National Crisis of Physician Burnout: What Can Be Done?

Chris Casey:
You're listening to Health Science Radio, a podcast from the historic Fitzsimons Building in the heart of the University of Colorado Anschutz Medical Campus. We talk with our researchers who are searching for answers to some of the biggest healthcare challenges across the spectrum of healthcare. Our scientists explore tomorrow's medicine, today.
My name is Chris Casey and I'm the director of digital storytelling here on campus. It's a pleasure as always to be joined by my co-host, Dr. Thomas Flaig, vice chancellor for research at CU Anschutz. Today we feature a discussion about the problem of physician burnout, some recent studies into the issue and the search for solutions to this growing crisis.
But first, as I mentioned, we are recording from the historic Fitzsimons Building in Aurora, Colorado. And being in a historic former hospital and having a podcast name that pays homage to the radio days of yore ... we are fond of indulging in a bit of historical patter to begin our program. And so once again, Tom, as our campus' expert, would you kindly indulge us with a latest kernel of CU Anschutz history.

Thomas Flaig:
It's a loose use of the word expert, by the way, but I'm happy to opine about some of the things going on here. So it's always neat to be in this historic building, a building that opened just right before Pearl Harbor. One of the stats out there is that injured troops from Pearl Harbor came within a few weeks of the opening of this building, so it was timely in that sense.
So I thought of one tidbit I could throw out there in terms of the history of this building, the historic Fitzsimons building. So Chris, you might know the answer to this, but I was thinking of the most famous person born in this building.

Chris Casey:
I'm racking my brain. I'm not-

Thomas Flaig:
You heard people talking about this in the hallway. I think there's been some talk about this.

Chris Casey:
A famous political figure, perhaps?

Thomas Flaig:
Political figure.

Chris Casey:
Perhaps political.

Thomas Flaig:
Now this is what I recall, but during one of the campaign swings when he was running for president, he mentioned being born in this building. In fact, I think he even mentioned, I think that he was born in the west wing of this building. So that was John Kerry, born in 1943. Again, former secretary of state, U.S. senator. So he might be, to my recollection or my understanding, the most famous individual born in this building. Not the most famous patient, of course, President Eisenhower, but the most famous person born in this building. If anybody has a different idea being a quote-unquote, "expert," I'd be happy to hear that input.

Chris Casey:
Well, perhaps one of our audience members will respond with something else that trumps that.

Thomas Flaig:
I would love to hear of another historic and notable person born in this great old building.

Chris Casey:
Well, thank you. As always, my knowledge base grows exponentially by learning about your vast store of trivial knowledge of our campus' history.

Thomas Flaig:
Trivial is a key part of that phrase here, Chris, for sure.

Chris Casey:
Well, thank you. And it is an election year, so I think that's a very apropos tidbit. As I mentioned, we are really looking forward to digging into today's topic, and we are privileged to have as a guest, one of the nation's premier thought leaders in physician burnout and engagement. As I mentioned, physician burnout has become a national crisis, and in fact, the Association of American Medical Colleges estimates that the United States will face a shortage of between 38,000 to 124,000 physicians by 2034.
Our guest is Dr. Lotte Dyrbye, a professor of medicine and senior associate dean for faculty, and chief well-being officer for the University of Colorado School of Medicine, where she oversees the offices for faculty experience. Her scope includes faculty affairs, relations and development, and initiatives focused on work and culture optimization. In addition, as a general internist, Dr. Dyrbye sees patients at the Lowry Clinic.
Dr. Dyrbye graduated from the University of Wisconsin Medical School in 1996 and completed an internship and residency in internal medicine at the University of Washington. After working in private practice, she joined the Mayo Clinic in 2001, where she was associate chair in the Department of Medicine and co-directed Mayo's physician well-being program. Her research is focused on trainee and healthcare worker professional well-being. Welcome, Dr. Dyrbye, it's great to have you with us here.

Lotte Dyrbye:
Thanks a lot for the invitation, really looking forward to our conversation.

