Medicine and Public Issues
28 May 2019

Estimating the Attributable Cost of Physician Burnout in the United States

Publication: Annals of Internal Medicine
Volume 170, Number 11

Abstract

Background:

Although physician burnout is associated with negative clinical and organizational outcomes, its economic costs are poorly understood. As a result, leaders in health care cannot properly assess the financial benefits of initiatives to remediate physician burnout.

Objective:

To estimate burnout-associated costs related to physician turnover and physicians reducing their clinical hours at national (U.S.) and organizational levels.

Design:

Cost-consequence analysis using a mathematical model.

Setting:

United States.

Participants:

Simulated population of U.S. physicians.

Measurements:

Model inputs were estimated by using the results of contemporary published research findings and industry reports.

Results:

On a national scale, the conservative base-case model estimates that approximately $4.6 billion in costs related to physician turnover and reduced clinical hours is attributable to burnout each year in the United States. This estimate ranged from $2.6 billion to $6.3 billion in multivariate probabilistic sensitivity analyses. At an organizational level, the annual economic cost associated with burnout related to turnover and reduced clinical hours is approximately $7600 per employed physician each year.

Limitations:

Possibility of nonresponse bias and incomplete control of confounders in source data. Some parameters were unavailable from data and had to be extrapolated.

Conclusion:

Together with previous evidence that burnout can effectively be reduced with moderate levels of investment, these findings suggest substantial economic value for policy and organizational expenditures for burnout reduction programs for physicians.

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Supplemental Material

Supplement 1. Supplemental Appendix

Supplement 2. Physician Burnout Calculator

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Donald Girard, MD, David Nardone, MD, David Hickam, MD, MPH, Timothy Goldfarb, MHA 24 June 2019
The Oregon Wellness Program: A Sttewide Program for Burnut
Letter to the Editor: Estimating the Attributable Cost of Physician Burnout in the United States. Han S, Shanafelt TD, Sinsky CA, et al.

To the Editor:
The article entitled Estimating the Attributable Cost of Physician Burnout in the United States (1) offers a concerning financial dimension to the crisis of physician burnout. As noted by Ellison in the accompanying editorial, the holistic burden of burnout is staggering and multidimensional, all of which are negative (2). These data should incentivize treatment, even if empiric. Oregon has established a health professionals’ counseling program, the Oregon Wellness Program. It uses Oregon’s largest medical societies as safe harbors from which to obtain services. It is designed to minimize barriers that prevent physicians from accessing the help they need. The program may serve as a template for other states.

In 2014, through many town meetings of state medical leaders, the Oregon Wellness Coalition (OWC) was established. Its goal was to advise on the feasibility to establish a statewide treatment program for healthcare professional with burnout symptoms. Through the Coalition’s work, the Oregon Wellness Program (OWP) was planned, developed and implemented. All Oregon licensed physicians, physician assistants, and select advance practice nurses may receive up to eight, confidential, free, non -reported counseling sessions per year provided by selected and experienced PhD, PsyD, or board certified psychiatrists in regional areas. Clients access the program through a single call-in number and are seen in person within 48-72 hours. Four of the state’s largest medical societies employ the clinicians. Two additional medical societies are now developing new programs. All clinicians have received a three-hour webinar that offers a primer on the OWP, its goals, methods, and clinicians’ expectations.

Finally, a confidential research protocol, using validated methods, has been implemented to evaluate the program and any changes in clients’ wellness markers.

Fiduciary support has been provided by a partnership between the OWP and a reputed state foundation with 501c3 status. Contributions have been obtained through health care systems and the Oregon Legislature. More than 200 hundred clients have accessed services and approximately 500 visits provided to the present.


Vital to the program are the lessons learned from an established wellness program for resident and faculty physicians in the state’s largest academic medical center (2003-current) (3). These include the imperative to avoid barriers that prevent clients from accessing services: voluntary; never mandatory; separate from employer systems’ credentialing programs and state licensing agencies; absolutely confidential, and with no reporting (minimal records and free).

