I may have to come back because I'm leaving work undone. So that's my role. And on the weekend, I might log on for an hour simply because I want my basket to be less full when I start on Monday. That's just a me thing.

I also tell patients, "Do not message me at night. Do not message me on the weekend. Don't send a lifeline because I'm not checking. Do you want me to answer you after a martini really?" I tell them upfront at the first visit, they don't always listen, but that's just what I do. Is that a sensible rule? I mean, obviously things need to be adaptable.

Dr Horst:

I think we're just having this conversation actually, but I think when we pushed patients onto patient portals, it's great, and there is increased access for asynchronous care, and that is putting a lot of pressure on clinicians. So a lot of your afterhours work, not all, it could be notes, but a lot of it is this administrative burden, answering patient messages, trying to write prior authorization letters or approve them or things like that. I do think that we need to think about how we are setting expectations for patients. Every new patient I see, I set very clear expectations around when they're going to get a message back from me, and our institution allows 3 business days to answer a message, so that is the expectation to them. Sometimes if I have patients who are—these are just little examples—but if you have someone who's starting to message a whole bunch within your EHR, I say, "If this is going to be a complex question, we're going to help you set up a telehealth visit to talk about this." And I set that at the beginning so that they understand I cannot go back and forth with them all day long about one question. We have to tag this into a space where I have time to think about you. And you need a visit.

Dr Cross:

That's really important for the listeners, particularly the younger listeners, I don't know what that rule is. Typically, for me, if it's 2 or 3 messages and we haven't resolved the problem, it's you need a visit. Or if it's a complex question, something that they have to send 3 messages, that is one message that it's that long, that's too complicated for a MyChart message.

Dr Horst:

And some people don't have—here could be a clinic access issue. So there's lots of cool tools in Epic where some people, and I've started to do this, where you can do some of your own scheduling. Some people don't want that, but I have access where I can actually schedule a telehealth visit off my template so that I can help address that quickly. And guess what? That's a full office visit that I've just done instead of spending the same amount of time going back and forth with the patient. So you could do that. Some institutions have allowed e-visit where if there's a patient-initiated question that you can actually bill for your time when you're going back and forth with the patient. Now that requires patient consent and documentation around evaluation and management, and that might be a place for you to think about.

Dr Cross:

Think it's easier to do the telehealth visit. And it's just - And it probably reimburses better.

Dr Horst:

It absolutely reimburses better, and some people don't have as much clinic access.

Dr Cross:

By the way, if the listeners like Sara and Ray are being mean, when you work with a lawyer, a lawyer's charging you for every email, every single thing that they're opening, and our cognition shouldn't be free.

Dr Horst:

Our cognition is not free. And if you add that up, if you're doing that for 10 patients a day, imagine how much time that you're taking. So we also need to help our patients understand that we care about you, and this is taking our cognitive time and space, and that is limited for us as well. I think the other thing that people need to think about a little bit more is how you are billing. So that's another strategy for how you can effectively capture your productivity and revenue. There are billing codes around transition care management where if you see someone, which you should hopefully try to get somebody in who's just in the hospital within 14 calendar days, if you see them in clinic, that's essentially the same revenue capture as a level 5 new patient visit. You have to do a little bit of work around that, and we're going to be adding some of this to the Gastro Digital Health website, but you should be doing that anyway. You set up the infrastructure for that so that patients know, "Oh, I have a visit with them in seven days," or, "I have a visit with them in 14 days. I can save my questions there." So you're setting the structure for patient expectations on how you're going to take care of them instead of this sort of like, "They don't know." As a patient, they don't know what they're supposed to be doing too, so you have to help them understand how you're going to best take care of them.

Dr Cross:

There's some other things that I learned with Epic that is interesting. So the frequent messengers. So one of the things I learned is that you can delay sending your message. So my goal is to respond to the patient that day, that business day, if I get it in business hours, but I don't feel like I'm obligated to answer their second or the third question that day. So oftentimes if it's coming back and forth, I'll delay my response until the next day. And I'm hoping that I'm level setting to say, "This is not going to be an ongoing back and forth messaging thread." And on the weekends, I've learned now— hopefully my patients aren't listening, I don't want them to know that I'm looking—so I'll delay. Like this morning, I logged on and did a few things, and I delayed the message till Monday morning.

