Marisha Burden, MD, MBA, professor of medicine and division head of hospital medicine at the University of Colorado School of Medicine, is studying the financial impact of burnout and mental health on hospitalist turnover, as well as the contribution of work structures and environment.
“This is something that touches every single clinician. It impacts every single patient, it impacts the bottom line, and all the organizational outcomes that we all care about,” Burden says. “It’s a big issue, yet we don't know what optimal is.”
A new grant from the National Institute of Occupational Safety and Health will give Burden and her team the opportunity to study work design and work structures that enable clinicians to perform at their best and hopefully stay in the field for the duration of their careers.
In clinical practice, there is evidence to guide practice when it comes to decisions on patient care, but not around optimal work design. There is little to no evidence on how many patients a hospitalist (a clinician who primarily practices in the hospital setting) or outpatient clinician should see.
“My passion is around building optimal work design to help clinicians thrive, patients get the best care, and organizations to also have the best outcomes. We must start making evidence-based decisions and look at things in a more holistic way,” says Burden, an investigator with the Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS).
Clinicians face numerous daily challenges that stem from high workloads, high cognitive load, and distractions and this can compromise patient care. This mismatch in job demands and resources can also lead to clinician burnout and moral injury.
“One of the paradoxes in this work is that there appear to be thresholds at which work quality or job performance starts to decline, as there is a finite capacity for a clinician to make high risk decisions, manage the many demands, while also working to ensure the highest quality of care,” Burden says. “Some previous research, which is now more than a decade old, showed that when hospitalists care for more than 15 patients that there was an exponential increase in length of stay and costs increased as well. We need more research as job demands have only increased and patients have increasingly more complex medical conditions.”
Burden and her team will use multi-site surveys, electronic health record meta data, and human resources data to determine the prevalence of burnout and mental health challenges in the hospitalist field and how it relates to turnover.
Burden and her team completed thirteen focus groups in October with more than 30 hospitalists from across the country to discuss the drivers of burnout and poor mental health in the field.
The study will examine the cost of turnover, specifically related to burnout and poor mental health. The researchers have started prework on this to consider the categories of cost to be thoughtful in their analysis.
“We hope to look at the question both from an indirect and direct cost perspective, so that when organizational leaders are thinking about, ‘does turnover really cost that much?’ There will be a more definitive dollar amount that highlights the consequences,” Burden says.
Financial threats can create uncertainty for an institution’s financial viability. This can cause organizational leaders to make decisions to function on short staffs and asking people to do more, which may have negative outcomes.
“We need to rethink our approach to managing workloads and work design. Rather than pushing clinicians beyond their limits, we should focus on sustainable strategies that benefit both the well-being of the workforce and the organization’s short- and long-term success,” Burden says.
Clinicians face near-constant stressors including the pandemic, long hours, and challenging workloads. Recent studies say that a large proportion of clinicians face burnout with many facing moral injury and nearly one-third of clinicians contemplating leaving their jobs.
“Taking care of patients is very fulfilling work, however, there can be a mismatch in work demands and resources allocated, along with a lack of predictability in the clinical workday which makes providing optimal care challenging. Patients have very complex medical problems that require significant cognitive effort from clinicians. The work environment is also filled with frequent interruptions and a great deal of uncertainty. Sometimes patients unexpectedly become sicker and require urgent evaluations. This unpredictability, combined with high workloads, impacts the long-term sustainability of the profession,” Burden says.
As the job market grows more competitive, health care workers will look for environments that allow them to do their best work and offer a fulfilling and supportive work environment for their employees. Organizations who don’t check these boxes may struggle to find the needed workforce. Burden and her team aim to make an important profession more sustainable.
“This is a very large project with 10 study sites, and it is very exciting,” Burden says. “The project has a great group of people behind it, we have very talented scientists, clinicians, and thought leaders involved.”
ACCORDS Core Directors, Liza Creel, PhD, associate professor in the division of health care policy research and director of the Economic Analysis Core and Kathryn Colborn, PhD, MSPH, associate professor in the division of health care policy research and director of the Biostatistics and Analytics Core will help support the grant.
Also working with Burden on the study is Angela Keniston, PhD, MSPH, assistant professor of medicine and the director of data analytics in the division of hospital medicine; Lotte Dyrbye, MD, MHPE, senior associate dean for faculty and chief well-being officer; Natalie Schwatka, PhD, MS, assistant professor in the Colorado School of Public Health; and Lauren McBeth, BA, data analytics program manager, and Evangeline Grobbel, MPH, business services entry professional in the division of hospital medicine.
“This project aims to build the evidence base around optimal work design, so that when organizations face financial concerns and constraints, they can make evidence-informed decisions and understand the true costs of decisions around work design. I hope this study will guide decision making not only in the short term, but also help organizational decision-makers to understand the longer-term impact of decisions,” Burden says.