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Physician BurnoutImprove Physician Satisfaction and Patient Outcomes

Learning Objectives:
At the end of this activity, you will be able to:
1. Describe why physician burnout is a pressing issue;
2. Identify key contributors to physician burnout;
3. Outline benefits of conducting an annual wellness survey to document intervention effectiveness;
4. Recognize different interventions available to address physician burnout.
0.5 Credit CME
How will this module help me?

  1. Provides key steps to help you prevent physician burnout in your practice.

  2. Offers strategies to construct a process to measure and improve physician well-being.

  3. Presents examples of successful burnout prevention programs in a variety of settings.

Introduction

What is physician burnout?

Burnout is a long-term stress reaction characterized by depersonalization, including cynical or negative attitudes toward patients, emotional exhaustion, a feeling of decreased personal achievement, and a lack of empathy for patients.1 By measuring and responding to burnout you will be able to:

  • Reduce sources of stress.

  • Intervene with programs and policies that support professional well-being.

  • Prevent burnout.

Recent studies show a national burnout rate of 43.9 percent among physicians in practice,2 including private practice, academic medical centers, and the Department of Veterans Affairs (VA). With almost half of U.S. doctors showing signs of burnout, and numerous adverse outcomes for physicians linked to burnout2, it is an important issue for organizations to address. Reducing burnout can have a positive impact on your practice, including improved patient satisfaction, higher physician retention rates, better morale in the office, and improved recruitment.

Seven STEPS to prevent physician burnout:

  1. Establish wellness as a quality indicator for your practice.

  2. Start a wellness committee and/or choose a wellness champion.

  3. Conduct an annual wellness survey.

  4. Meet regularly with leaders and/or team members to discuss data and interventions to promote well-being.

  5. Initiate selected interventions.

  6. Quiz Ref IDRepeat the survey within the year to reevaluate well-being.

  7. Seek answers within the data, refine the interventions, and continue to make improvements.

Step 1 Establish wellness as a quality indicator for your practice.

Encourage your practice or organization to recognize the impact of burnout on physicians as well as patients, the quality of care delivered, and the financial impact (e.g., through turnover). Establish well-being–the inverse of burnout—as a quality indicator that you regularly measure in your practice. Consider using annual burnout scores as a sign of the health of the practitioner workforce within your organization; if scores should slide, use the interventions described in STEP 5 to turn things around.

Box Section Ref ID

Q&A

  • Why does burnout matter?

    Quiz Ref IDStressful work conditions and burnout can lead to the following practice issues3:

    • Increased errors.

    • Reduced empathy for patients.

    • Reduced patient satisfaction.

    • Decreased patient adherence to treatment recommendations.

    • Increased physician intent to leave the practice.

  • What are the benefits of addressing burnout?

    By addressing burnout, practices and health systems are more likely to achieve other organizational goals, such as better quality of care, improved patient safety, more effective physician recruitment, and higher retention rates.

  • What factors can contribute to burnout?

    Quiz Ref IDThe “Big 4” factors known to contribute to stress and burnout include1:

    1. Lack of control over work conditions.

    2. Time pressure.

    3. Chaotic workplaces.

    4. Lack of alignment of values (around mission, purpose, and compensation) between physicians and their leaders.

  • Why does control over the work environment matter and how does it contribute to burnout?

    Physicians who are unable to control their work are not able to balance the competing demands of the practice with their personal commitments. This results in increased stress and eventual burnout.2

    When work demands are balanced by the ability to control one's schedule, burnout is less prevalent. When demands are heavy, workers (in this case, physicians) use work control to mitigate stress and avoid burnout. For example, physicians who are also parents often need to adjust end-of-day and start-of-day schedules to allow for dropping off or picking up children at child care. Having control over their workday reduces the likelihood of burnout.

“Burnout makes it nearly impossible for individuals to provide compassionate care for their patients.”