Dr Horst:

It's a great tip, and that is just something you learn that, right? Listen, I live in Epic every day, and if we don't spend time teaching people these small little tips that can save them, you've now set a patient expectation. I delay messages all the time. In fact, one of the things I do is if I'm on a telehealth visit and I know the patient's going to need labs in 3 months, I put the labs in and then I delay send them a message in 3 months, and I say, "Hey, I'm going to delay send this to you. You're going to get a message from me in 3 months reminding you to get labs." And so you can set up all of this infrastructure around how you're managing patients, and so now you're not getting the message back that I can't refill this med because their labs are late. You are helping them without adding messages on the front end.

The other piece that I think is really important when you're thinking about how you can structure things so that you get less messages is when you think about taking care of a patient with inflammatory bowel disease and you're trying to get a highly effective therapy, not advanced therapy, we talked about that yesterday, a highly effective therapy like a biologic or a small molecule, a lot of times those need prior auths, then you may need an appeal. What I have done is then in my initial note, every single patient, if they meet criteria for moderate to severe disease, I clearly note moderate to severe disease, I note prednisone dependence or prednisone failure. I note what medications they failed. It takes 3 minutes to add that into every single note. And if you know you're starting an advanced or a highly effective therapy that may have some back and forth with insurance, build a smart phrase that has 4 references already put into your initial note. That's going to help your team send that note off rather than having to build a letter around it. You have all of that built into your initial note. You're also helping your team get less messages. So these are small things that we all need to talk about and think about.

Dr Cross:

Yeah, that's even more important for the practices that aren't lucky like you and I, that we have specialty pharmacy teams that support us, and so they're doing the letters, so that's one less thing that is for burnout.

Let's talk about work-life balance and let's talk about our shared experiences. So I read a leadership book, I can't remember the name, but it talked about your life is like 4 burners on the stove. You have your health, you have your family, you have work, and you have friends. And the person who wrote the book said you can only have one burner going at one time. And I think what that means is in the moment you can have one burner that you can't—and so for me as a senior faculty now that's 55 years old, that's been doing this for a while, for the listeners to give some background, I started at University of Maryland and it was not an IBD center of excellence. And I started myself with a half of a secretary, and over many years it became bigger. And when I started to get asked to do things that were work-related, they could be with industry, they could be CME, they could be education, this could be things locally. These can be committees, these can be leadership roles, whatever. At that point in my career and going into mid-career, I felt like I couldn't say no to anything. The problem is if you have that approach, and Sara understands why that's your approach, you're missing something. You're putting stress points on your family, you're putting stress points on your health because you just don't have… there's always something to do. And so I got to a crisis point in my life where I sat with my wife and we said, "You can do 2 extra..." For me, it was the extracurricular stuff, not so much the local stuff, but you can do 2 extra things a month.

And that was my grounding, and it was fair because it allowed me to do the fun things and see my friends in the IBD community, but it also kept me grounded at work, grounded in my research, grounded in, importantly, my family, my kids, and my wife, and less so friends, because again, those 4 burners can't run at the same time. So if you really want to be successful at work and you really want to have a relationship with your wife and kids, you're going to give something up. So to me, that was a very reasonable thing, and I think it sustained me and it kept me married, and it kept me as a father who was able to coach my kids, but I had to make that decision almost like at an inflection crisis point in my life.

So Sara, and you have unique experiences as a woman, which I think are even more challenging, but what are your experiences? What would you tell the listeners? How do you balance that? How do you say no?

Dr Horst:

Yeah, this is such a great question. I love that you've opened up and talked about this. Again, I think we need to talk about it, and I think people need to understand that this isn't easy. I think for me, it's evolved over time, but oftentimes when you're thinking about this, you sort of anchor on a book or two, and I anchored on this book called 4,000 Weeks, and this book is, you have 4,000 weeks of your life, and we spend a lot of time on thinking about these little tasks that we're doing, and if we just can get more efficient on these little tasks, and we sort of lose sight of the bigger view of our life, and I think that's what you did with the 4 burners, and this book helped me do that as well.

I have evolved over time, but one of the things I really had to understand was what is my view of success? It was a little hard, especially early career, because a lot of times what I was looking at, what was success for me was I have to look like that person, and it took me a while to realize that my actual core values didn't look like anybody else. My measures of success were different. I wanted to spend time, especially when my kids were young at home, I wanted to grow an IBD patient care career, but I also learned this third piece that I really liked doing things in the EHR, and that evolved for me over time, health IT and clinical informatics, and so I had to anchor my goals on that, and then when I was asked to do things, I had to say, "Is that going to help me get to that higher goal?" If it was a yes, I would take something else off my plate to put that in.

