Clinician Well-Being—Addressing Global Needs for Improvements in the Health Care Field: A Joint Opinion From the American College of Cardiology, American Heart Association, European Society of Cardiology, and the World Heart Federation
2021; Lippincott Williams & Wilkins; Volume: 144; Issue: 7 Linguagem: Inglês
10.1161/circulationaha.121.055748
ISSN1524-4539
AutoresLaxmi S. Mehta, Mitchell S.V. Elkind, Stephan Achenbach, Fausto J. Pinto, Athena Poppas,
Tópico(s)Healthcare professionals’ stress and burnout
ResumoHomeCirculationVol. 144, No. 7Clinician Well-Being—Addressing Global Needs for Improvements in the Health Care Field: A Joint Opinion From the American College of Cardiology, American Heart Association, European Society of Cardiology, and the World Heart Federation LetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toLetterPDF/EPUBClinician Well-Being—Addressing Global Needs for Improvements in the Health Care Field: A Joint Opinion From the American College of Cardiology, American Heart Association, European Society of Cardiology, and the World Heart Federation Laxmi S. Mehta, MD, Mitchell S.V. Elkind, MD, MS, Stephan Achenbach, MD, Fausto J. Pinto, MD and Athena Poppas, MD, MACC Laxmi S. MehtaLaxmi S. Mehta Correspondence to: Laxmi S. Mehta, MD, Division of Cardiology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Suite 200, DHLRI, Columbus, OH 43210. Email E-mail Address: [email protected]. Twitter @DrLaxmiMehta https://orcid.org/0000-0003-3493-1930 Division of Cardiology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus (L.S.M.). , Mitchell S.V. ElkindMitchell S.V. Elkind https://orcid.org/0000-0003-2562-1156 President, American Heart Association (M.S.V.E.). Department of Neurology, Vagelos College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY (M.S.V.E.). , Stephan AchenbachStephan Achenbach President, European Society of Cardiology (S.A.). Department of Cardiology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (S.A.). , Fausto J. PintoFausto J. Pinto https://orcid.org/0000-0002-8034-4529 President, World Heart Federation (F.J.P.). Cardiology Department, University Hospital Sta Maria, CHULN, CCUL, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal (F.J.P.). and Athena PoppasAthena Poppas President, American College of Cardiology (A.P.). Division of Cardiology, Department of Internal Medicine, Warren Alpert Medical School of Brown University, Providence, RI (A.P.). Originally published13 Jul 2021https://doi.org/10.1161/CIRCULATIONAHA.121.055748Circulation. 2021;144:e151–e155"Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity."—The World Health Organization1As clinicians, we strive for improved health for our patients; yet, it is increasingly clear that our own well-being is an essential component of the quadruple aim: to improve population health, enhance patient experience, reduce costs, and improve the work life of health care workers.2 Clinician well-being is described as experiencing satisfaction and engagement with work, while also having a feeling of professional fulfillment and a sense of meaning in work.3 Conversely, burnout is an occupational phenomenon that is defined as emotional exhaustion, depersonalization, and a sense of low personal accomplishment in a perceived stressful work environment.4 Although burnout is a sign of clinical distress and a barrier to clinician well-being, its absence alone does not confer a state of well-being. Rather, burnout is one of the more extreme negative components along the spectrum of clinician well-being (Figure 1), and can coexist with other common mental health conditions (eg, anxiety and depression).Download figureDownload PowerPointFigure 1. Well-being in cardiology. The quadruple aim (left) and the spectrum of burnout symptoms and mental well-being (right).Drivers of Burnout and its consequencesOver the past several decades, there have been dramatic changes in health care with the evolution of technology, increased regulatory burden, and the exponential growth of clerical burden, partly brought about by the widespread introduction of electronic health records. These developments come at a cost to the well-being and work-life balance of clinicians. There are several key drivers (Figure 2) that can influence clinician burnout when the levels are less than optimal: workload and job demands, efficiency and resources, control over work, work-life integration (WLI), alignment of individual and organizational values, social support/community at work, and meaning in work.3,5 Furthermore, women are under-represented in cardiology and may have more stressors contributing to burnout due to lack of career promotion, inequalities in resources (financial), and