Available via license: CC BY-NC-ND
Content may be subject to copyright.
Effect of Organization-Directed Workplace
Interventions on Physician Burnout:
A Systematic Review
Paul F. DeChant, MD; Annabel Acs, MPH; Kyu B. Rhee, MD; Talia S. Boulanger, MS;
Jane L. Snowdon, PhD; Michael A. Tutty, PhD; Christine A. Sinsky, MD;
and Kelly J. Thomas Craig, PhD
Abstract
To assess the impact of organization-directed workplace interventions on physician burnout, including
stress or job satisfaction in all settings, we conducted a systematic review of the literature published from
January 1, 2007, to October 3, 2018, from multiple databases. Manual searches of grey literature and
bibliographies were also performed. Of the 633 identified citations, 50 met inclusion criteria. Four unique
categories of organization-directed workplace interventions were identified. Teamwork involved initiatives
to incorporate scribes or medical assistants into electronic health record (EHR) processes, expand team
responsibilities, and improve communication among physicians. Time studies evaluated the impact of
schedule adjustments, duty hour restrictions, and time-banking initiatives. Transitions referred to work-
flow changes such as process improvement initiatives or policy changes within the organization. Tech-
nology related to the implementation or improvement of EHRs. Of the 50 included studies, 35 (70.0%)
reported interventions that successfully improved the 3 measures of physician burnout, job satisfaction,
and/or stress. The largest benefits resulted from interventions that improved processes, promoted team-
based care, and incorporated the use of scribes/medical assistants to complete EHR documentation and
tasks. Implementation of EHR interventions to improve clinical workflows worsened burnout, but EHR
improvements had positive effects. Time interventions had mixed effects on burnout. The results of our
study suggest that organization-directed workplace interventions that improve processes, optimize EHRs,
reduce clerical burden by the use of scribes, and implement team-based care can lessen physician burnout.
Benefits of process changes can enhance physician resiliency, augment care provided by the team, and
optimize the coordination and communication of patient care and health information.
ª2019 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/)nMayo Clin Proc Inn Qual Out 2019;3(4):384-408
The prevalence of physician burnout is
substantial, with more than half of US
physicians reporting at least one symp-
tom of burnout, which is significantly higher
than that in the general population.
1
Burnout
is defined as a long-term stress reaction marked
by loss of enthusiasm for work (emotional
exhaustion), feelings of cynicism (depersonal-
ization), and a lack of sense of personal accom-
plishment.
2
Causes of physician burnout
include time pressure, chaotic environments,
requirements for electronic health records
(EHRs), and responsibilities outside of work.
3
Physician burnout can affect physician
health and quality of care.
4e6
As a result of
stress, physicians may experience depression
or anxiety, may engage in alcohol and/or
drug abuse,
7
and have suicide rates that are
1.2 to 2.4 times higher than that of the general
population.
8
Work-related stress can also lead
to lower patient satisfaction and care quality
and increased medical error rates and malprac-
tice risk.
9e11
Burnout also has potentially
serious financial implications for the health
care system
12e14
by leading to physician
shortages and in costs to replace a physician,
which can exceed $500,000 to $1,000,000
per physician.
5,15
Interventions to address burnout have been
classified as either physician-directed or
From IBM Watson Health,
Cambridge, MA (P.F.D., A.A.,
K.B.R., T.S.B., J.L.S., K.J.T.C.);
and the American Medical
Association, Chicago, IL
(M.A.T., C.A.S.).
REVIEW
384 Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org nª2019 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
organization-directed.
16
Physician-directed in-
terventions aim to enhance resilience among
physicians through activities such as promoting
mindfulness or cognitive behavioral techniques
to improve an individual’s ability to cope,
communicate effectively, and increase compe-
tency. However, these supportive physician-
directed approaches may be insufficient
because they address individual solutions.
Burnout more often stems from organizational-
or system-level factors,
17
and interventions to
prevent burnout may be more effective when
they focus on changing the system rather than
individual physicians.