Steven Lockman, MD, Senior Medical Director, Neurosciences, Orthopedics and Rehabilitation Service Line/Chief, Physical Medicine and Rehabilitation Hennepin County Medical Center, Minneapolis, MN
Step 2 Start a wellness committee and/or choose a wellness champion.

If you have a solo or small practice, a wellness champion may be a better option than a committee. Wellness champions are individuals within an organization who promote the use of wellness resources, model positive behaviors such as leaving work on time, and encourage employees to complete the annual wellness survey.

A wellness committee should be made up of practitioners (MDs, DOs, NPs, and PAs) from various disciplines and administrators from different departments (e.g., finance, management) who can work with your practice or organizational leaders to measure burnout periodically. Committee members can then present data to practitioners and brainstorm solutions to challenges. The committee should plan to meet for about one hour each month to review current projects, plan new initiatives, discuss survey data, and respond to new opportunities or stresses.

Box Section Ref ID

Q&A

  • Who should be on the wellness committee in my organization?

    All relevant practice stakeholders should be involved in wellness initiatives. This approach can work for many types of practitioners, including hospital-based physicians, surgeons, non-office-based physicians, and advanced practice providers (APPs), such as nurse practitioners (NPs) and physician assistants (PAs). Depending on the size of the practice or organization, representatives can be drawn from different functional areas. Practice professionals will learn from each other and be able to spread findings and news throughout the organization.

Step 3 Conduct an annual wellness survey.

The importance of conducting an annual wellness survey cannot be overstated. There are many benefits to conducting a wellness survey, including:

  • It is a great predictor of behavior. For example, asking people directly about their intention to leave an organization is more than twice as accurate than many predictive analytics models.4

  • It gives people the chance to feel heard. The act of completing a survey gives people a specific channel for expressing themselves, even when the results are anonymous.

  • It can be a vehicle for change. Once practice and organizational leaders are aware of the results, specific interventions can be chosen to address concerns that are discovered in the survey.

With physician burnout itself attributed to organizational factors, solutions can be found—and should be made—at the organizational level. That's why it is crucial to recognize physician well-being challenges in your organization and to understand the types of solutions that can be tailored to the needs of your health system, its physicians, and its care teams. It is important to (1) select a validated assessment tool, (2) integrate measurement into your overall organizational strategy to improve physician well-being, and (3) act on any significant findings that may serve to reduce burnout and increase professional satisfaction.

The American Medical Association (AMA) can help you measure—and support—physician well-being.

The AMA recognizes that a healthy, stable workforce translates directly to healthy care systems—and a healthier nation. Rigorous research and practice science is the foundation of the work we do to inform practice transformation efforts. Our ongoing research is advancing evidence-based solutions designed to increase Joy in Medicine™.

The AMA uses the Mini-Z burnout assessment, which is derived from work performed by Mark Linzer, MD, in the Physician Worklife Survey.5 The Mini-Z comprises 10 items and one open-ended question which assess satisfaction, stress, burnout, work control, chaos, values alignment, teamwork, documentation, time pressure, excess electronic health record (EHR) use at home, and EHR proficiency.

Our team of practice transformation experts can help you assess your workforce's well-being and offer guidance and targeted solutions that empower you to succeed in supporting their well-being and improving your bottom line.

To learn more, please contact us directly at stepsforward@ama-assn.org and we will respond to your request within one business day.

Box Section Ref ID

Q&A

  • Why should my practice measure stress and burnout?

    Recent studies show a national burnout rate of 43.9 percent among physicians in practice,2 including private practice, academic medical centers, and the Department of Veterans Affairs (VA). With almost half of U.S. doctors showing signs of burnout, and numerous adverse outcomes for physicians linked to burnout2, it is an important issue for organizations to address. Reducing burnout can have a positive impact on your practice, including improved patient satisfaction, higher physician retention rates, better morale in the office, and improved recruitment.

Step 4 Meet regularly with leaders and/or team members to discuss data and interventions to promote well-being.

