Keywords

Understanding and Cultivating Pediatrician Well-Being

In this chapter, we focus on two related concepts: stress—particularly chronic stress—and workload. We offer definitions and background on these terms and explore problems and potential solutions associated with these complex phenomena. You will find parallels in the understanding between stress and workload, and “fixes” for one will sometimes augment or support a “fix” for the other.

What Is Stress? (An Evolving Understanding)

The oft-used term “stress” can simply be defined as “a constraining force or influence” [1], but there is currently no universally accepted definition and significant ambiguity remains around this term [2]. Stress is a complex concept which is attributed to varied phenomena. It may be classified according to the nature of the stressor (physiological vs. psychological), its influence on the individual (positive eustress vs. negative distress) [3, 4], and even the exposure time of the stressor (acute vs. chronic) [2].

The term “stress,” as we commonly use it in the medical realm, was originally offered in 1937 by Dr. Hans Selye. A Hungarian physician and organic chemist, he studied the biologic responses of the body to the many demands made upon it. This is now commonly referred to as “stress physiology.” Selye defined stress as “the body’s nonspecific response to any demand for change” [5]. He focused on the gap between demand and capacity, primarily studying responses in the endocrine system. He elegantly described extensive hormonal pathways that are activated when demands are placed on the body.

Over time, our understanding of the stress response has evolved. The work of Harvard physiologist Walter B. Cannon introduced us to the concept of the “fight or flight response”—a scenario of inner events triggering a cascade of changes in the autonomic nervous system [6, 7]. We know now that these two mechanisms, hormonal and neurologic, occur simultaneously, as the body and mind seek to close the gap between capacity and demand.

As we have broadened our understanding of stress, we are recognizing the importance of cognitive processes in regulating our physiologic responses. We are also discovering the role of the immune system in the stress response. To understand “stress” thus requires an exploration of the mind–body connection. This intersection between psychological processes, our nervous system, hormones, and the immune system has fostered a new field of inquiry in medicine known as “psychoneuroimmunology” [8]. The understanding of this mind–body connection gives rise to an expanded definition of “stress”: “A condition, both psychological and physiological, experienced when an individual perceives that demands exceed the personal and social resources the individual is able to mobilize” [6]. This additionally explains how “stress” has entered our vernacular as a verb. To wit, when one says, “I’m stressed” or “I’m stressing,” they capture the experience of mind and body of a state in which capacity and demand feel unmatched.

Stress: Why Does It Matter?

Eustress

Stress in its positive form, “eustress” [5], can improve our health and facilitate performance. Positive stress plays an important role in motivation, adaptation, and responding to our environment. This is the type of stress we perceive when we are excited, but without any real threat or fear present. Imagine anticipating a first date, competing in a race, or vying for a promotion at work. This subspecies of stress was described by Seyle as the “spice of life”; feeling alive and excited about living.

Acute stress, when moderate, may also be beneficial. This occurs when we face something unexpected that requires an immediate response. Recall the experience of narrowly avoiding a minor car accident. Our stress response allows us to react when such a potentially threatening thing happens, helping us to stay safe and to learn from the experience. We deal with the stressor, then quickly move on. Other positive outcomes of moderate acute stress include increased confidence, less fear of change, and seeing future stress as an opportunity for growth. Short-lived stress can even improve our alertness and boost our memory [9]. Experiencing some manageable stressors, with recovery in between, can make us more robust, resilient, and less reactive to future stress [10].

Negative Stress

While positive stress can enhance performance and life, negative stress can injure our health and well-being. Negative stress may feel unpleasant and is often perceived to be outside of our coping abilities. When negative stress is excessively high or sustained for prolonged periods of time, it can profoundly impair our health and quality of life [11].

Pediatricians know firsthand that children who are under chronic stress and do not have adequate coping resources are at increased risk for health problems, both in childhood and adulthood [12]. Many of our patients suffer significant adversity or marginalization via poverty, racism, neglect, abuse, or neighborhood violence. Others suffer the effects of substance abuse or mental illness of their parents or guardians. The results of these types of severe chronic stress can be toxic to our patients’ developing brains and biologic systems. This chronic, cumulative toll disrupts developing nervous, cardiovascular, immune, and metabolic systems. These disruptions, in turn, can lead to lifelong impairments in learning, behavior, and physical and mental health [12]. Moreover, such stress can accumulate in marginalized communities, generation after generation [13]!

The science of chronic/toxic stress has thus become an essential tool to help pediatricians understand that they can make a critical difference in adult health outcomes. As the future of our society, in part, depends on the healthy development of the next generations, the stakes are high that we get this right—to best support health, across the lifespan and beyond.