Chris Casey:
We are very much as well. Well, this is a very complex topic, and with many contributing factors and profound ripple effects that occur throughout the healthcare spectrum. And so just to start off our conversation, could you talk, Lotte, about how the issue of physician burnout, where it began? I understand it preceded the pandemic, and then perhaps how the pandemic even exacerbated the current problem?

Lotte Dyrbye:
Yeah, that's a really great question. So certainly the pandemic has highlighted the problem, but we've known that there's been a high prevalence of burnout in healthcare workers, really, for decades. So we started really looking at the problem through a research lens, boy, it must now be 14, almost 20 years ago. And the work really started in residence, so seeing that there was a high prevalence in residence, then that led to other studies going, "Oh, wow, medical students have it. And then wow, look at it, it's a big issue in physicians as well." And lots of variability by specialty, as you would expect.
And then here it's about 20-some months into the pandemic when we did another big national study of physicians from all different specialties, so neurologists, surgeons, pediatricians, and academic as well as in private practice, we saw unfortunately, whoa, although the numbers had generally trended down for several years, we saw this enormous spike, as you would expect.
But it wasn't homogeneous, so how the pandemic impacted doctors varied a lot by the type of doctor. So for people who were doing elective surgery, all of a sudden they really had nothing to do, so their work stress went down, maybe their financial stress went up, but their work stress went down. And then you think about the infectious disease doctors, the hospitalists, the pulmonary critical care docs and the general internists, the family medicine docs, their work stress went way up. So we saw really high prevalence of burnout, particularly in the front line, caring for patients with COVID.

Thomas Flaig:
Was that worse directly in the first six months or 12 months? And now we're into this pandemic thing, some distance, how is that altered? Is it improving a little bit now? Are there still some lingering effects?

Lotte Dyrbye:
Well, we just closed a big national study of physicians, again, all specialties across the United States looking to see, OK, have we come out on the other end? And a preliminary peek at the data shows that there's hope that while we had a big stress point during the pandemic, it does look like for many of the different specialties that there's been a little bit of relief. But we're still very early in the data analysis phase to really know. But I think that's our gut intuition, right?

Thomas Flaig:
Right, yeah.

Lotte Dyrbye:
Burnout is caused from high levels of work stress. And we know that work stress went really high in the pandemic. And it's always been high, but it went really high, and now it's starting to settle down a little bit again.

Thomas Flaig:
And I think the factors, too, of academic versus non-academic. I'm curious just what's the overlay in terms of burnout with those two different areas?

Lotte Dyrbye:
So in the big national studies that we've done in collaboration with the American Medical Association, we've seen that being in private practice is a higher risk for having burnout relative to physicians who are in academic medicine. So even after we control for work hours and variety of other factors, we do see that. And having been in private practice, the stressors are different. When I would take vacation, I was still paying my staff, so it was really hard to completely let go. But here in academics we have a lot of other stressors with teaching and research and so it's different. But in aggregate, it does look like the physicians in private practice are probably at higher risk.

Thomas Flaig:
So it's really fascinating to hear about the difference between private practice and academics. My wife is a practicing private practice physician. There are different stressors, they're in both realms, but I can certainly understand that takeaway from what I've seen in my own life.

Lotte Dyrbye:
And some of it might also have to do with compensation. We know that that's another independent predictor of burnout. So if you're in a kind of fee-for-service model where your salary depends completely on your billing, you're at higher risk relative to physicians who maybe are in a mixed compensation model where they have some protected salary and then some is based on revenue generated, or the rare physician who's in a completely salaried model. So yeah, there are different stressors. No job is stress-less.

Chris Casey:
And Tom, you found the recent JAMA study that talked about a survey of 15 academic medical institutions. And this ties into that question you just asked. So the data collected on that study showed 37% of the physicians at the academic medical institutions met the criteria for burnout, and 32% reported moderate or greater intention to leave within two years. Could you talk about that study, Lotte, and what that tells you?