disparities in mentorship while working in environments that lack diversity, equity, inclusion, and belonging.6Download figureDownload PowerPointFigure 2. The personal and professional ramifications and drivers of burnout and potential strategies to address clinician well-being. The personal and professional ramifications of burnout (left), drivers of burnout when less than optimal levels (center circle), and potential strategies to address clinician well-being (right).Unfortunately, there are serious personal and professional costs associated with clinician burnout (Figure 2). Personal ramifications of burnout include higher rates of alcohol abuse, substance use, dysfunctional relationships, depression, and suicide.7–10 Although mental health conditions can occur along the spectrum of burnout, it is important to recognize that not all burned out clinicians will develop mental health conditions, and not all clinicians with mental health conditions will experience burnout. Professional ramifications of clinician burnout include higher rates of medical errors, lower quality of care, decreased patient satisfaction, increased disruptive behavior, and loss of professionalism accompanied by a decreased level of empathy.3,5,11–14 Health system expenditures related to the burnout of staff are steep when taking into account institutional costs due to decreased productivity and increased clinician turnover.15–18 In the past year, the coronavirus disease 2019 pandemic has caused additional strain on clinicians through increased patient mortality, personal and family safety concerns, fear of the unknown, and increased work demands. Although clinician well-being is now openly discussed in the media, the stigma of seeking mental health counseling among clinicians remains.Assessing burnout and its drivers by conducting surveys is a critical step to understanding the factors that need to be addressed to cultivate an engaged and efficient workforce and to mitigate clinician burnout. Hence, burnout is a metric to measure and monitor, whereas clinician well-being is the goal in cardiology and medicine. With this joint opinion, the American College of Cardiology (ACC), American Heart Association (AHA), European Society of Cardiology (ESC), and World Heart Federation call for global action in health care reform, research, and policy development to address clinician well-being. Further, we aim to generate awareness about the impact of burnout and potential solutions to improve clinician well-being in cardiovascular medicine.Cardiology Burnout DataSurvey data among 2274 US cardiologists and fellows-in-training reported that more than one-quarter reported being burned out and almost 50% were stressed; only 23.7% reported that they were enjoying their work. Women reported burnout more frequently compared with men. Also, midcareer cardiologists more frequently reported burnout compared with fellows-in-training and early- or late-career cardiologists. Neither type of practice setting nor type of cardiovascular subspeciality had an impact on burnout, but burned-out respondents did report more time spent in direct clinical practice. Overall, most were satisfied with their career; however, burned-out respondents were less satisfied with achieving their professional goals or their desired financial compensation, and they were less likely to recommend cardiology as a career. Compared with their peers, burned-out physicians were less likely to report feeling valued or being treated fairly at work. Drivers associated with burnout among cardiologists include lack of control over workload, a hectic work environment, misalignment of values, and insufficient documentation time.19 Data among US physicians from all different specialties demonstrated that 39.8% reported burnout and 42.7% satisfaction with WLI, whereas other data among physician assistants and nurses have shown lower burnout rates (35.8% and 29.7%, respectively) and higher WLI rates (65.3% and 55.5%, respectively).20–22 There is a dearth of survey data specific to cardiovascular professionals; however, the drivers of burnout among cardiologists may likely be extrapolated to the cardiovascular workforce.Health Care Organizational StrategiesHealth care organizations have predominately focused on the concept of "fixing the employee" with individual-focused programs (self-resiliency and stress management training) as the solution to improving well-being; however, much more effort needs to be tailored to systemic issues that affect the work environment. Intentional refinement of practice environments with highly functioning teams within which clinicians can optimally care for patients enables all team members to find