16
Some examples of
organization-directed interventions include
changing schedules, reducing the intensity of
workloads, improving teamwork, and
increasing physician participation in decision
making.
To date, the effectiveness of organization-
directed workplace or workflow interventions
has not been fully examined. The objective of
this review was to assess the evidence on the ef-
fect of organization-directed workplace inter-
ventions on physician burnout systematically.
METHODS
Search Strategy
MEDLINE, Embase, and the Cochrane Library
databases were searched on October 3, 2018,
for relevant articles published in English from
January 1, 2007, to October 3, 2018, that re-
ported on organization-directed interventions
for physician burnout related to work, the work-
place, or workflow. Search terms included physi-
cian,burnout,stress,workflow,time and motion
studies,lean,work engagement,psychosocial factors,
work behaviors,health outcomes,job performance,
job satisfaction,job-person fit,organizational factors,
and quadruple aim. Manual searches of grey liter-
ature including key conferences and organization
websites and bibliographies were also performed.
Search details are available in Supplemental
Tables 1 through 7 (available online at http://
www.mcpiqojournal.org).
Screening Process
One investigator (K.J.T.C. or A.A.) screened all
titles and abstracts for eligibility against a priori
established inclusion criteria (Supplemental
Table 8, available online at http://www.
mcpiqojournal.org). Studies marked for
inclusion underwent full-text screening by 2 in-
dependent reviewers (K.J.T.C. and A.A.), and
discrepancies were resolved by adjudication
or, if necessary, by a third reviewer. All results
at both title/abstract and full-text review stages
were tracked in DistillerSR (Evidence Partners).
Data Extraction and Quality Assessment
Included studies were extracted into struc-
tured forms by one reviewer (A.A.) and
checked for accuracy and completeness by a
second (K.J.T.C). Study quality was assessed
using the Oxford Centre for Evidence-based
Medicine Levels of Evidence
18
(Table 1)by2
independent reviewers (K.J.T.C. and A.A.),
and disagreements were resolved by a third
reviewer (T.B.).
RESULTS
Literature searches yielded 633 unique cita-
tions (Figure 1), of which 140 articles were
ARTICLE HIGHLIGHTS
dThere is increasing awareness that physician burnout is a cause
of diminished health and retention of physicians and their care
teams, quality of patient care, and viability of health care sys-
tems. Many causes of burnout derive from organizational- and
system-level factors, including electronic health records (EHRs).
dMost studies evaluating the impact of organization-directed in-
terventions on physician burnout are of poor quality. More
randomized controlled trials are needed to adequately test the
effect of organization-directed interventions on physician
burnout.
dThere is evidence from a few high-quality studies that (1) the
largest benefits result from interventions that improve work-
place processes, promote team-based care, and incorporate the
use of scribes or medical assistants to complete EHR docu-
mentation and tasks; (2) modifications to intensivists’schedules
for shift work or interrupted schedules significantly reduces
burnout; and (3) duty hour requirements and protected sleep
have no significant effect on reducing burnout among residents.
dEvidence from poor-quality studies suggests that EHR training
and technological improvements of EHR reduce burnout;
however, evidence from high-quality studies is needed to
identify which technological improvements have the greatest
impact.