Lotte Dyrbye:
Yeah, well, it builds on some other studies that have been done in both big national samples of U.S. surgeons, as well as our big national studies of U.S. physicians, including private practice and academic docs. There's a strong association between burnout. So if you have a high amount of work stress and you get burnout. And intent to leave, which is what that study was about, sort of asking people, "What's the likelihood you're going to leave your current job in the next couple of years?"
Now we do have other single institution studies, so studies that have been done within a single academic medical center or practice where they've looked at responses to surveys and then actually crossed it with personnel records. And they've seen that burnout in physicians is associated with a two-fold increased odds of the physician actually leaving that practice. So not only have we seen associations on cross-sectional studies, but we've also seen that burnout actually predicts people actually quitting and leaving their job.
But overall turnover in physicians is kind of low. Another way that we kind of have a release valve is we cut back on the time taking care of patients. So in a big study I led at Mayo Clinic, we saw that for even just people's degree of burnout, if it even just increased by 1%, their odds of actually reducing the time they take care of patients over the subsequent two years was like 43%. So there was a huge relationship and longitudinal studies between, "I'm feeling burnt out, so I'm going to reduce the amount of time I'm taking care of patients." And on average, these docs were reducing the amount of time they took care of patients by 20%, so a whole day a week.
And if you actually extrapolate the Mayo data to national data, let's say we just take the Mayo numbers and we say, OK, this is the same for all U.S. physicians, it equates to three graduating classes of medical students simply not taking care of patients, so it's a big impact.

Thomas Flaig:
Huge impact.

Lotte Dyrbye:
And we see it not only in doctors, but when we studied 42,000 healthcare workers – so nurses and pharmacists and physical therapists – we see the exact same thing. If they're burnt out two years later, there's a really high likelihood that they've reduced their time taking care of patients.

Thomas Flaig:
I saw this study, it made me think of some of the research that I know you've done and previous conversations we've had. And the end point here was intention to leave. It's one question I had just in general, is that leaving academic medicine or leaving the practice of medicine altogether, or some hybrid of that?

Lotte Dyrbye:
Yeah, well, the question you ask, "What's the likelihood you're going to leave your current job in the next couple of years?" And if docs say that they have moderate or higher intent to leave, about a quarter of them will do so. And the study does ask a follow-up question, like, "OK, why are you leaving? Are you going to retire because you're over 65? Are you going to retire early? Are you going to pursue a job outside of medicine? Are you going to leave academic medicine altogether? Are you pursuing leadership opportunities, or are you in pursuit of greener pastures? Do you think your practice will be better if you work at a different organization?"
And there definitely is a pretty big chunk of people who are just leaving medicine altogether, and that's really sad to see. There's a huge investment obviously in becoming a physician – societal investment, personal investment. We need access to care, and here we have physicians experiencing burnout, leaving their jobs, leaving medicine, cutting back on the time they're taking care of patients.

Thomas Flaig:
Just anecdotally, I think in my own life, I've seen maybe a trend earlier where people are shifting from academics to private practice or private practice to academics, and I've seen more recently people leaving the practice of medicine more completely rather than shifting within fields, so to speak. And that has a huge impact. We're going to talk about the shortage issue, it's upcoming, but it certainly compounds that.

Lotte Dyrbye:
Yeah, it really does. It's a huge issue. And I think that's why leaders in medicine have really called it the burnout crisis. It's been labeled such by the head of the National Academy of Medicine and other big organizations that this impacts access to care. And what we haven't talked about yet is its impact on quality and safety and patient experience.

Chris Casey:
Yeah, and I'd like to touch on that aspect. But just referencing another study that caught my eye, and this shows that the problem is even global in scale beyond the borders of the United States. A study of about 1,800 health professionals, including physicians, nurses, midwives, employed by hospitals and clinics in Switzerland found a significant association between burnout and thoughts of leaving medicine as well that found that the determinants seemed to be work-life balance was a strong predictor of burnout for physicians. And then also the mismatch of effort versus reward was a big predictor in that particular study. Could you talk about some of those as contributing factors?