The OWP may serve as a model for other states to use to provide begin meaningful treatment for those who suffer from burnout symptoms.

Word count 412

Donald E. Girard, MD
David A. Nardone, MD
David H. Hickam, MD, MPH
Timothy Goldfarb, MHA


References:
1. Han S, Shanafelt TD, Sinsky CA, Awad KM, Drybye LN, Fiscus LC, et al. Estimating the Attributable Cost of Physician Burnout in the United States. Ann Intern Med 2019; 170: 784-790.
2. Ellison EM. Beyond the Economics of Burnout. Ann Intern Med 2019; 170: 807-808.
3. Cedfeldt AS, Bower E, Flores C, Brunett P. Choi D, Girard DE. Promoting resident wellness: evaluation of a time off policy to increase residents’ utilization of health care services. Acad Med. 2015 May; 90 (%): 678-83. Doi: 10.1097/ACM.0000000000000541. PMID
/Users/Don/Desktop/LTE AIM #4 6-21-2019.doc

Disclosures: NONE

Liselotte N. Dyrbye, M.D., M.H.P.E. 1 6 August 2019
In Reply
We thank Girard and colleagues for their interest in our paper. With over a third of physicians, residents, and medical students experiencing substantial symptoms of burnout1,2 programs, such as the one established by the Oregon Wellness Coalition, designed to help individuals recover and to lower barriers to treatment are vital to helping our community heal.
It is time, however, for us to move beyond providing support for those in distress, and focus on improving the practice environment to prevent excessive work stress and burnout in the first place. Practice improvement and innovation is complex. Processes and procedures are deeply ingrained in routine, team members can feel threatened and be reluctant to change, and patient care needs to continue uninterrupted. Despite these challenges, existing data suggests that organizational level interventions are feasible and likely more effective than individual level interventions.3
Successfully addressing the underlying drivers of burnout will require resources and investment to bring about meaningful, sustained structural change. Our analysis indicating the profound economic cost of physician burnout on the healthcare delivery system provides a strong rational to invest sufficient resources to address the problem.4 For the average organization with 200 physicians, physician turnover and reduced clinical hours attributable to burnout costs $1.5 million per year. Measuring physician well-being at regular intervals, developing and implementing interventions to improve the practice environment, taking specific steps to reduce workplace isolation, and equipping leaders with transformational and participatory leadership skills are necessary first steps. Vanguard institutions, professional societies, and other stakeholders should fund organizational science to develop and test system level approaches to prevent and reduce physician burnout.
The moral and business cases to address this issue have been made. Now it is time for organizations, payers, regulators, and the profession to improve the practice environment for the sake of patients, physicians, and society at large.5
Liselotte N. Dyrbye, M.D., M.H.P.E. 1
Karim M. Awad, M.D.2
Lynne C. Fiscus, M.D., M.P.H.3
Christine A. Sinsky, M.D.4
Tait D. Shanafelt, M.D.5

1 Mayo Clinic, Rochester, MN
2Atrius Health, Boston, MA
3University of North Carolina Physicians Network, Morrisville, NC
4 American Medical Association, Chicago, IL
5 Stanford University School of Medicine, Palo Alto, CA


Reference

1. Shanafelt T, West CP, Sinsky C, et al. Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population between 2011-2017. Mayo Clin Proc In press (ePub available).
2. Dyrbye LN, Burke SE, Hardeman RR, et al. Association of clinical specialty with symptoms of burnout and career choice regret among us resident physicians. JAMA 2018;320:1114-30.
3. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 2016;388:2272-81.
4. Han S, Shanafelt TD, Sinsky CA, et al. Estimating the Attributable Cost of Physician Burnout in the United StatesCost of Physician Burnout. Annals of Internal Medicine 2019;170:784-90.
5. Shanafelt TD, Schein E, Minor LB, Trockel M, Schein P, Kirch D. Healing the Professional Culture of Medicine. Mayo Clin Proc 2019.

Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 170Number 114 June 2019
Pages: 784 - 790

History

Published online: 28 May 2019
Published in issue: 4 June 2019

Keywords

Authors

Affiliations

Shasha Han, MS
National University of Singapore, Singapore (S.H.)
Tait D. Shanafelt, MD
Stanford University School of Medicine, Palo Alto, California (T.D.S., M.T.)
Christine A. Sinsky, MD
American Medical Association, Chicago, Illinois (C.A.S.)
Karim M. Awad, MD
Atrius Health, Boston, Massachusetts (K.M.A.)
Liselotte N. Dyrbye, MD, MHPE
Mayo Clinic, Rochester, Minnesota (L.N.D.)
Lynne C. Fiscus, MD, MPH
University of North Carolina Physicians Network, Morrisville, North Carolina (L.C.F.)
Mickey Trockel, MD
Stanford University School of Medicine, Palo Alto, California (T.D.S., M.T.)
Joel Goh, PhD
National University of Singapore, Singapore, and Harvard Business School, Boston, Massachusetts (J.G.)
Acknowledgment: The authors thank the deputy editor, statistical editor, and 2 anonymous reviewers for their feedback, which helped us to improve this paper.
Grant Support: Dr. Dyrbye has received grants from the American Medical Association Accelerating Change in Medical Education Consortium, the Physicians Foundation, and the National Institutes of Health. Dr. Goh received a startup grant (R-314-000-110-133) from the National University of Singapore.
Corresponding Author: Joel Goh, PhD, National University of Singapore Business School, 15 Kent Ridge Drive, #08-04, Singapore 119245, Singapore; e-mail, [email protected].
Current Author Addresses: Ms. Han: National University of Singapore Business School, 15 Kent Ridge Drive, #08-69, Singapore 119245, Singapore.
Dr. Shanafelt: 300 Pasteur Drive, Suite 3215, Stanford, CA 94305.
Dr. Sinsky: American Medical Association, 330 North Wabash Avenue, Chicago, IL 60611.
Dr. Awad: 133 Brookline Avenue, Boston, MA 02215.
Dr. Dyrbye: Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905.
Dr. Fiscus: 613 Sugarberry Road, Chapel Hill, NC 27514.
Dr. Trockel: Psychiatry Clinic, 401 Quarry Road, Room 2303, Stanford, CA 94305.
Dr. Goh: National University of Singapore Business School, 15 Kent Ridge Drive, #08-04, Singapore 119245, Singapore.
Author Contributions: Conception and design: S. Han, T.D. Shanafelt, C.A. Sinsky, K.M. Awad, L.N. Dyrbye, L.C. Fiscus, M. Trockel, J. Goh.
Analysis and interpretation of the data: S. Han, T.D. Shanafelt, L.N. Dyrbye, J. Goh.
Drafting of the article: S. Han, K.M. Awad, J. Goh.
Critical revision for important intellectual content: S. Han, T.D. Shanafelt, C.A. Sinsky, L.N. Dyrbye, M. Trockel, J. Goh.
Final approval of the article: S. Han, T.D. Shanafelt, C.A. Sinsky, K.M. Awad, L.N. Dyrbye, L.C. Fiscus, M. Trockel, J. Goh.
Statistical expertise: S. Han, J. Goh.
Administrative, technical, or logistic support: T.D. Shanafelt, L.N. Dyrbye.
Collection and assembly of data: S. Han, T.D. Shanafelt, L.C. Fiscus, J. Goh.
This article was published at Annals.org on 28 May 2019.

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Shasha Han, Tait D. Shanafelt, Christine A. Sinsky, et al. Estimating the Attributable Cost of Physician Burnout in the United States. Ann Intern Med.2019;170:784-790. [Epub 28 May 2019]. doi:10.7326/M18-1422

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