Share burnout assessment data with your organization's leaders as well as other team members. Meet regularly to discuss the data. An easy way to share the results of the assessment is to create a document with summary data for all respondents. After reviewing the data, identify the areas of greatest concern, either by practice or department, or the entire organization as a whole. Based on the problem area(s), select appropriate interventions to address them. More information can be found in the article, “10 Bold Steps to Prevent Burnout in General Internal Medicine.”6

Figure 1.
Conceptual model of the feedback loop to prevent physician stress, burnout, and turnover.
Conceptual model of the feedback loop to prevent physician stress, burnout, and turnover.

This figure shows how burnout-related symptoms can be reduced through ongoing measurement.

Adapted with permission6
Box Section Ref ID

Q&A

  • Should data be shared across the practice or organization?

    That is a decisions the wellness committee or wellness champion will have to make. Some leaders may feel they are being attacked if their results are poor. Others may want to see where they rank compared to others. Sharing the data across practices provides an opportunity to introduce thoughtful and consistent programs throughout the organization to strengthen team culture. Have a plan in place to address what you discover. If a prior survey did not result in meaningful actions, consider making some changes before resurveying to avoid “survey fatigue” and adding to burnout.

  • What about naysayers who believe burnout doesn't matter?

    • Appeal to what motivates them, including their experiences as a busy health care practitioner, administrator, or patient. You could ask, “Would you like yourself or your family members to receive care from a frustrated, cynical, or angry physician?”

    • Emphasize the relationship between work conditions that lead to burnout and turnover and recruitment challenges. Replacing a single physician is estimated to cost between $500,000 to $1,000,000.6

    • Provide evidence of the relationships between burnout improvement and beneficial effects on quality and safety in your practice.

    • Assess changes as burnout decreases and present findings in key metrics, such as the patient experience, cost of care, and staff productivity.

Step 5 Initiate selected interventions.

Quiz Ref IDPrioritize and select interventions to address burnout where it exists. Interventions generally fall into the following categories:

  1. Workflow redesign.

  2. Better communication between practitioners in your practice.

  3. Quality improvement (QI) projects targeted to address clinician concerns.

Your practice may also consider developing a resource list that details how individual practitioners can reduce burnout through time management, delegation, exercise, sleep, and mindfulness. You can find additional resources within the STEPS Forward™ Physician Well-Being module.

Workflow redesign.

Workflow redesigns to reduce burnout may include: pairing nurses or medical assistants (MAs) with physicians in stable relationships, improving preparation and organization by implementing pre-visit planning with pre-visit labs, sharing tasks with non-physician staff, including having MAs document patient visit information into the medical record, and altering workflow between MAs and appointment coordinators. You may also consider if the time allotted for daily visits, procedures, or bedside inpatient care in your practice is insufficient or if it is causing time pressure for your team.

Please see other STEPS Forward™ modules for suggestions to improve workflow in your practice.

Communication.

Communication intervention projects could include: co-location of key team members (e.g., MAs, nurses, and practitioners), daily huddles to discuss complex patients and care coordination, and scheduling monthly practitioner meetings focused on work-life balance or challenging situations in patient care.

Please see other STEPS Forward™ modules for assistance with improving communication in your practice.

Quality Improvement (QI).

Selecting quality improvement projects that directly address physician concerns reduces burnout by empowering them to create change. Projects could include: a streamlined prescription renewal process, screening patients for depression, employing non-clinicians to perform administrative duties such as tracking forms and sending faxes, presenting burnout assessment results and developing solutions, and implementing new processes to manage hypertension or pre-diabetes management programs.

Table 1.
Examples of Interventions to Reduce Burnout in your Practice.

A summary of interventions performed as part of the Healthy Work Place (HWP) study conducted by Mark Linzer, MD, and colleagues.5 Adapted with permission.