Lotte Dyrbye:
Yeah. The biggest contributing factor to burnout, regardless of who you look at, if you look at physicians or you look at the general U.S. population, it's work hours. So work hours is the number one driver. In general, docs work about 10 hours more a week than the average U.S. worker, so we put in a ton of hours. And that obviously along with the unpredictability, people getting sick or needing surgeries, contributes to this challenge between managing work responsibilities and responsibilities outside of work, or what we've often called work-home conflict, or a problem with work-life integration.
So we see that having work-home conflicts, that is an independent predictor of burnout. So if you have problems with that work-life balance or work-life integration, you are more likely to experience burnout. But it's also how you solve them when they do happen. So if you have enough camaraderie at work where people can help you out, or you have enough flexibility at work where you can get that done and meet your home responsibility, the impact of that work home conflict is less. If you can sort of, OK, you're having a conflict, but you can figure out how to do both, you can be the super person.
But if you're solving your work-home conflicts in favor of work, that is also by itself an independent predictor of burnout. But why are those things happening? They're happening because work hours are really high, they're happening because autonomy and flexibility is low, and then they're happening because medicine is unpredictable, people get sick outside of 9-to-5 Monday through Friday, so it's definitely complicated.
And there's a variety of other drivers. We have relatively hard-to-use health information technology or what we call the electronic health record, it is not super user-friendly. It's not as easy to use as your iPhone; it's complicated. And there's a variety of other things, whether it's prior authorization forms, or you can go on and on and on about all the system factors that are contributing to high work stress for physicians and other members of the team.

Chris Casey:
Right. That administrative overhead, I think that's kind of a generic term that you could apply to that kind of problem. Just that extra amount of administrative work that I imagine physicians and healthcare workers in general are dealing with. Could you also talk about the rise in these automated doctor-patient interactions through apps – the portals that allow that quick patient interaction with their physician ask a question spur of the moment, any time of day. How is that also contributing, perhaps?

Lotte Dyrbye:
Yeah, so we often refer to it as the patient portal. So when I go and send a message to my primary care doc, I use my phone, I open up the app for where I get care, and I enter my question or whatever it is of the day. And then, from the physician side, the questions come as what we call sort of in-basket messages. So your email is your inbox and your electronic health record messages from patients is your in-basket. And we know that the number of in-basket messages physicians receive every day is an independent predictor of their burnout.
So it's a great communication tool. I can facilitate my mom getting care, or I can get my questions answered. People can get refinement in their insulin regimen if they have diabetes without missing work or having to arrange daycare or finding someone to drive you. It's a great powerful tool to improve people's experiences and health. But on the flip side, medicine wasn't ready for it. So here I am in clinic seeing patients all day long and these messages from patients are coming at me at the same time and there's no time allocated in most physicians’ workday to read these messages, to respond to them appropriately, to give them the thought that they deserve.
So it's become a huge stressor. The idea is good. The idea is great – helping patients and their families get the care they need. It's just on the medicine side of that, we need to figure out how to manage this volume in a way that falls within the work day and that leverages all members of the care team. Does that question really need to be answered by the physician or could it be answered by the medical assistant, the pharmacist, the nurse, other members of the care team? So it's a pain point, and I think that we're doing a lot of work redesign and innovation in healthcare to really try to get a handle on that.

Thomas Flaig:
I think this has become a bigger issue, and I think all of us in healthcare want to be helpful. And I think as you said, I think many of us can see the value of having that accessibility. It is different though, and I think the expectations in the doctor-patient interaction has changed in the pandemic. That's one thing that I've heard, and I've seen that. Some of those questions you see are pretty addressable, it's a quick thing.
The hardest thing for me I would say is that I see questions that I can't adequately... I'm an oncologist, I can't adequately address, and I see frustration as soon as I say, "I think we need to schedule a formal visit or something." So it seems to me that the expectations changed during the pandemic. A lot of us see the value, but we haven't quite figured out how that works or what's an appropriate type of question, ones that one really shouldn't try to address via these sorts of things.