SYSTEMATIC REVIEW ON PHYSICIAN BURNOUT
Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org 385
TABLE 1. Study Characteristics Stratified by Intervention Type
a
Reference, year Country Study design
No. of
participants Population and setting Type of intervention Outcome Follow-up
Level
of evidence
b
Teamwork (N¼20)
Chapman & Blash,
19
2017
United States Cross-sectional 886 Primary care practices Teamwork:
Employing medical
assistants in an
innovative model of
care with new roles
with a focus on career
advancement, training,
and enhanced
compensation for the
new medical assistant
roles
Staff satisfaction 4 y 4
Contratto et al,
20
2016
United States Pre-post intervention
survey
9 Physicians
Urban academic general
internal medicine
primary care practice
Teamwork: To
evaluate the impact
of using full-time
clerical support to
enter tests ordered
by physicians,
identify incomplete
health maintenance
measures, and
preload new patient
information
14-Item survey 4 mo 4
Contratto et al,
21
2017
United States Quasi-experimental
(single-group
pre-post
intervention) mixed-
methods
7 Academic general internal
medicine practice
Teamwork: Clerical
support personnel
for physician order
entry
Physician satisfaction 4 mo 4
Danila et al,
22
2018 United States Pre-post intervention
survey
6 Physicians (3
rheumatologists and 3
endocrinologists)
Rheumatology and
endocrinology clinics
Teamwork: Use of
scribes
JSS 6 wk 4
Gidwani et al,
23
2017
United States RCT 4 Physicians
Academic family medicine
clinic
Teamwork: Use of
scribes to draft all
relevant
documentation
Physician satisfaction,
measured by a 5-
item instrument that
included physicians’
perceptions of
medical record
quality and accuracy
1y 1b
Continued on next page
MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES
386 Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org
TABLE 1. Continued
Reference, year Country Study design
No. of
participants Population and setting Type of intervention Outcome Follow-up
Level
of evidence
b
Teamwork (N¼20), continued
Heaton et al,
24
2016 Multinational Systematic review NA NA Teamwork: Use of
scribes
Physician satisfaction NA 4
Hung et al,
25
2018 United States Pre-post intervention
survey
680 Physicians
46 Primary care
departments in a large
ambulatory care delivery
system
Teamwork/
Transitions: Lean-
based workflow
redesigns, which
included colocating
physician and medical
assistant dyads,
delegating major
responsibilities to
nonphysician staff,
and mandating
greater coordination
and communication
among all care team
members
MBI 3 y 4
Imdieke & Martel,
26
2017
United States Quasi-experimental,
nonrandomized pre-
and post-
intervention study
2 Internal medicine
physicians
Hospital-based, outpatient
primary care clinic
Teamwork:
Incorporating
medical scribes in an
ambulatory clinic to
support physician
documentation in
the electronic
medical record
Physician satisfaction 4-6 wk 4
Koshy et al,
27
2010 United States Nonrandomized,
static-group
comparison study
5 Urologists, residents
Urology clinic within a
single academic medical
center
Teamwork: Scribes
to record electronic
medical information
throughout the
patient-physician
encounter
Physician acceptance
and satisfaction
10 mo 4
Linzer et al,
28
2015 United States Cluster RCT 166 (135
completed
the study)
Primary care physicians
(family and general
internists)
34 Clinics in Upper
Midwest and NYC
Teamwork/
Transitions:
Projects to improve
communication,
changes in workflow,
and targeted quality
improvement
projects
Survey tools from
MEMO and PWS
12 mo, 18 mo 2b
Continued on next page
SYSTEMATIC REVIEW ON PHYSICIAN BURNOUT
Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org 387
TABLE 1. Continued
Reference, year Country Study design
No. of
participants Population and setting Type of intervention Outcome Follow-up
Level
of evidence
b
Teamwork (N¼20), continued
Linzer et al,
29
2017 United States Cluster RCT 165 Primary care physicians
(family and general
internists)
34 Clinics in Upper
Midwest and NYC
Teamwork/
Transitions:
Quality
improvement
projects to improve
communication
between physicians,
workflow design,
and chronic disease
management
OWL 6 mo, 12 mo 2b
McCormick et al,
30
2018
United States Pre-post intervention
survey
6 Urologists
Academic urology clinic
Teamwork: Use of
scribes
Work satisfaction 3 mo 4
Pierce et al,
31