WORKFLOWCOMMUNICATIONQUALITY IMPROVEMENT (QI)OTHER
Shift responsibilities of entering data into the EHR from the physician to an MA or other team member.Improve interpersonal communication and teamwork.Implement a hypertension management program.Implement panel management.
Learn more in team documentation.Learn more in team meetings.
Better patient flow through the clinic.Improve opportunities for informal communication among providers, such as a shared lounge or periodic shared meals.Establish quality improvement projects for issues of importance to providers.Dashboard of patient population measures for clinicians.
Learn more in pre-visit planning and pre-visit laboratory testing.Learn more in team culture.
Share information to make the practice or organization more efficient.Monthly formal discussions on patient care for clinicians to improve collegiality.Free up time for nurses and physicians by implementing an annual prescription renewal process.Present wellness data to prompt discussions on changing the clinic environment.
Assess workflow between MAs and nurses to identify opportunities for change.Informal survey of clinicians for a “wish list” of issues to be corrected.Implement a pre-diabetes management program.
Learn more in expanded rooming and discharge protocols.
More time for nursing and MA team members to complete tasks.Share organizational updates with monthly email or meeting with leaders.Implement processes to improve medication adherence.
Pair one MA with each physician.Clinicians meet individually with leadership to review operations and identify concerns.Use the PDSA method to address inefficiencies in the patient portal.
Learn more in expanded rooming and discharge protocols.
Box Section Ref ID

Q&A

  • Should self-care interventions be included to reduce burnout?

    Yes, self-care is an important behavior that physicians in your practice can use to reduce their individual stress levels and prevent burnout. Some self-care interventions include meditation, actively managing health sleeping and eating habits, participating in a regular exercise routine, engaging in hobbies, or taking mini-breaks throughout the day in a quiet space to decompress.

  • Will some interventions require a financial investment?

    Yes, some interventions do have costs associated with them. But burnout is likely to be even more costly to your organization or practice. Each physician who leaves the practice creates additional recruitment costs, reduces revenue, and adds stress to the remaining physicians. This suggests that investing money now to reduce physician stress and burnout could provide significant return on investment down the road.

  • Are all interventions expensive?

    No, many are very inexpensive. Re-engineering schedules and making team meetings more productive are examples of inexpensive interventions. However, some needed interventions to reduce chaos, such as additional exam rooms for more efficient use of physician time, require resource investment.

    Another low-cost intervention is discussing clinic or departmental values. Lack of values alignment with leaders is a known contributor to stress and burnout, but you can alleviate this source of stress by making time to discuss and agree on shared values.8

    For example, begin staff meetings with an interesting case and allow time for group discussion. Physicians chose their profession for the medicine. Discussing rare or interesting cases can re-energize your physicians and help them reconnect with the joy of practicing medicine. Another free option is to create a list of values that your practice deems important.

    This exercise can be valuable even in a solo practice. Consider starting with a short list to develop further, such as:

    • Excellence

    • Equity

    • Respect

    • Advocacy

    • Quality over productivity

    • Work-home balance

    • Compassion

  • I've heard people talk about “meetings with meaning.” What are they and how can I use them as an intervention?

    Practitioners have limited time to meet. Restructuring meetings to address clinical cases or challenging patients and issues of concern to them, rather than administrative issues, is a successful way to reduce practitioner stress. This type of meetings is considered a “meeting with meaning.”

  • What is “career fit” and how can that help practitioners?

    Career fit is the extent to which individuals are able to focus their effort on the aspect(s) of work that they find most meaningful.9 Physicians often have a particular passion they wish to pursue (e.g., education, research, QI). When the allotted time a physician has to pursue what they are passionate about falls below 10 to 20 percent, burnout rises dramatically from 29.9 percent to 53.8 percent.9 Physicians may decide to devote part of their work week to what interests them most, whether that is workflow improvement or strengthening communication in the office.

  • Can burnout be helped by community service?

    Practitioners who are burning out may benefit from leading community service programs outside of the clinic, such as providing health education for children or adults. Studies have shown that community service can substantially reduce burnout, as it brings people closer to their true values and mission in medicine.10

  • What kind of interventions work for practitioners with very high burnout?