Lotte Dyrbye:
It is really complicated, and there's so many different sides to that. There's the part around that I think healthcare has really failed in educating patients about how to use the portal, when to use the portal, what types of messages to send. And then I think on the flip side, us as physicians, we want to serve the patient.
And then there's our own personal guardrails. If we totally burn ourselves out, we're not going to deliver good care to the patient. We're going to cut back on our hours, we're going to leave our practice. So we do need to put down those guardrails and say, "OK, we need to convert this to at least a telephone appointment or a video appointment," or, "Wow, you actually really need a physical exam. You need some labs; you need an X-ray. You need to come in." But there's growing pains with this new technology, and it's on both sides. Patients need to learn how to use it, we need to learn what their guardrails are, and we need to leverage the team better.

Chris Casey:
You co-developed a well-being index while you were at the Mayo Clinic, and it's currently being used by more than 1,000 healthcare organizations. Could you just talk about what that index is and how that's contributing toward better well-being among healthcare professionals?

Lotte Dyrbye:
So when we were doing our research and our studies early on, we ask people to fill out these very long surveys, 100 items plus. And people wanted to know their score, they wanted to know where they were at. And as a researcher, we weren't really set up and have the infrastructure to give people that kind of feedback. And then as we got to thinking about, "Well, how can we give people that kind of feedback?" The skills that we use are complicated, they're hard to analyze, they're not super simple, we couldn't just take our 100 items and put it on a website and let people fill them out and get immediate scores back.
So we went through this process of developing a validated short instrument to help physicians and other healthcare workers really self-assess their level of distress and get immediate feedback. And for some it's burnout, but for others it's other dimensions of their wellbeing. So the tool is developed to help people gauge their level of well-being across multiple different domains. And then it's validated in different groups, so there's physicians and nurses and dentists and pharmacists and advanced practice professionals, medical students and residents.
And any individual can use the app for free and see immediately, "What's my well-being like? How am I doing relative to people who are like me?" and then importantly, I think, access resources. Institutions that have a subscription can use it as a way to gauge how a whole population is doing. “How are the nurses in neurology doing?” for example. And push very specific resources like the resources that are available to nurses. And (resources) in one city might be different than the resources available to nurses in another city if it's a big healthcare system. So it can help people navigate what are the resources that are available.
Now, you may wonder, well, why do docs need this? Don't they diagnose all day long? Don't they know this? And when we studied it, we had people use the tool, fill out various validated instruments, and then just simply answer a question how they thought their well-being was relative to peers. And it was a little bit of the Lake Wobegon phenomenon, right? 80% of people thought they were …

Thomas Flaig:
Above average.

Lotte Dyrbye:
... at or above average, including the bottom third. So although we diagnose all day long, it is actually really hard to look in that mirror and self-assess where you're at. And ideally you want people to make course corrections rather than wait until their relationship falls apart, or they deliver bad quality of care to patients, or they're cutting back on their work hours. So that was the intent – it was to give people data in their hands so they could self-calibrate, figure out do they need to do something different and seek help when they need it.

Chris Casey:
And could you then talk about, we touched on this earlier, but just the big problem of burnout among healthcare professionals, physicians, is there a tangible way to assess what the effect is or what the effects are occurring with the patients, at the patient level?

Lotte Dyrbye:
So there's been multiple meta-analysis and systematic reviews that have shown that burnout in healthcare workers and in physicians negatively impacts patient care in a whole host, a variety, of ways. So if we look at that data... Well, the data is summarized from one of the National Academy of Medicine consensus study reports. It's summarized in the U.S. Surgeon General's Report on healthcare worker well-being as well. But we can just pick out a few examples.
So we know from our research that surgeons who have burned out are twice as likely to say they've committed a major medical error. And not only are they twice as likely to say they've committed a major medical error, but they're twice as likely to be involved in a medical malpractice litigation suit relative to surgeons who don't have burnout. If you switch to the in-patient setting, we know that the level of burnout in nurses and doctors in intensive care unit is an independent predictor of patient mortality.
And if you look more broadly at the nursing literature, the level of burnout in nurses is an independent predictor of hospital-associated infections. So those are just some examples about how burnout in physicians and in nurses is really associated with negative impacts on quality and safety of care.