value and purpose in their work and can result in improved outcomes for the health care organization and patients. It is imperative for health care organizations to support the psychosocial health of their employees and be accountable for a holistic approach. One such method is the Stanford WellMD Professional Fulfillment Model, which incorporates culture of wellness, practice efficiency, and personal resiliency domains,23 while also taking into account the intrinsic (eg, recognition, trust, meaning in work) and extrinsic (eg, call schedule, compensation, technology) driving factors that can be modified.Organizational infrastructure is necessary to provide the foundational means to maintain work environments within which clinicians may thrive. The burnout and wellness hierarchy model, adapted from Maslow's hierarchy of needs, provides a prioritized stepwise approach for health care leaders to address clinicians' professional fulfillment: basic physiological and mental health needs first; safety and security second; respect from administrators, colleagues, and patients third; appreciation and interpersonal connection fourth; and finally, resources and time to treat patients and practice medicine fully.24 For instance, some techniques by which health care organizations could foster a healthy and resilient workforce include ensuring adequate rest and recovery time, supplying appropriate personal protective equipment, reducing systemic inefficiencies and improving team dynamics, compensating fairly and transparently, and facilitating more direct time with patients.In addition, health care organizations need to provide employees with a structure to allow for confidential reporting of mistreatment and also to destigmatize clinicians' access to mental health resources. Hospital credentialing committees need to refine their inquiries into mental health conditions so that it does not perpetuate a culture of either under-reporting of mental health conditions or undertreatment due to the fear of the loss of hospital privileges among clinicians.Regular assessment of clinician burnout is essential to understand the effectiveness of implemented strategic pilot projects. Similar to the concepts of prevention of cardiovascular disease, secondary prevention is achieved with targeted approaches to prevent recurrent burnout; however, investment in primary and primordial prevention is equally crucial to reduce or potentially avoid burnout all together.Role of Medical Specialty SocietiesClinician wellness is a broad entity that requires medical specialty societies to develop a multipronged approach to make meaningful progress. To support their members, medical societies will need to continue to provide recommendations to health care organizations and advocate for meaningful health policy changes. Furthermore, development of cardiology-specific tools that may improve practice efficiency or clinician knowledge base in a timely and convenient fashion is imperative. Medical specialty societies are also key in developing a sense of community for their members. Engaged members of medical specialty societies often cite global social networks as a recurring theme for ongoing involvement in societal committees and attendance at national conferences. However, medical societies will need to continue to expand their initiatives in diversity and inclusion so that all members feel valued and have a sense of belonging. In addition, the medical specialty societies will need to consider innovative ways to deliver educational content and offer networking opportunities, especially in light of resource constraints and increased need for virtual platforms.In March 2020, the ACC's Board of Trustees commissioned the Task Force on Clinician Well-Being to help focus its strategy to address clinician well-being. Several surveys have been launched to assess the prevalence of and drivers of burnout among ACC members. Member sections are integrating well-being themes in their various offerings to members, including toolkits, webinars, and conferences. Recent webinars share cardiologists' perspectives of mental health conditions as well as inform the viewers regarding signs and symptoms of anxiety and depression, encourage treatment, and provide members the contact information for confidential counseling resources. Additionally, clinician well-being was incorporated into the 2020 ACC/AHA Professionalism and Ethics conference, and the formal recommendations were recently published.25Also, in Europe, nearly 4000 medical faculty and researchers from 17 ESC member countries in 2018 completed the ESC-sponsored "Culture and Leadership in Cardiology in Europe" C-Change Faculty Survey. Overall, cardiologists