At the same time, this emerging understanding of chronic stress applies to pediatricians and other healthcare workers. Many of us are those previously vulnerable children. Others of us suffer from more moderate but persistent stress that, nonetheless, may profoundly impair our health and well-being, punctuated with more severe stressors arising from work, personal life, or societal events. Applying what we know to be true for our patients’ health is paramount to ensuring our own healthy lives.

Stress and Our Health: The Mind–Body Connection

The field of mind–body medicine has become important in the treatment of a vast number of disease states as well as in the understanding of our overall well-being [14]. Now referred to as “psychoneuroimmunology” (PNI), this field of research studies the complex interactions between the central and peripheral nervous systems, the endocrine system, the immune system [15], and psychological processes. PNI focuses on how stress, and in particular chronic stress, can modify these interactions.

The demands of our careers and lives can be challenging, often unremitting, and require enormous effort to be sustained. Beyond the difficulties of living in a fast-paced society, physicians bear additional burdens and duties—heavy patient responsibilities, excessive workloads, giving bad news, negative clinical outcomes, and working with difficult patients, to name a few. Beyond direct clinical care exist omnipresent tasks, documentation requirements, and insufficient autonomy in many practice environments. Additional stressors include medical school debt, sleep deprivation, and often even self-imposed stress from committed and conscientious personalities.

Moreover, beyond these commonly reported general stressors in medicine, pediatricians who belong to marginalized or under-represented minority groups may suffer from a deeper, often insidious process, resulting in what is known as “minority stress” [16]. Minority stress is felt to be distinct and refers to the additional stress that members of marginalized groups experience because of the prejudice and discrimination they face (due to race, ethnicity, gender identity, disability, etc.). Minority stress is chronic because it remains through someone’s life due to underlying social processes, institutions, and structures. The shame of such marginalization often goes unnoticed or ignored, amplifying feelings of isolation and invisibility.

The experience of minority stress is damaging to mental and physical health [17]; being on the receiving end of overt mistreatment, and the structural bias in our systems, affects mental health and increases the risk of adverse health outcomes [17]. Because of these additional burdens, understanding the unique workplace experiences of minority pediatricians and mitigating such stressors is critical [18] (see Case Study 6.1).

Case Study 6.1 Minority Stress

Dr. Kay is a black woman and one of the five minority physicians in her pediatric residency program. In addition to the typical rigors and stress of training, she describes nearly daily situations that leave her feeling isolated and depressed.

She is frequently mistaken for non-medical staff (despite the white coat and stethoscope), and her name is often interchanged with the other black residents (as though they were all the same person). These daily sleights leave her feeling invisible, insignificant, and ashamed. She regularly considers leaving the program but does not tell anyone.

On top of it all, she performs the role of race ambassador for her program, appointed to the equity committee and asked to develop diversity curricula for her institution. All these place extra workplace burdens on her, at a time in training when she wants and needs to focus on her primary goal of learning to take care of sick children and their families.

Pediatric residency is a demanding time for all trainees, both emotionally and physically. Residents who identify with groups under represented in medicine often bear additional burdens. Better understanding the unique experiences of such pediatricians is necessary to successfully create a diverse, inclusive, and healthy workforce [18].

The Effects of Cumulative Stress

Our careers and lives can be intense. The demands of a fast-paced society, the sequelae of our own adverse childhood events, the chronic microaggressions of systemic bias, and the heavy responsibilities of the conscientious pediatrician are always at play. This unremitting intensity requires enormous effort to keep functioning at a high level. One of the ways we react to such physical and mental strain is by activating interconnected neuroendocrine pathways. This response allows us to confront and deal with the challenges and, ideally, re-establish equilibrium and continue on [11].

An early pioneer in the field was physiologist Walter B. Cannon. He was interested in our reaction to stress and outlined a scenario of inner events which he coined the “Fight or Flight Reaction” [7]. He described cortical centers in the brain that upon perceiving a disturbing stimulus, then activated peripheral networks in the visceral autonomic nervous system.

Recall that the autonomic nervous system (ANS) is part of the peripheral nervous system that is responsible for many critical physiologic functions, most of which are beyond our conscious control: heart rate, constriction/dilation of blood vessels, pupillary response, hormone secretion, and digestion, to name a few. The ANS has two subdivisions: the sympathetic and parasympathetic. The sympathetic branch will respond to whatever alarm is relayed to it to help mobilize the body for action; the “Fight or Flight” response. Conversely, the parasympathetic branch is organized to digest, assimilate, and conserve energy, as well as to promote rest; the “Rest and Digest” response. These reactions are also referred to as the “Stress” and “Relaxation” responses, respectively [19]. Both branches of the ANS are always working together, synergistically, to bring homeostasis to the body’s vital functions.