Thomas Flaig:
Just a couple of questions myself here, so if you had to... It's a complex topic, I think providers think about it a lot. I think we probably lack insights. As you're saying, it's hard to see it in yourself, look in the mirror. What kind of take-home message would you have for providers to be aware of this, and what actions they can take if they're experiencing this?

Lotte Dyrbye:
Yeah, I think it's important to keep in mind that docs don't have burnout because they have a resiliency deficiency.

Thomas Flaig:
Agreed.

Lotte Dyrbye:
It's coming from the system. But that also doesn't mean we're completely off the hook. So we're on the hook to be positive change agents. There's a lot of work that we can do to improve our healthcare system, to improve how tasks are distributed, to improve the electronic health record. You pick your poison. We are a smart group of people, and we have a responsibility to lean in, and whether that's participating in pilots or suggesting ideas for how to improve things within a hospital or a clinic or work unit, being the ones who actually are the process-improvement specialists.
But there's a whole range of ways that we can contribute that we lean in to the system factors to help address them, and that's complicated, and it's not going to fix it tomorrow. So what are the things that we can do today or more in the moment? One is obviously if we are feeling very distressed to seek professional help. We've just got to put that out there that that's super important. And we just need to do that simply. But short of that, the other pieces that are really helpful is for us to build our social support.
So if you take, for example, a group of individuals who served in the war, had a horribly traumatic experience in the field, the single most protective factor against that soldier developing PTSD is their perception of social support. We see the same sort of thing in studies of healthcare workers. Our perceptions of social support is incredibly protective against a variety of different forms of distress. So it begs the question, what are you doing today to build your relationships inside and outside of work?
So that's something, yes, lean in and try to improve the system, and in the meantime make friends, take time for recreation, engage in meaningful conversations with others so that anything that is building social support and helping you also build a little bit of an identity outside of being a doctor turns out to really be super important. And there's a couple of other pieces that we've learned are super important.
One really relates to go see cool people like me. So docs who are up to date in their primary care, their preventive services are more likely to have a high quality of life and not have burnout. Docs who are not doing delayed gratification. So there are a group of docs who say, "I love to go fishing and I'm going to go do that when I retire."

Thomas Flaig:
Oh, yes.

Lotte Dyrbye:
Right. That's delayed gratification. I'm sorry. No, find time to go fishing on a more regular basis. Nurture that part of you that is outside of your professional life. And maybe you'll go fishing with other people and then you can kind of get a two-for-oner in terms of building your social support and engaging in recreation activities that you enjoy. So there are definitely things that we all can do in the moment, like seeking care appropriately, building our social support, leaning in, being positive change agents, and taking care of ourselves in a variety of different ways.

Thomas Flaig:
And this may not fit, but I just wanted to open up, would you have a take-home message for healthcare leaders as well, and is that a different message or a different way of thinking about this issue?

Lotte Dyrbye:
So there's no single-size solution, I think that's probably the most important piece. There has to be organizational will to make well-being of the healthcare worker a priority in order for any organization to have a chance to bend the needle. But once that will is there, then you start to see healthcare worker well-being really being a performance metric. And once it's on the scorecard for leaders, then you start to see more meaningful action.
And that needs to be the full cycle that we think about with quality improvement. It means we measure what the level of well-being is in our physicians and other team members. We do action planning, we try to implement things. And we're not going to fix it overnight, and what works in GI is not necessarily going to work in ophthalmology, but we're going to make an effort and we're going to have a commitment to be in this game for the long run. And those are the organizations that can bend the needle.

Thomas Flaig:
I think it's a really important message. And I would just say that from your finer point earlier about the quality that stems from that many hospitals and healthcare systems are focused on quality. It's fantastic. This is certainly part of that equation.

Lotte Dyrbye:
Yeah. Which is why it's been called the quadruple aim. So to really improve the patient care, the quality of care, safety, cost, all those pieces of the patient experience, you have to think about it, really, through the quadruple aim, so that very much includes the professional well-being of your healthcare workforce.