So that's number one, is that you have to learn that strategic no. And if I said no, I said no, and thank you so much for that opportunity. The reason I'm not doing this is because my career goals are this direction and you should ask this person. So now you're doing this sort of, you're not just saying no, you're saying, I'm telling you why. And usually it's somebody up higher that's asking you, so I'm telling you why. I'm explaining my ultimate career goals so you can put that in your head to ask me something else. And you're helping someone around you to elevate as well.

Dr Cross:

I think I heard you say also thank you for the opportunity.

Dr Horst:

Thank you for the opportunity. Yes. So there's that space. So I learned to try to do that. And then the last piece, what I think is so important for me was that I very deliberately, this is the way I work, but I live by my calendar, so I actually block things off. I have clinic time. When that happens, my email is off. I'm immersed in clinic, I'm there. My door is open for clinic questions. My door is open for message basket. And it's given me space to do that. Then I have time where my clinic is off. So I'm off there and I'm doing my administrative work and that piece is also helpful. And then when I'm home, I turn everything else off and I'm home and I have space for that. I put space for my health. So I try to put space and block time to make sure that I'm doing exercise. And that's what's helped me is to, sometimes my door is open and sometimes my door is closed. So I think those are things that have helped me.

And the last piece, what I think is really important is that you need someone to help you. So for you I was your wife, you all met and talked and figured out, okay, I can do two things per month. I've had some people say they have someone who's like a “frentor” or somebody who's mid-level right where they are. They will talk about opportunities and say, "Hey, is this going to help my career?" So they involve other people in their time management as well. And I think that is a very great idea. So have someone bounce ideas off someone, whether it's your mentor or a friend or something. If you get asked to do something, make sure that it's the right thing to do.

Dr Cross:

So I just have 3 quick points and then I want to ask you one fun question. Okay. One of the things you should have heard Sara say is that finding things that are meaningful, that you're passionate about, that excite you, that has been clearly shown to combat burnout. And so finding what you're passionate about. The other thing is we talk about, I talk about the narcissism meter. I have to be careful I say this, but all doctors are narcissists to some degree. And there's an element of narcissism that's important. You want your team, you need to be confident. You want your patients to feel that you're confident and comfortable. But when you're asked to do things, one of the things that I ask myself is, am I feeding my narcissism or is this something that's really important and something I really want to do? So understanding why is this? Do I want this approval of giving a talk where people are giving me that validation or is this something that is important to me that really excites me and drives me? And I think that's a little bit different. I'm forgetting my third point. There was something I was going to say when I'm forgetting, but that's okay.

Dr Horst:

I think what you say in that second piece is really important. And I think for me, just from my personal experience is however you call it. narcissism, or an external view of success. So in medicine, I feel like a lot of times we see a ladder that we're supposed to climb up and I was on that ladder. I still am on the ladder. And I was just climbing up it because that is what I learned to do in medicine. And I had to really, and you did it too, you had to step back and say, "Why am I climbing this ladder? Is it for me? Is it because of what I'm passionate about or is it because that has been what everybody's telling me I need to do?" And those are two very different things. So pulling those apart is really hard and sometimes you need people to help you do that, whether that's a life coach or a professional coach or a therapist or your wife or your friends. And you probably need help pulling that apart a little bit, but it's so important because it helps you understand how you can say yes to things

Dr Cross:

And I remember what I was going to say, the third point, and I got this from listening to you—compartmentalizing your day. And we also all have a little bit of the ‘tism’ to be able to get through our day and keep our blinders on and stay focused. And my wife says that the house could be falling around me when I'm doing work. I'm just focused on what I'm doing. I realized about a year and a half ago that I come home in that mode. I'm still in that mode. I haven't turned it off. And my youngest said to me, "You don't even ask me how my day was." And I realize it's not because I'm a bad person or not a nice person, it's because I'm still in that. And now when I come home, I shut it off and I try to like, "I'm husband, I'm dad, I'm home. I'm home. My dogs are here. I need to turn the ‘tism’ off now and just be normal."

Dr Horst:

Exactly. And for me too, when my kids were younger, I could not get everything done in the day because I had to be home at a certain time. So I turn it off and then sometimes I turn it back on later in the evening. And that's not necessarily a bad thing, but I made space for it.

Dr Cross:

All right. We're going to ask you, we're going to do a best of ACG follow-up. So I'll ask you the fun question. And Sara, this has been great. And I think even the listeners that aren't physicians might find this useful. Yeah. Great, Sara. Thanks.

Dr Horst:

Thank you.