By Ami B. Bhatt, MD, FACC
April 12, 2018
Physician burnout continues to be a significant concern for the medical workforce. Importantly, it can also affect patient experience (encompassing both quality and safety of care). Over half of United States physicians report at least one symptom of burnout including a decrease in empathy, decreased self-worth, and emotional exhaustion. Whereas the original research from several years ago suggested that front-line physicians in the primary care and emergency medicine space are at greatest risk, we now know that burnout is seen in many medical specialties. Not only do half of US physicians report being “burned out,” an equal percentage would not recommend a career in medicine to their children.1, 2
Clinical medicine is a field where decision fatigue is considerable and may be an important contributor to burnout. Just one example was an assessment of primary care clinicians’ likelihood of prescribing antibiotics for respiratory infections. The frequency of prescribing increased during clinic sessions, consistent with the hypothesis that decision fatigue progressively impairs clinicians’ ability to resist ordering inappropriate treatments.3
Addressing Decision Fatigue
Physician leaders can address burnout by specifically decreasing decision fatigue, allowing their physicians to be better supported and share responsibility where appropriate. There are several mechanisms many of us have implemented to address decision fatigue among physicians:
- Team-based care decreases fatigue by delegating decision-making to other qualified clinicians including advanced care providers, nurses, social workers and palliative care teams.
- Implementation of algorithms aids the clinician by providing an entire medical team (including administrative staff) with clear guidelines for providing patient care.
However, both these mechanisms still require physician pre-planning and oversight. Physician burnout is often the combined effect of “feeling overworked” while losing autonomy and feeling undervalued. To address both of those concerns simultaneously we can turn to principles of behavioral science.
Behavioral medicine teaches us that defaults can influence decision-making without restricting choice. It is important for physicians in that it preserves autonomy while decreasing decision-making needs. The power of defaults has been harnessed in pharmaceutical ordering (favoring generic medications and improving patient adherence and lowering cost), order entry sets for peri-procedural algorithms to increase patient safety, and even the more recent creation of “dot phrases” in the electronic health record to improve communication and education via patient notes.
A recent study supporting the power of defaults in the opioid crisis revealed that implementing a 10-tablet default prescription in the electronic health record in emergency departments was successful in having physicians prescribe a lower quantity of tablets consistent with prescribing guidelines.4 Well-targeted defaults built into the infrastructure of outpatient medical practice may decrease the repetitive physician burden while promoting patient care.
Physician “burnout” has been a concern for the medical workforce for many years but is now reaching a tipping point. As we work to address wellness, administrative burden, and joy of practice, it is important that each solution address a specific facet of the burnout syndrome. Implementing strategic infrastructure-based solutions to decrease decision fatigue is a mechanism which may lead to clinician wellness while preserving autonomy and increase joy in the practice of medicine.
1. Mayo Clinic 2014.
2. Jackson Healthcare, 2013 Physician Outlook and Practice Trends.
3. Linder JA, Doctor JN, Friedberg MW, Reyes Nieva H, Birks C, Meeker D, Fox CR. Time of Day and the Decision to Prescribe Antibiotics. JAMA Intern Med. 2014;174(12):2029–2031.
4. Delgado, M.K., Shofer, F.S., Patel, M.S. et al. Association between Electronic Medical Record Implementation of Default Opioid Prescription Quantities and Prescribing Behavior in Two Emergency Departments. J Gen Intern Med. 2018 Jan 16. doi: 10.1007/s11606-017-4286-5.
Dr. Ami Bhatt is the director of outpatient cardiology as well as adult congenital heart disease at the Massachusetts General Hospital Heart Center where she leads initiatives to provide state-of-the-art subspecialty cardiac care, runs her own Telemedicine Clinic for Adults with Congenital Heart Disease, and creates platforms for virtual cardiovascular care. Her research centers on using medical and patient-reported data to create prediction algorithms for risk stratification and optimal resource utilization.