and research professionals have high leadership aspirations and a high degree of personal satisfaction in their work. However, approximately one-quarter of individuals did not view their institutions as providing the best opportunities for meaningful work, and one-third did not feel they were supportive of career advancement. The ESC has been using these findings to guide future strategic initiatives that aim to provide appropriate support for cardiologists in Europe and enable satisfaction within their work environment.The ACC, AHA, ESC, and World Heart Federation acknowledge that clinician well-being is paramount to providing high-quality patient care and are committed to improving the well-being of the cardiovascular workforce.Medical specialty societies will need to continue to identify and promote for the reduction of administrative complexities and practice inefficiencies, which are burdensome and hinder professional fulfillment and patient care. Advocating for appropriate initiatives to improve clinician well-being and mental health resources, while also influencing the elimination of nonessential regulation and document requirements, is key. Furthermore, assisting in combatting the stigma of mental health conditions and the negative ramifications by licensing boards of a history of treated medical health conditions are crucial endeavors for medical specialty societies. Collaboration with other specialties is necessary, including leveraging the expertise of psychiatrists and clinical psychologists. The House of Cardiology will continue to work together and strategize to maintain the well-being of our profession and keep the meaning and joy of caring for patients.Disclosures Dr Elkind serves as an unpaid Officer of the American Heart Association. Dr Poppas reports financial interest in GE. The other authors report no conflicts of interest.Footnoteshttps://www.ahajournals.org/journal/circThe views expressed in this manuscript are those of the authors and therefore do not necessarily reflect the respective policies of the American College of Cardiology, the American Heart Association, Inc., the European Society of Cardiology, or the World Heart Federation.For Disclosures, see page e154.How to cite this article: Mehta LS, Elkind MSV, Achenbach S, Pinto FJ, Poppas A. Clinician well-being—addressing global needs for improvements in the health care field: a joint opinion from the American College of Cardiology, American Heart Association, European Society of Cardiology, and the World Heart Federation. Circulation. 2021;144:e00–e00. doi: 10.1161/CIRCULATIONAHA.121.055748Correspondence to: Laxmi S. Mehta, MD, Division of Cardiology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Suite 200, DHLRI, Columbus, OH 43210. Email Laxmi.[email protected]edu. Twitter @DrLaxmiMehtaReferences1. Constitution of the World Health Organization. 45th edition. Geneva, Switzerland: World Health Organization; 2006.Google Scholar2. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider.Ann Fam Med. 2014; 12:573–576. doi: 10.1370/afm.1713CrossrefMedlineGoogle Scholar3. National Academies of Sciences, Engineering, and Medicine. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press; 2019.Google Scholar4. Maslach C, Jackson SE, Leiter M. The Maslach Burnout Inventory Manual.In: Evaluating Stress: A Book of Resources. Volume 3. Lanham, MD: The Scarecrow Press; 1997:191–218.Google Scholar5. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.Mayo Clin Proc. 2017; 92:129–146. doi: 10.1016/j.mayocp.2016.10.004CrossrefMedlineGoogle Scholar6. Templeton K, Bernstein C, Sukhera J, Nora LM, et al.. Gender-Based Differences in Burnout: Issues Faced By Women Physicians. NAM Perspectives Discussion Paper. Washington DC: National Academy of Medicine; 2019.Google Scholar7. Oreskovich MR. Alcohol use does not equal abuse-reply.Arch Surg. 2012; 147:786. doi: 10.1001/archsurg.2012.1275CrossrefMedlineGoogle Scholar8. Shanafelt TD, Balch CM, Dyrbye L, Bechamps G, Russell T, Satele D, Rummans T, Swartz K, Novotny PJ, Sloan J, et al.. Special report: suicidal ideation among American surgeons.Arch Surg. 2011; 146:54–62. doi: 10.1001/archsurg.2010.292CrossrefMedlineGoogle Scholar9. Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, Durning S, Moutier C, Szydlo DW, Novotny PJ, et al.. Burnout and suicidal ideation among U.S. medical students.Ann Intern Med. 2008; 149:334–341. doi: 10.7326/0003-4819-149-5-200809020-00008CrossrefMedlineGoogle Scholar10. Oreskovich MR, Kaups KL, Balch CM, Hanks JB, Satele D, Sloan J, Meredith C, Buhl A, Dyrbye LN, Shanafelt TD. Prevalence of alcohol use disorders among American surgeons.Arch Surg. 2012; 147:168–174. doi: 10.1001/archsurg.2011.1481CrossrefMedlineGoogle Scholar11. Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, Collicott P, Novotny PJ, Sloan J, Freischlag J. Burnout and medical errors among American surgeons.Ann Surg. 2010; 251:995–1000. doi: 10.1097/SLA.0b013e3181bfdab3CrossrefMedlineGoogle Scholar12. West CP, Huschka MM, Novotny PJ, Sloan JA, Kolars JC, Habermann TM, Shanafelt TD. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study.JAMA. 2006; 296:1071–1078. doi: 10.1001/jama.296.9.1071CrossrefMedlineGoogle Scholar13. Williams ES, Manwell LB, Konrad TR, Linzer M. The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study.Health Care Manage Rev. 2007; 32:203–212. doi: 10.1097/01.HMR.0000281626.28363.59CrossrefMedlineGoogle Scholar14. Haas JS, Cook EF, Puopolo AL, Burstin HR, Cleary PD, Brennan TA. Is the professional satisfaction of general internists associated with patient satisfaction?J Gen Intern Med. 2000; 15:122–128. doi: 10.1046/j.1525-1497.2000.02219.xCrossrefMedlineGoogle Scholar15. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being.JAMA Intern Med. 2017; 177:1826–1832. doi: 10.1001/jamainternmed.2017.4340CrossrefMedlineGoogle Scholar16. Williams ES, Konrad TR, Scheckler WE, Pathman DE, Linzer M, McMurray JE, Gerrity M, Schwartz M. Understanding physicians' intentions to withdraw from practice: the role of job satisfaction, job stress, mental and physical health. 2001.Health Care Manage Rev. 2010; 35:105–115. doi: 10.1097/01.HMR.0000304509.58297.6fCrossrefMedlineGoogle Scholar17. Dewa CS, Loong D, Bonato S, Thanh NX, Jacobs P. How does burnout affect physician productivity? A systematic literature review.BMC Health Serv Res. 2014; 14:325. doi: 10.1186/1472-6963-14-325CrossrefMedlineGoogle Scholar18. Shanafelt TD, Raymond M, Kosty M, Satele D, Horn L, Pippen J, Chu Q, Chew H, Clark WB, Hanley AE, et al.. Satisfaction with work-life balance and the career and retirement plans of US oncologists.J Clin Oncol. 2014; 32:1127–1135. doi: 10.1200/JCO.2013.53.4560CrossrefMedlineGoogle Scholar19. Mehta LS, Lewis SJ, Duvernoy CS, Rzeszut AK, Walsh MN, Harrington RA, Poppas A, Linzer M, Binkley PF, Douglas PS; American College of Cardiology Women in Cardiology Leadership Council. Burnout and career satisfaction among U.S. cardiologists.J Am Coll Cardiol. 2019; 73:3345–3348. doi: 10.1016/j.jacc.2019.04.031CrossrefMedlineGoogle Scholar20. Shanafelt TD, West CP, Sinsky C, Trockel M, Tutty M, Satele DV, Carlasare LE, Dyrbye LN. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017.Mayo Clin Proc. 2019; 94:1681–1694. doi: 10.1016/j.mayocp.2018.10.023CrossrefMedlineGoogle Scholar21. Dyrbye LN, West CP, Halasy M, O'Laughlin DJ, Satele D, Shanafelt T. Burnout and satisfaction with work-life integration among PAs relative to other workers.JAAPA. 2020; 33:35–44. doi: 10.1097/01.JAA.0000660156.17502.e6CrossrefMedlineGoogle Scholar22. Dyrbye LN, West CP, Johnson PO, Cipriano PF, Beatty DE, Peterson C, Major-Elechi B, Shanafelt T. Burnout and satisfaction with work-life integration among nurses.J Occup Environ Med. 2019; 61:689–698. doi: 10.1097/JOM.0000000000001637CrossrefMedlineGoogle Scholar23. Stanford Medicine. The Stanford Model of Professional Fulfillment.Accessed March 30, 2021. https://wellmd.stanford.edu/about/model-external.htmlGoogle Scholar24. Shapiro DE, Duquette C, Abbott LM, Babineau T, Pearl A, Haidet P. Beyond burnout: a physician wellness hierarchy designed to prioritize interventions at the systems level.Am J Med. 2019; 132:556–563. doi: 10.1016/j.amjmed.2018.11.028CrossrefMedlineGoogle Scholar25. Benjamin IJ, Valentine CM, Oetgen WJ, Sheehan KA, Brindis RG, Roach WH, Harrington RA, Levine GN, Redberg RF, Broccolo BM, et al.. 2020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics: a consensus conference report.Circulation. 2021; 143:e1035–e1087. doi: 10.1161/CIR.0000000000000963LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails August 17, 2021Vol 144, Issue 7Article InformationMetrics Download: 1,547 The article has been copublished with permission in the Journal of the American College of Cardiology, Circulation, the European Heart Journal, and Global Heart. ©The Author(s) 2021. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits noncommercial reuse, distribution, and reproduction in any medium, provided the original work is properly cited. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. When citing this article, a citation from any of the journals listed is appropriate.https://doi.org/10.1161/CIRCULATIONAHA.121.055748PMID: 34254529 Originally publishedJuly 13, 2021 Keywordspractice efficiencywell-beingprofessional fulfillmentresiliencyburnoutPDF download
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