The Stress Response: Physiology

Consider what happens in the ANS when we confront an acute stressor. Imagine we are crossing the street and we realize that we are about to be hit by a truck! Cortical centers in the brain sense this disturbing stimulus and activate the ANS. The sympathetic branch responds nearly immediately. Heart rate increases and blood vessels constrict. Blood gets shunted to skeletal muscle, literally preparing to run away. The liver releases its stored glucose to provide energy. Our pupils dilate, taking in as much light as possible to see the danger, and we start to sweat. Functions not required for our immediate survival are placed on hold,(digestion, absorption of nutrients, elimination, and sexual functions).

The sympathetic signal goes to the adrenal glands, where the medulla secretes the stress hormones epinephrine and norepinephrine. Each of these then acts as a chemical messenger with far reaching effects, priming the body for action. Sympathetic action also triggers the renin–angiotensin–aldosterone system (RAAS). This is crucial in regulating blood volume and systemic vascular resistance, which together influence cardiac output and arterial pressure.

There is a parallel and simultaneous hormonal response in the hypothalamic–pituitary–adrenal axis (HPA). While part of the stress response travels through the nervous system, there is also biochemical messaging, involving a cascade reaction of hormones, each one setting off the release of the next. Selye traced out an intricate path of hormones during stress. Recall that as cortical centers perceive a demand, a signal is sent to the HPA axis. The hypothalamus secretes a neurohormone, corticotropin-releasing factor (CRF), which activates the pituitary gland. The pituitary, in turn, releases adrenocorticotropic hormone (ACTH). ACTH is a hormone trigger. It travels to the adrenals via the bloodstream, where it then stimulates the outer adrenal layer (cortex), to release the glucocorticoids (GCs).

Most organs and tissues, including immune cells, express glucocorticoid receptors and are responsive stress-induced GC release. GCs, in particular cortisol, raise blood sugar and modulate the body’s immunologic defenses. Cortisol affects carbohydrate, fat, and protein metabolism and has anti-inflammatory, immunosuppressive, and vasoconstrictive effects throughout the body [15].

The immune system is deeply entwined in these processes. Receptors for stress neuropeptides and hormones are broadly expressed in immune cells. High or persistent levels of cortisol have immunosuppressive effects, partially mediated by direct action on lymphocytes. Cortisol does so in a variety of ways, by inhibiting IL-2 (T-cell growth factor), inducing T-cell apoptosis, and impairing the release of these important immune cells from the lymphoid tissue [15, 20, 21].

The stress reaction is also known to induce the acute phase response commonly associated with infections and tissue damage. It increases levels of circulating cytokines and other biomarkers of inflammation [22]. This “fight or flight” reaction thus sets into motion a neuroimmune circuit that stimulates the immune system to mount a protective response intended to prevent harm, repair damage, and restore homeostasis. This is the stress response—a vital, adaptive, life-saving response to a threat.

Chronic Stress

And yet … most of our threats are not a truck. Rather, the threats often take the familiar form of excessive and unremitting professional demands—unrealistic performance expectations, complex patients, conflicts with coworkers, inadequate training, or documentation pressures. The list is long. Predictably though, the stress response, physiologically, remains the same. Our bodies do not particularly distinguish one stressor from another in their response.

As the inflammatory response induced by our neuroimmune pathways persists, we begin to see the precursors to disease, particularly when the response becomes chronic. Vasoconstriction, sodium retention, insulin resistance, inflammation, and immune dysregulation ensue. These, in turn, presage certain disease states, whose development has been linked to chronic stress and inflammation: cardiovascular disease, diabetes, cancer, autoimmune syndromes, and neurodegenerative disease [11, 23]. Moreover, proinflammatory cytokines induced by stress are also involved in the development of depression and anxiety [24]. In this way, the manner in which we handle stress influences the way the body handles precursors to illness.

As we repeatedly perceive demands as exceeding our coping abilities it can profoundly affect our health and quality of life. When noxious stimuli are perceived as too intense or their duration too long, the stress response does not resolve into a state of homeostasis. Rather, neuroendocrine parameters remain altered, and in this way, chronic stress becomes a driver of chronic disease. The stress response, designed to protect, repair, and restore, becomes injurious to our physical health, mental health, and overall well-being.