2017 United States Pre-post intervention
survey
55 Physicians and advanced
practice clinicians
Academic hospital
Teamwork: 13
Team-based and
organizational tactics
to improve
resilience, including
expansion of
leadership roles,
faculty coaching for
new hires, and
value-based clinical
schedule redesign
NR 3 y 4
Pozdnyakova et al,
32
2018
United States Prospective, pre-post
pilot study
6 General internal medicine
faculty
Teamwork: Use of
scribes to complete
EHR
Workplace satisfaction;
burnout
1wk 4
Quenot et al,
33
2012
France Longitudinal,
monocentric,
before-and-after,
interventional study
4 Physicians
ICU
Teamwork: Intensive
communication
strategy regarding
end-of-life practices
in the ICU to
alleviate stress for
caregivers
MBI Post-intervention 4
Shaw et al,
34
2017 United States Pre-post intervention
survey
NR Medical doctors
NR
Teamwork: Team-
based primary care
redesign, “Primary
Care 2.0”, with the
goal of addressing
NR 5 mo 4
Continued on next page
MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES
388 Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org
TABLE 1. Continued
Reference, year Country Study design
No. of
participants Population and setting Type of intervention Outcome Follow-up
Level
of evidence
b
the Quadruple Aim
of health care (ie,
the Triple Aim plus
reducing workforce
burnout) with the
following
components: (1) an
expanded “care
coordinator”role
for medical assistants
including scribing,
population health
management, and
between-visit care
management, (2)
health coaching and
motivational
interviewing, (3)
“lean”quality
improvement to
support a Learning
Health System, (4)
telehealth, (5)
protected physician
time for care
coordination, and
(6) an onsite
extended
interdisciplinary care
team (ie, mental
health, pharmacy,
physical therapy)
Shultz &
Holmstrom,
35
2015
Multinational Systematic review NA Emergency department,
urology, or cardiology
clinicians
Teamwork: Use of
scribes
Clinician satisfaction NA 4
Was & Cornaby,
36
2016
United States Pre-post intervention
survey
23 Residents
Large academic center
Teamwork:
Common space for
residents (ie, “Gas
Lounge”)
NR Post-intervention 4
Continued on next page
SYSTEMATIC REVIEW ON PHYSICIAN BURNOUT
Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org 389
TABLE 1. Continued
Reference, year Country Study design
No. of
participants Population and setting Type of intervention Outcome Follow-up
Level
of evidence
b
Teamwork (N¼20), continued
West et al,
37
2014 United States RCT 74 Physicians
Department of medicine at
the Mayo Clinic
Teamwork: 19
Biweekly facilitated
physician discussion
groups incorporating
elements of
mindfulness,
reflection, shared
experience, and
small group learning
JSS, Empowerment at
Work Scale, Medical
Outcomes Study
Short-Form Health
Survey, MBI,
Perceived Stress
Scale, Jefferson Scale
of Physician
Empathy
1y 1b
Willard-Grace
et al,
38
2017
United States Cross-sectional 236 Clinicians
County-run primary care
clinics
Teamwork: A
defined model of
team-based care in
which the
association between
enhanced roles for
medical assistants,
registered nurses,
and behavioral
health professionals
is defined
MBI NR 4
Time (N¼14)
Ali et al,
39
2011 United States Cluster RCT 45 Physicians with various
specialties
ICU
Time: Two intensivist
staffing schedules
were compared:
continuous and
interrupted
(rotations every 2
wk) for 14 mo
Scales derived from the
National Study of
the Changing
Workforce
9mo 1b
Desai et al,
40
2018 United States Cluster-randomized
trial
80 First-year residents
63 Internal medicine
residency practices
Time: Duty hour
policies of the 2011
ACGME
Overall well-being, MBI 7 mo 1b
Fassiotto &
Maldonado,
41
2016
United States Pre-post intervention
survey
60 Medical school faculty
NR
Time: Time-banking
intervention
measures
unacknowledged
teaching, service, and
NR Post-intervention 4
Continued on next page
MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES
390 Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org
TABLE 1. Continued
Reference, year Country Study design
No. of
participants Population and setting Type of intervention Outcome Follow-up
Level
of evidence
b
clinical activities and
acknowledges them
with practical
rewards
Garland et al,
42
2012
Canada Crossover RCT 34 Physicians
ICU
Time: Shift work
staffing in which
there was 24-7
intensivist presence.