Chris Casey:
Yeah, this is a fascinating topic because so many of the folks we'll talk to here are very much focused on their project in the lab. This is a problem that goes well beyond the walls of the clinic, the institution, this ripples through broader society. I'm just curious what spurred your personal interest in this area? Because you've become a national expert on this topic, so it must be close to your heart for some particular reason.

Lotte Dyrbye:
Yeah, I think that it really stems from I think underlying curiosity. So, Dr. (Tait) Shanafelt, who has led much of this work was actually my intern at University of Washington. And he came to Mayo Clinic in Rochester, Minnesota, where I was practicing for 20 years as a general internist and an academic as a HEMOC fellow, I believe. And then he came on staff, and I remember him giving grand rounds talking about burnout in residents and how it was associated with suboptimal patient care. And at the time, I was very involved in medical school education, so I was teaching very bright-eyed medical students on physical exams and how to be a doctor. And simply had the question, "When does this start?"
And then here we are 20 years later, still working closely with Dr. Shanafelt, and now also Dr. Colin West at Mayo, and others across the country, really looking at this not only in physicians and practice, but also medical students and residents and other members of the healthcare team.

Chris Casey:
Well, the topic can just expand and branch into numerous avenues. We didn't even touch on a study you did not too long ago into mistreatment of physicians who are mistreated, discriminated against by patients, the family members and visitors. So could you maybe just touch a little on what your most salient takeaway was from that study, Dr. Dyrbye, and then maybe if there's any course correction there or any solutions that maybe have percolated to the surface after that study?

Lotte Dyrbye:
I'm glad you brought that up, Chris. We often think about, "Oh, it's the electronic health record," or, "Oh, it's the in-basket messages." And yes, and even if we had the perfect electronic health record, and we'd figured out how to manage all these in-basket messages, we would still have a problem. Some of the stress that we experience at work comes more from our culture. It can come from leadership behaviors, it can come from how we treat each other, and it can come from the behaviors that we see from patients, families and visitors. So in our big national study of U.S. physicians, we found about 30% of physicians had really experienced mistreatment in a variety of different forms from patients, families and visitors.
Just imagine you're missing your kid's fifth birthday because you're in the emergency room. And you go to see this patient, you want to take care of this patient. And the patient says, "Nobody who looks like you; I don't want you." And this is happening – this is happening a lot. And it is happening to women physicians, and it's happening to ethnic and racially-diverse physicians. It is happening more to younger physicians, and it's happening a lot to our colleagues in the emergency department.
And as you would expect when you have these sorts of experiences at work from patients, families and visitors who you're trying so hard just to give good care to, it increases your work stress and it causes burnout. The more of them that are happening to you, the higher your odds of burnout. So this is something that's really important for us to respond to, and that response needs to come in so many different ways.
The first time it happened to me, I've been in practice a long time, and I was in the hospital taking care of a patient and I had a whole team and the patient was racist, and I was so busy picking my jaw off the floor that I did not say the right thing in the moment. And I had never been trained how to say the right thing in the moment. And I think in our era of patient satisfaction, I didn't know if my employer would have my back if I said what was going on in my head. So I let myself down, I let my team down.
And I think the tide has turned on that, so we are learning how to respond appropriately in the moment, how to stand up for one another. Many healthcare organizations have policies in place to tell healthcare workers, "These are our values and we have your back. Give patients, families and visitors conduct information." Really, we've come to that? But we have. So I think organizations are trying to address this problem and to do a bit of course correction, but it's an issue, and it's one of these other system-level drivers that we need to continue to work on.

Thomas Flaig:
Well, I just want to say that the work you're doing in this area is really important, and this is such a critical, pressing topic. I'd just like to thank you for all you've been doing over time and being such a great expert on our campus and nationally in this very important area.

Lotte Dyrbye:
Thanks a lot, Tom. I appreciate that.

Chris Casey: I agree wholeheartedly, and we look forward to seeing what the results of more of your work down the road is, Dr. Dyrbye. And again, thank you for joining us.

Lotte Dyrbye:
Thanks a lot.