The Relaxation Response: An Antidote to Stress

The sympathetic branch of the nervous system is akin to the gas pedal of the stress response, priming the body for action. The parasympathetic branch, however, serves as the brake, undoing the work of the sympathetic division, following a stressful situation.

Harvard cardiologist, Dr. Herbert Benson, pioneered research focusing on this parasympathetic response which he called “The Relaxation Response” [19]. He described this as a near opposite of the fight or flight response and demonstrated an integrated hypothalamic response which resulted in a generalized decrease of sympathetic tone and increase of parasympathetic activity.

Preganglionic neurons of the parasympathetic system arise from the brainstem and exit the CNS through the cranial nerves. Seventy-five percent of all parasympathetic fibers reside in cranial nerve X, the vagus nerve [25]. The vagus, the longest cranial nerve, wanders down the thorax and abdomen, innervating all the major organs of the body. Vagal stimulation releases acetylcholine (Ach), the principal neurotransmitter of the parasympathetic nervous system. Nerve fibers that release Ach are referred to as cholinergic fibers and elicit a predictable physiologic response: decreased heart rate, vasodilation, augmentation of peristalsis, and modulation of inflammation via cytokine inhibition [26, 27].

Beyond simply describing the physiology of the parasympathetic nervous system, Benson studied the conditions by which parasympathetic tone could be consciously activated. In doing so he effectively demonstrated an antidote to stress. He showed that we could consciously stimulate vagal tone and thus the release of Ach, by learning to practice various methods of deep relaxation [19].

There are a variety of techniques and practices known to active the parasympathetic nervous system, in which Ach becomes like a tranquilizer that can be self-administered. These include mindfulness and other forms of meditation, slow deep breathing, progressive muscle relaxation, guided imagery, biofeedback, yoga, prayer, laughter, experiences in nature, and the cultivation of positive emotions, such as gratitude and compassion [28]. While this list is by no means exhaustive, we begin to see how a variety of simple methods can support our health [14, 28, 29]. To quote Dr. Benson, “Mind-body science has now reached a stage where it should be accepted as the third major treatment/prevention option, standing as equal with drugs and surgery in the clinical medical pantheon” [30].

Intentionally cultivating a state of deep relaxation on a regular basis allows for relaxation to become a habituated response to the stressors of daily living, ultimately promoting health, resilience, and well-being [14, 19]. Such is the power of mind–body medicine, both for our patients and for ourselves.

Understanding Workload

Like stress, workload can be defined in several ways. Typically, the “amount” of work is defined and measured either as work output or based on its impact on the worker [31]. Work output seems straightforward and often involves counts: for a physician this could include metrics such as numbers of appointments, procedures completed, or papers published. Impact on worker metrics can include physiologic measures such as heart rate or heart rate variability, eye movement tracking [32], or survey tools. The most commonly used measure in this latter category is the NASA Task Load Index, the domains of which are summarized in Table 6.1 [33].

Table 6.1 NASA task load index domains
Full size table

Physician Work Demands Elaborated

These domains likely resonate with most readers and dovetail with the concepst of stress, both acute and chronic, described above. For instance, most physicians and other healthcare workers have an inherent sense of how different the workload is when comparing simple versus complex patient visits, low versus high acuity situations, or clear versus uncertain diagnoses. The mental demands of these situations vary considerably. Additionally, clinical scenarios involving bad news, unanticipated negative outcomes, disclosures of error, normal distress, and a spate of other emotionally laden content (for physician and patient) create higher mental demand than more “routine” interactions. Given the need for physicians to engage in the dual cognitive and emotional work of empathy and compassion, many elements of physician work will cross into multiple task load domains [34, 35]. The workload of complex encounters with high emotion or uncertainty are partially captured in the mental demand domain but also in the frustration, effort, and performance domains. These demands are certainly not measured in visit count metrics, relative value units, and other measures that attempt to quantify work done. In fact, when “counts” metrics like visit volumes are prioritized, the temporal demand on complex visits can be heightened. There are individual mental demands that can occur as a result of the relationship between individual characteristics or history and the system or society in which we work. As a specific example, the concept of stereotype threat captures the mental-emotional load of being judged based on negative stereotype about a marginalized group [36, 37].

Physical demands

run the gamut from working in hot conditions wearing personal protective equipment, sleep deprivation associated with night-time or prolonged shifts to prolonged standing and poor ergonomic conditions. Prolonged sitting, even, exerts stress and is a known risk factor for cardiovascular disease [38]. Additionally, unnecessary movement, considered a form of “waste” in efficiency optimization, adds to physical work. Examples include walking long distances to retrieve medical supplies or fine motor examples, such as the need to excessively move a mouse to accomplish a task in the electronic health record (EHR).

