Improving Clinician Work Life: An SGIM Journey

The newly released National Plan for Health Workforce Well-Being¹ by the National Academy of Medicine (NAM) is of profound importance to our work lives as general internists and the learners, staff, colleagues, and patients with whom we work. The capacity and well-being of the U.S. health workforce have been under threat by an epidemic of burnout, and two years of the COVID-19 pandemic has exacerbated this systems issue. Now, at least 40% of nurses, 20% of physicians, and more than 25% of state and local public health department employees are considering leaving their professions. The National Plan is a stellar example of clear, actionable steps that can be taken to improve work and learning environments and clinician, trainee, staff, and patient outcomes. In this article, we identify some of the foundational work performed by SGIM members and colleagues that has contributed to the basis of this groundbreaking report.

Though not directly involved in preparation of the report, our team, in collaboration with many SGIM members and leaders in the field, has had the privilege of working in this space for more than two decades. In 1996, our work started with funding from the Robert Wood Johnson Foundation to perform a national study of physician work life and job satisfaction. The SGIM Career Satisfaction Study Group, led by Elnora Rhodes (SGIM Executive Director), Bob Konrad, Julia McMurray, Eric Williams, and the Physician Worklife Study Team supported this initial work. This was followed by years of study supported by the Agency for Healthcare Research and Quality (AHRQ), including 1) the Minimizing Error, Maximizing Outcome Study (MEMO) linking work conditions to clinician and patient outcomes in 119 clinics under the leadership of Mark Linzer and Linda Baier Manwell, 2) the Healthy Work Place (HWP) randomized trial in 34 clinics testing interventions to reduce burnout (led by Sara Poplau), and 3) the Minimizing Stress Maximizing Success from the Electronic Health Record (EHR) project (MS Squared), led by Phil Kroth and Nancy Morioka Douglas, with a mixed methods assessment of clinician outcomes related to EHR use. Recently, members of our team have been honored to work with the Office of the Surgeon General on their “Heal Advisory” for the nation’s healthcare workers, a document with overlap and synergy with the NAM report.²

Many SGIM members were pioneers in this field and have contributed to the work that predated the NAM National Report (with apologies to any omitted in this brief summary). SGIM’s Part Time Careers and Work Life Balance Interest groups and Horn Scholarship (championed by Carole Warde, Rachel Levine, and Hilit Mechaber) were ahead of their time in recognizing the importance of work life factors. Significant accomplishments in this field were spearheaded by SGIM members including Anita Varkey’s “Separate and Unequal” paper (after an SGIM plenary presentation) on work conditions in clinics serving racially minoritized groups,³ an SGIM workshop on 10 bold steps to reduce burnout in GIM and a follow-up project on the end of the 15–20-minute Primary Care visit by 16 ACLGIM leaders calling attention to time pressure during patient visits. Other notable SGIM-led or shared work predating the NAM report included Steve Yale’s work with rural clinicians and Ellie Grossman’s work with inner city clinicians in the Healthy Work Place trial, Chris Sinsky’s landmark work on time spent on indirect patient care (2 hours for every one hour in clinic),⁴ Tait Shanafelt, Lotte Dyrbye, and Colin West’s galvanizing work on burnout measures and prevalence,⁵ and Kriti Prasad’s study on correlates of stress and burnout during the Covid pandemic, demonstrating high stress among workers of color, women and non-binary workers.⁶

This work provided evidence-based support for the foundations upon which the National Plan is based. For example, clinicians in MEMO focus groups described chaos in work conditions, which has remained an important measure of workplace challenge. The above programs and studies have shown that work overload, time pressure, and organizational culture are determinants of whether one burns out or thrives, and whether one wishes to leave or stay in their job; other partners have written on the need to protect worker mental health.⁷ These predictor variables for burnout emanated from clinicians and learners who shared their stories with us over the years.

It is a critically important time for healthcare worker well-being, as clinician and worker distress, especially in primary care, are very high. The National Plan speaks of a need to “optimize work conditions” to address childcare benefits, establish key performance indicators for tracking, reduce stigma from mental health matters, and value the well-being of the workforce.¹ We resonate with all these suggestions. Among our many partners in this work have been the Institute for Healthcare Improvement (Joy in Work international network, Jessica Perlo, lead), the American College of Physicians (ACP wellness champion training, led by Kerri Palamara, Susan Hingle, and Daisy Smith), the American Medical Association (partnering on Coping with COVID) and Mini Z (Zero Burnout) measures with Chris Sinsky and Nancy Nankivil, and the American Board of Internal Medicine (clinician trust in organizations initiative, with thanks to Dan Wolfson and Tim Lynch).

The NAM report concludes with: “there is an ethical obligation to take action to protect those who care for all of us.” We fully agree and are grateful to our NAM partners for their inspirational work. This is the work that must be done. We in SGIM are honored to share in this work and fully endorse the timely and forward-looking NAM report.