    Add a comment box on the survey for those respondents who have the highest burnout score (i.e., 5 on the 5-point scale, “I am so burned out I cannot go on…”) so that they can provide more information about reasons they feel this way. List a telephone number directly on the survey for a person to call for help, for example, the “Employee Assistance Program,” human resources, or a member of the wellness committee. Alternatively, if you do not survey anonymously, you can let individuals know that you will be contacting those who indicate very high burnout.

Step 6 Repeat the survey within the year to reevaluate well-being.

Compare prevalence of stress and burnout from before and after your intervention(s). Use a simple spreadsheet or graph to show changes in stress levels, burnout, satisfaction, control over work, chaos, and alignment of values over time. Develop an understanding of what worked and celebrate those successes. Examine factors that saw no change or a rise in burnout prevalence after the intervention and seek remediable explanations.

Step 7 Seek answers within data, refine the interventions, and continue to make improvements.

Use your burnout assessment results to determine which interventions are working, refocus on those interventions, and reinvigorate your team to carry them out in your practice. In areas where burnout is increasing or observed improvements are not sustained, analyze the results to guide new or modified interventions. The commitment of the wellness committee or wellness champion to the interventions will help convince physicians that your practice is dedicated to staying on a path to reduce burnout.

Box Section Ref ID

Q&A

Conclusion

Physician stress and burnout can have a significant impact on the quality of care delivered to patients, organizational productivity, morale, and costs. You can take corrective action early by identifying sources of stress and developing interventional approaches that will help your organization reduce burnout and promote the well-being of all practitioners.

Box Section Ref ID
Graphic Jump Location
AMA Pearls

AMA Pearls

Wellness interventions work.

Improving workflow within the practice is the most powerful antidote to burnout. This approach increases the odds of reducing burnout six-fold.5 Targeted quality improvement projects addressing clinician concerns increase the odds of reducing burnout five-fold.5 Improving communication between team members can improve the odds of professional satisfaction up to three-fold.5

Please see other STEPS Forward™ modules for guidance on practice redesign to improve workflow, communication, and practice culture.

Celebrate successes.

Try not to embarrass or blame people with high burnout rates. Be supportive and encourage improvement. Congratulate leaders on identifying issues and taking steps to address the issue. Provide additional concrete actions they can take. Be creative with them in seeking ways to improve their department, unit, or practice. Function as a liaison with clinic administration to find best practices and advocate for bigger organizational or practice changes when they are needed to make a difference for individual departments or units.

Change is slow and steady.

Don't try to move the needle too far, too fast. Patience is needed to make sustained work-life improvements. Small improvements can make a difference in the day-to-day work lives of physicians, so do not be discouraged if you cannot make big changes right away.

The unsolvable can be solved.

Don't be intimidated or discouraged by your challenges. Ask your colleagues for possible solutions. You may find that the problem has been discussed and solutions have been identified but not shared across the organization. Be creative when looking for partners. Don't forget you could have allies in other departments, such as finance and billing, environmental services, or quality improvement. Every person will see the problem from a different perspective, so seek to understand what they see and how they would fix it.

Don't be afraid to create new work schedules.

Consider alternative clinic structures, such as “7 days on, 7 days off,” even for predominantly ambulatory physicians. At Hennepin County Medical Center (HCMC) in Minneapolis, MN, graduating residents suggested a 7-on, 7-off model to encourage careers in ambulatory medicine. HCMC took their advice and developed a model program for new faculty hires. They've since hired two physicians and three nurse practitioners to join the two full-time clinicians with the 7-on, 7-off work schedules. The work schedule includes atypical work hours, but the practitioners have a week off in-between. They are leading the organization in certain aspects of innovation, such as measuring the impact of scribes and problem-oriented charting on quality of care, practitioner satisfaction, and clinic finances.

Graphic Jump Location

AMA Pearls


“The creation of a Provider Wellness Program at HCMC demonstrates that we recognize that the well-being of providers is critical to the health and wellness of our patients. Small changes that come from the suggestions of providers can be hugely impactful and strengthen the unity of the care teams, thereby improving the quality of care and satisfaction of patients, families, and providers.” Suzanne Schwartz, MS, Director of Operations, Hennepin County Medical Center, Minneapolis, MN

If you standardize, customize.