Temporal demands

are intrinsically experienced when there is a schedule to adhere to, especially when the schedule does not accommodate all of the work to be done. For instance, it has been estimated that it would take 7.4 h/working day to provide preventive services alone to a panel of 2500 family medicine patients [39]. Adding in acute and chronic patient care increases this time to 21.7 h/day [40]. Feasible or sustainable? Clearly not. The impact of temporal workload demands can be measured by failure to adhere to a schedule (i.e., frequency and amplitude of “running late”) or the amount of work that remains incomplete at the end of a reasonable period of time (i.e., a workday or charts closed by a particular benchmark). An escalating backlog of incomplete work indicates that the workload is too high for the individual or team to complete within the allotted time. Temporal demands also occur when there is conflict between types of work—for instance, clinical work with academic work or committee membership, the so-called work–work conflict. The experience of an escalating amount of work to do in multiple domains can be experienced as frustration or a feeling of being stressed [41]. The workload an individual experiences, however, is not confined to work: parenting or caregiving roles and responsibilities that occur largely “outside of work” add to individual workload. These tend to be distributed unevenly by gender, with women performing a preponderance of these duties in most heterosexual couples [42]. This excess workload is one reason why women physicians reduce professional effort [43]. The concept of stereotype threat, introduced above, relates to the individual internal experience of stereotype. However, “the minority tax” is an evocative term developed to describe the additional responsibilities placed on physicians in under-represented groups that accrues as a result of efforts to increase diversity [44]. Therefore, physicians from under-represented or marginalized groups may carry greater “tangible” workload, and its associated temporal demand, while also managing greater mental workload, creating a cumulative work burden.

Effort

is dynamic and involves individual and team characteristics including skill, team function, and even time of day. For instance, a task that might be relatively simple early in a work shift may be quite difficult later in the shift, based upon depletion of energy. This is illustrated by studies of primary care physicians. Opioid prescribing is more likely to occur at the end of a clinic day, while vaccine administration and other preventive care measures are less likely to be provided [45,46,47]. These studies suggest that fatigue and depletion of cognitive resources modify effort and performance. In a study of pediatric hospitalists, mental demands, effort, and frustration were all significantly higher in the afternoon compared to morning [48]. Effort, too, can vary with training and competence. For example, a task that is simple and routine for a seasoned pediatric infectious disease physician would be expected to take substantially more effort for a pediatric infectious disease fellow. Building skills in communication, empathy, and compassion can lower distress and improve performance [49,50,51,52,53]. A helpful model to understand workload is the demands–resources model [54]. In this model, higher levels of competence would be understood as a personal resource that reduces the impact of the work on the worker by lowering effort. Higher levels of skill in compassion is not only valuable within the physician-patient encounter for the patient, but has an important impact on the physician. Compassion enhances vagal tone and reduces the experience of distress in what may be a weighty situation [55, 56].

Physician Workload and Its Impact

Many people have wondered whether other highly trained professionals experience levels of burnout as high as physicians. In a 2019 study published by Shanafelt et al. 3971 physicians were compared to 285 lawyers and PhDs. The physicians in the sample reported working more hours, and that each additional hour conferred additional risk of burnout. However, after controlling for number of hours worked, there was still an excess risk simply associated with being a physician [57]. This excess burnout experienced by physicians points to there being something about physician work and the way in which it is accomplished—the system of work—that differs from other highly educated professionals. In the development of the Physician Task Load Index, a dose–response relationship was found between escalating task load and burnout [56].

Work Out of Balance

Physician workload is routinely too high to be accomplished during the allotted workday. Primary tasks include direct patient care, reading and “deep thinking” to resolve uncertainty and develop solutions, and often unpredictable work to assist emergently ill or distressed patients. Often, however, the available time is largely consumed by documentation, responding to non-urgent patient messages in an electronic portal, coordinating care with colleagues and other care-team members, and managing communication of test results [58]. When schedule design takes into account only direct patient care and not the entirety of the work, it either increases time pressure during the clinical day or moves work into the personal life of the physician. A solution enacted by many dedicated physicians is to continue working beyond their designated work hours in the electronic health record—the so-called pajama time. All forms of work spillage create work–home conflict and deplete time for relaxation and restoration. Modifications in reimbursement to reflect total time spent caring for a patient, rather than only face-to-face time, have the potential to improve this situation. Work out of balance not only has the capacity to cause stress and burnout. As studied in pediatric nurses it also reduces job performance and increases errors [59, 60].

