How Can Clinician Well-Being Be Improved and Sustained in Palliative Care?

Definition and Models of Well-Being

It is impossible to discuss well-being without acknowledging the conditions that lead to widespread clinician burnout, the growing awareness of which over the past decades led to its recognition as a national public health crisis in 2019 in the report “A Crisis in Healthcare: A Call To Action on Physician Burnout,” from the Massachusetts Medical Society and Harvard’s School of Public Health. The advent of the electronic health record (EHR), reimbursement rates that have not kept pace with rising health care expenditures, increasing documentation requirements, and greater patient complexity have led to more diffuse clinical responsibilities with burgeoning clerical tasks. Workplace inefficiencies, work–home conflicts, lack of input or control for clinicians regarding decisions impacting their work lives, loss of social connectedness and feelings of belonging, and insufficiently supportive leadership culture have also contributed to the current epidemic. Even efforts to improve physicians’ well-being have been met with limited success. For example, whereas reductions in house-staff work hours have improved overall work conditions, unintended consequences such as work compression and increased handoffs have emerged.

Burnout is characterized by emotional exhaustion, depersonalization (i.e., cynicism), and low sense of personal accomplishment. Burnout is commonly measured by the Maslach Burnout Inventory (MBI); other common assessment tools include the Mayo Clinic Well-Being Index, the Professional Quality of Life Scale, and the Resilience Scale. Other forms of emotional distress can be measured for a more complete assessment of well-being, including mental illness symptom clusters. It is important to note that the MBI and other assessment tools were not developed to diagnose an individual with a mental health condition, but rather to assess burnout of the collective workplace and thereby encourage employers to promote healthy work environments. Some authors have pointed out that what is being measured as “burnout” is actually a nebulous concept with roots in large-scale societal conditions. This chapter focuses on burnout and well-being as workplace conditions rather than as indicators of individual employees’ emotional health or distress.

The consequences of health care burnout are numerous and potentially grave. They include harms to the individual, including occupational injury, substance misuse, suicide risk, career regret, and suboptimal professional development. Additionally, health care worker burnout can result in harms to the organization and to society through impairments in professionalism, productivity, ethical practice, quality of care, quality of communication, and patient satisfaction. Burnout can also lead to increased patient safety incidents, malpractice claims, turnover, absenteeism, and presenteeism (i.e., showing up to work despite not feeling well).

Well-being, however, should not be defined as the absence of burnout. Clinicians may rightly respond negatively to such a categorization, as to become “burned out” implies an individual shortcoming, rather than capturing the full picture of the problem and its root causes. On the other hand, well-being is a subjective, complex, and far-reaching concept touching on all areas of one’s life—including those outside of work. Therefore many experts aim to narrow the focus of clinician well-being efforts to target factors that one’s workplace can reasonably influence, and place emphasis on minimizing barriers to well-being imposed by the workplace while maintaining sustainability of the workforce. With this lens, “professional fulfillment” has been proposed as a well-being goal for individuals and organizations within the health care workplace, as depicted in the conceptual model adapted by the Icahn School of Medicine at Mount Sinai, from the Stanford and National Academy of Medicine models ( Fig. 80.1 ). One publication addresses physician well-being as follows: “professionally fulfilled physicians—defined as those who experience happiness or meaningfulness, self-worth, self-efficacy, and satisfaction at work—are better equipped not only to practice the art and science of clinical care, but also to lead the effort to identify and implement much-needed improvements to our systems of care.”

Impact of the COVID-19 Pandemic on Well-Being

At the time of this writing, the novel coronavirus pandemic has brought about unprecedented challenges to clinician well-being. Frontline clinicians and trainees have been placed at risk of infection, redeployed to new roles outside their comfort zones, and isolated from loved ones. Palliative care clinicians have witnessed unparalleled suffering and experienced much secondary, and in some cases, primary, trauma. The full impact of COVID-19 on clinician well-being is not yet known, and there is concern about the long-term consequences. When health care workers experience high levels of anxiety alongside ongoing uncertainty and lack of control, they are at risk for developing stress-induced syndromes. Physicians in particular may not access health care, especially mental health care, when needed, for a variety of reasons including lack of time, stigma, and perfectionism.

Institutions have approached COVID-19 well-being frameworks with a combination of rapid needs assessment and deployment of resources—including buddy systems, basic needs support, and expanded mental health programming—and an eye to a prolonged period of disaster recovery, characterized by waxing and waning emotional phases, mental health risks, and substance abuse risks. There is still much to learn about how to prioritize COVID-19–related well-being sequelae and also continue to address the “prepandemic” root causes of widespread burnout. More than ever before, health care institutions and the lay public recognize the need to address clinician well-being.

Evidence-Based Approaches to Clinician Well-Being at the System Level

The system-level challenges to clinician well-being and the resultant negative impacts on patients have been widely recognized, and the need for action promoted as a core element of high-quality health care. The U.S. Centers for Medicare & Medicaid Services (CMS) has highlighted this priority by creating the new Office of Burden Reduction and Health Informatics. A recent report from the National Academy of Medicine calls on the health care system to take action against burnout by striving toward the following six goals: (1) create positive work environments; (2) address burnout in training and at the early career stage; (3) reduce tasks that do not improve patient care; (4) improve usability and relevance of health IT; (5) reduce stigma and improve burnout recovery services; and (6) create a national research agenda on clinician well-being. Table 80.1 describes the rationale for each goal, ways in which the goal may be pursued broadly to impact all clinicians, and specific ways action may be taken by palliative care programs.