Remember to adjust standard work for complex lives. Most busy practitioners' schedules don't fit comfortably in four-hour boxes (8 a.m. to noon, 1 p.m. to 5 p.m.). Allow for flexibility, especially around the beginning and end of work shifts.

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Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

Successful completion of this CME activity, which includes participation in the activity and individual assessment of and feedback to the learner, enables the learner to earn up to 0.5 MOC points in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABP MOC credit.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn their required annual part II self-assessment credit in the American Board of Otolaryngology – Head and Neck Surgery’s Continuing Certification program (formerly known as MOC). It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of recognizing participation.

Article Information

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of .50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Target Audience: This activity is designed to meet the educational needs of practicing physicians, practice administrators, and allied health professionals.

*Disclaimers: Individuals below who are marked with an asterisk contributed towards Version 1 of this learning activity.

Statement of Competency: This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice, interdisciplinary teamwork, quality improvement and informatics.

Planning Committee:

  • Christine A. Sinsky, MD, FACP, Vice President, Professional Satisfaction, American Medical Association*

  • Marie Brown, MD, MACP, Senior Physician Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association & Associate Professor, Rush Medical College, Rush University Medical Center

  • Renee DuBois, MPH, Senior Practice Transformation Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association

  • Brittany Thele, MS, Program Administrator, Professional Satisfaction and Practice Sustainability, American Medical Association

  • Ashley C. Cummings, MBA, CRCR, CME Program Committee, American Medical Association

  • Rita LePard, CME Program Committee, American Medical Association*

  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association*

  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, American Medical Association*

  • Krystal White, MBA, Program Administrator, Professional Satisfaction and Practice Sustainability, American Medical Association*

Content Reviewers:

  • J. James Rohack, MD, FACC, FACP, Senior Advisor and former President, American Medical Association

  • Renee DuBois, MPH, Senior Practice Transformation Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association

  • Brittany Thele, MS, Program Administrator, Professional Satisfaction and Practice Sustainability, American Medical Association

  • Patrick Alguire, MD, FACP, Senior Vice President, Medical Education, American College of Physicians*

  • Beth Averbeck, MD, Associate Medical Director, Primary Care, HealthPartners Medical Group*

  • Eileen Barrett, MD, MPH, Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, University of New Mexico*

  • Linda Carruthers, RDN, LD, Registered Dietitian/Nutritionist, Licensed Dietitian, Mayo Clinic Health System*

  • Laura Guzman-Corrales, MPH, Sr. Project Coordinator, Hennepin County Medical Center*

  • Carrie A. Horwitch, MD, FACP, Key Clinical Faculty, Virginia Mason Medical Center, Seattle, WA*

  • Sean McKinney, Vice President, Medical Education, American College of Physicians*

  • Mark Linzer, MD, FACP, Division Director, General Internal Medicine, Professor of Medicine, Hennepin County Medical Center*

  • Sara Poplau, Assistant Director, Office of Professional Worklife, Hennepin County Medical Center*

  • Christina Reimer, MD, FACP, General Internal Medicine, Colorado Health Medical Group/University of Colorado Health*

  • Tait Shanafelt, MD, Professor of Medicine, Mayo Clinic*

  • Susan Thompson Hingle, MD, FACP, Professor of Medicine, Southern Illinois University School of Medicine*

  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association*

  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, American Medical Association*

About the AMA Professional Satisfaction and Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

The project described was supported by Funding Opportunity Number CMS-1L1-15-002 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

ABMS MOC Statement: Through the American Board of Medical Specialties (“ABMS”) ongoing commitment to increase access to practice relevant Maintenance of Certification (“MOC”) Activities, this activity has met the requirements as an MOC Part II CME Activity. Please review the ABMS Continuing Certification Directory to see what ABMS Member Boards have accepted this activity.

Renewal Date: February 22, 2016; May 23, 2019

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