Job Control and Workload

Interestingly, job control can be a moderating factor in the relationship between workload and burnout [61]. Combining a workday in which physicians feel reduced control over work and experience the encroachment of work into their personal time could certainly create a sense of being controlled by work rather than “in control” of work. Distractions and interruptions, another common feature in physicians’ work days, reduce sense of control, quality of care and increase frustration and cognitive burden [48, 62, 63]. Moreover, constantly feeling out of control and behind, especially when our performance is tied to the health and well-being of our patients can engender significant anxiety.

Earlier in this chapter we emphasized the importance of mitigating stress. It seems no wonder that under circumstances in which physicians routinely lack time for rest, exercise, and other ways of promoting resilience and reducing stress that burnout accrues. Not only does excess workload itself contribute to poor patient care but it is known that burnout does as well [64,65,66,67,68,69]. When physicians feel their only recourse is to reduce their clinical effort, leave a practice or retire early—patients, organizations, and society lose [70, 71]. This makes a powerful case that “right-sizing” workload from a holistic perspective, and enabling flexibility pertaining to phase of life and other factors, will help create an engaged, sustainable professional workforce [72].

Work Resources, and Solutions

As was implied above, a demand may not be experienced equally by individuals, across time of day, or in different work systems. This highlights the crucial counter-balancing effect of work resources—the demands–resources model in action [54]. This may also bring to mind Selye’s conception presented earlier in this chapter of stress as a balance between demand and capacity. Examples of systems-based resources include inclusion and training of other team members in a care team, such as a dedicated medical assistant, nurse, advanced practice provider, or even a scribe. The number and type of disciplines included in a care team depend upon the specific tasks that are needed to support the work of the physician and their patient. Scribes, for instance, specifically alleviate a substantial portion of documentation burden from physicians and in some cases complete order entry. In advanced team-based care systems, physicians work as part of a team with—depending upon specialty—an advanced practice provider, nurse, medical assistant, licensed athletic trainer, or other clinical discipline. In these models, a team member may serve as a scribe, they may guide a patient through a visit, or even initiate their evaluation. In primary care settings they may also assess preventive health needs and administer vaccines. Team members may also potentially engage in other clinically facilitative work such as patient education or motivational interviewing. These models create time and space for physicians to focus on the face-to-face care, including diagnostic interviewing, treatment decisions, and counseling. They also may create additional benefits when the team is highly functioning—a team of mutual support surrounding the care of patients, in which physicians and their documentation are not the sole repositories of memory for a patient’s care plan [73]. Other team members can then assist in addressing patient concerns more fully and better engage in continuity of care. This latter element can reduce downstream added work and work interruptions for physicians. Additionally, a fully engaged team increases sense of belonging and support, important bolstering resources for physician and team members alike [74] (see Case Study 6.2).

Individuals and their life circumstances differ and are dynamic over their career course. Consider a physician with a young child and a sick parent. They may already have a level of chronic stress that makes a previously bearable situation simply untenable. At these times, resources aimed at childcare, eldercare, robust compassionate leave policies, flexibility in scheduling total number of hours worked per week, or stress management training may be critically important to retaining this physician and allowing them to thrive during this phase (see Case Study 6.3).

Case Study 6.3 Work and Personal Demands

“At the start of COVID I was drowning—3 young children (including a toddler) suddenly at home full time and loss of our usual backup childcare option (high-risk-for-COVID grandparents), my husband working 80+ h/week given his role in the ventilator supply chain and high demands in my role …. Combine this with general stress around the uncertainty and underlying anxiety, and it was a disaster!” This quote, from an academic general pediatrician highlights overlap of work, personal life, external factors, and roles that can contribute to total workload, and stress. Solutions in this situation included personal strategies (prioritizing, focusing on the most important matters, stress management, support) as well as strategies at work (supportive leadership, temporary reduction in duties). This chapter was written during the COVID-19 Pandemic, which has underscored the interconnectedness of the healthcare system with the world outside the walls of healthcare organizations. This physician also highlighted how challenging it can be to ask for what is needed. Cultivating a culture that reduces the difficulty of discussing workload and stress can lead to proactive solutions that help keep physicians and other team members engaged and productive.

An example of a system designed to address problems of both work–home and work–work interference, reducing temporal demands for academic faculty, is a novel “time-banking” system [75]. In this system, faculty experienced integrated planning focusing on career and life outside of work, coaching to create a customized plan and a time-banking system. In this system, work that was largely uncompensated (such as mentoring or committee service) or inherently valuable (such as filling clinical service for a colleague at late notice) earned credits in the time-bank. These credits could be used for support services at home or work. Among clinical faculty, the majority utilized their credits toward home support (83% of female faculty members’ credits and 84% of male faculty members’ credits).

The Electronic Health Record: A Complex Case of Demands and Resources

When one considers demands and resources, almost no construct carries the weight of the electronic health record (EHR)—indeed, the EHR offers both. For instance, well-functioning decision-support, ability to foster collaboration, and making needed information easy to find are important resources. However, as outlined previously, physicians spend excessive time documenting and completing unscheduled work within the EHR. Additionally, when a new electronic health record (EHR) is implemented or significant changes in an EHR occur, workloads increase—at least temporarily. When a new skill is needed, the cognitive demands entailed in completing a task—even a familiar one—increase. In “Why doctors hate their computers,” Dr. Atul Gawande describes how the implementation of a new electronic health record at his hospital system increased workload for physicians. He also describes how the $1.6 billion price tag of implementing the new EHR at Partners Healthcare encompassed less than $100 million for software, the rest of the cost was related to lost revenue and paying for tech support as the organization slowed down operations due to the learning curve of the new software. He also interviewed physicians who detailed examples of how previously simple tasks (such as ordering a pap smear) required multiple additional steps after implementation, in part because physicians were not central to the design of each individual workflow. Beyond the increases in complexity in individual tasks, the advent of computerized order entry systems has been shown to increase interruptions and task-switching during work [76]. An EHR comes with unquestionable benefits but has become emblematic of what is wrong with physician workload. This points to some of the fundamental “pain points” physicians experience that add to the chronic stress related to their significant workloads.

Physicians have limited power in most settings to design systems that work for them, and their workday is interrupted repeatedly by tasks that do not specifically advance the care of their patients. Physicians who spend a higher amount of time on administrative duties experience more burnout and less career satisfaction [77]. Physicians in general spend their worklives in a complex information ecosystem. Face-to-face communication with patients and team members can be eroded by time interacting with the electronic health record, email, and other communication methods used by individual physicians (text, or social media, for instance) or organizations (internal messaging systems). The need to attend to all of these streams of information, many of which include demands, increases workload. Within the electronic health record itself, addressing cognitive workload specifically is an important active area of inquiry to reduce effort and increase performance [78]. Since meaning and sense of purpose fuel physicians and other healthcare providers designing work systems to prioritize meaningful work and reduce work that does not directly contribute to the mission of providing their patients with excellent care reduces unhappiness and burnout. A simple, but elegant example of this is the use of RFID swipe cards to log into workstations. This helped one practice save 56 h/year/physician (see [79].

Case Study 6.2 Documentation Support

An academic pediatrician wrote “I was always behind. I was always days or weeks behind in closing my charts. They just mounted, and the further I got from the appointment date, the harder they were to complete. Not only because I couldn’t remember all the details, but I just felt awful. I felt sick to my stomach thinking about them. I even felt a little bit like a bad doctor …. I spent as much time as I could with my patients and their families, coordinating care for them, counseling them. I gave great care. But if the measure of a doctor is closing charts, I was falling short. I figured I’d have to take a vacation just to close charts. And when I thought about that, I literally wept. I was so exhausted. However, I got help … when I got a scribe, things changed so much for the better. My notes are at least written by the end of the day and almost all of them are closed by the time I go home. I no longer feel like I am drowning. The documentation still needs to get done, but my relationship with it has completely changed.” (See Acknowledgement).

This story captures a common experience among physicians who experience the addition of a scribe—whether in-the-room or through a virtual scribing service. Reducing administrative burden so that the physician can focus on the patient can exert a highly well-being enhancing effect.

On Efficiency

When one considers examples such as the RFID card to log on to workstations, one could wonder how 56 h/year—the equivalent of about one full work-week under current work expectations for full-time physicians—might be spent. It is easy for workplaces to view this enhanced efficiency as time in which another patient appointment could be added, for instance. However, in a survey of 15,181 US physicians carried out by Medscape in 2020, 49% of all physicians responded that they would reduce their compensation significantly if it would provide them with more personal time and improved work–life balance [80]. This highlights that understanding the goals and values of individual physicians may allow organizations to achieve matching between their long-term needs (competent, compassionate, thriving physicians to care for patients) and needs that may vary over time for a physician. Allowing them to make choices about their workload in terms of full-time equivalency, patient panel size, and work density—with reasonable trade-offs for compensation—can provide them with a sense of control as well as sending the meaningful message that their practice or healthcare organization values them, inclusive of their full life.

It is important to keep in mind that interventions to address workload have focused on both work “bulk” and the manageability of the work [78, 81,82,83,84]. Interventions to address the bulk of work [83, 84] include shorter periods of duty (shift or rotation length). However, examples given earlier in this chapter include interventions to specifically make work more manageable within the work period [73, 78, 79]. Interventions such as these might be expected to reduce the need to continue to shorten duty periods. Evidence is mounting, as well, that the well-being of the entire healthcare team is of critical importance. In a study examining VA-based primary care clinics, any turnover within a clinical team increased burnout in the subsequent 6 months, even when controlling for panel morbidity and size [85]. This makes holistic evaluation of workflows and team function critical.

Interventions that do not directly alter workload in the system may modify an individual’s experience or management of the workload. For instance, a professional coaching intervention, including specific coaching sessions on managing workload as well as work–life balance and pursuing hobbies and interests, significantly reduced emotional exhaustion and total burnout in physicians who received the intervention. Interestingly, other metrics of work engagement and job satisfaction did not improve [86]. This discrepancy may show that while individual management and experience of an overall unchanged system can change, that meaningful system change may be a pre-requisite for improving job satisfaction and engagement. The authors emphasized that while coaching can help, it should supplement organizational initiatives to improve work systems and workload. Another example of an intervention that improves burnout is a facilitated discussion model (1 h of paid time every other week) that connected groups of physicians with facilitators to explore topics including well-being and distress, patient relationship and communication, as well as work–home interference and balancing personal and professional life. In a randomized trial of this intervention, burnout was reduced, sustained at 1 year, in the intervention group while it increased in the control group. This study also found that metrics of work engagement and meaning in work rose in the intervention group [87]. This trial emphasizes how buoying and critical meaning, connection, and organizational sanction—with paid time—of these critical constructs are to physician well-being. In the demands–resources model of workload, these fall squarely into the resources column. Both of these trials provide evidence that augmenting resources while leaving demands unchanged can improve well-being.

A physician, leader, or organization may ask … “whose job is this?” “Who owns the work of finding solutions to physician stress and workload?” Systems design, practice standards, practice resource, electronic health record usability optimization are owned, largely, by the practice or organization. It is critical that leaders and organizations develop a well-being assessment that becomes part of every initiative they undertake, whether intended to improve well-being, or not. As new elements of workload appear, how will they be supported with resources? Can another element of workload stop or be shared with another care team member? However, individuals also hold some of the keys to improving their own well-being. Learning to set appropriate boundaries with work, examining and improving their own health and well-being behaviors, availing themselves of opportunities to improve efficiency and competence within their system of practice, for example, are all within individual control and can markedly improve well-being.

Critical Steps in Systems Design to Optimize Physician Work for Well-Being

The National Academy of Medicine’s report “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-being” outlines specific guidelines for designing systems that enhance well-being [31]. The report advocates for a systems approach that incorporates organizational values, engaged and committed leadership, and assessing care team well-being as a primary outcome. Specific recommendations for work system redesign include attending to the following domains: enhancing meaning in work, provision of adequate resources (time, staff, opportunities to learn, control, technological usability), and work systems that facilitate teamwork, communication, and professionalism. Moreover, they recommend that organizations build infrastructure for an accountable improvement system—essentially turning the power of quality improvement that most healthcare organizations have developed to address patient safety and process improvement to the task of healthcare team well-being. This system should be adequately resourced and use human-centered design processes with well-being as their focus. Interventions to reduce physician burnout have been diverse and include a subset focused on workload [81,82,83,84]. Some of these [83, 84] include shorter periods of duty (shift or rotation length). However, examples given earlier in this chapter include interventions to specifically make work more manageable within the work period [73, 79]. Interventions such as these might be expected to reduce the need to continue to shorten duty periods. Evidence is mounting, as well, that the well-being of the entire healthcare team is of critical importance. In a study examining VA-based primary care clinics, any turnover within a clinical team increased burnout in the subsequent 6 months, even when controlling for panel morbidity and size [85]. This makes holistic evaluation of workflows and team function critical.

Stress and Workload

In this chapter we have reviewed chronic stress, stress physiology, and the health implications of chronic stress. We then focused on understanding workload. While the impact of stress is related to an individual’s capacity and the demands placed upon them, workload is experienced as a balance of demands and resources, both internal and external to an individual. We explored facets of physician workload, the cost of excess workload, and discussed strategies to manage workload. When attending to the concepts of stress and workload, there is absolutely benefit in focusing on building each individual’s capacity. However, re-designing work systems to appopriately balance demands with resources, and to reduce demands that do not support the meaning and purpose of medicine, is imperative.