The same pool of
intensivists supplied
day shift and night
shift coverage. In any
given week, a single
intensivist was
responsible for all 7-
day shifts, whereas 2
different intensivists
alternated the 7
night shifts
MBI (emotional
exhaustion subscale)
Post-intervention 1b
Kim &
Wiedermann,
43
2011
United States Prospective cohort 56 Residents
Large pediatric training
program
Time: 2003 ACGME
work hour limits
NR 7 y 4
Landrigan et al,
44
2008
United States Prospective cohort 220 Residents
Pediatric residency
programs at hospitals
Time: 2003 ACGME
work hour limits for
US resident
physicians. Residents
can work no more
than 30 consecutive
hours and no more
than 80 to 88 h/wk,
averaged over 4 wk
MBI 1 y 4
Lucas et al,
45
2012 United States Cluster randomized
crossover
noninferiority trial
62 Physicians
University-affiliated
teaching hospital
Time: Assignment to
random sequences
of 2- and 4-wk
rotations
Questionnaire includes
questions from
MEMO study,
Perceived Stress
Scale, MBI, national
job burnout survey
2/4 wk 1b
Moeller & Walker,
46
2017
United States Pre-post intervention
survey
NR Physicians
NR
Time: Practice
Refresh pilot
NR NR 4
Continued on next page
SYSTEMATIC REVIEW ON PHYSICIAN BURNOUT
Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org 391
TABLE 1. Continued
Reference, year Country Study design
No. of
participants Population and setting Type of intervention Outcome Follow-up
Level
of evidence
b
program that initially
reduces and then
gradually increases
the time physicians
spend with patients
so that physicians
can learn and
practice skills in
efficiency,
teamwork, and self-
care
Morrow et al,
47
2014
United Kingdom Cross-sectional 82 Junior doctors
Deanery
Time: United
Kingdom WTR
applied fully to
junior doctors since
2009, with a limit of
48 h/wk, averaged
across a reference
period of 26 wk,
alongside specified
minimum rest
periods
NA NA 4
Parshuram et al,
48
2015
Canada RCT 47 Residents
University-affiliated ICUs
Time: In-house
overnight schedules
of 24, 16, or 12 h
MBI 2 mo 2b
Ripp et al,
49
2015
United States Pre-post intervention
survey
128 (2011-2012
cohort); 111 (2008-
2009 cohort)
Internal medicine residents
Academic medical centers
Time: 2011 ACGME
modified duty hours
standards to limit
continuous duty of
first-year residents
to 16 h
MBI, ESS 1 y 4
Schuh et al,
50
2011
United States Prospective, unblinded
study
34 Neurology residents
Neurology residency
program
Time: 2008 Institute
of Medicine work
duty hour
recommendations
that limit shifts to 16
or 24 h with a 5-h
MBI 1 mo 4
Continued on next page
MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES
392 Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org
TABLE 1. Continued
Reference, year Country Study design
No. of
participants Population and setting Type of intervention Outcome Follow-up
Level
of evidence
b
nap, eliminate
averaging of any on-
call shifts, increase
time off between
shifts for night float
and overnight call,
limit consecutive
night float shifts to 4,
and provide 1 d off/
wk/5 per mo
without averaging
Shea et al,
51
2014
United States RCT 106 Graduate internal medicine
interns
Internal medicine service
hospital
Time: A 2-h period of
protected time in
which interns were
expected to sleep
(12:30 AM-5:30 AM)
for 4 wk
MBI Post-intervention 1b
Tucker et al,
52
2010
Wales Cross-sectional 336 Residents and interns
NR
Time: Schedule
design
Questionnaire
developed for study
NA 4
Transitions (N[9)
Albadry et al,
53
2014 Egypt Cross-sectional 140 Residents and assistant
lecturers
Outpatient clinic
Transitions: Six
Sigma methodology
as quality
improvement
intervention
MBI 6 mo 4
Amis & Osicki,
54
2018
United Kingdom Pre-post intervention
survey
13 First-year residents Transitions: A
checklist aimed to
reduce the number
of inappropriate
prescribing tasks
Job satisfaction 3 Weekends 4
Callahan et al,
55
2018
United States Pre-post intervention
survey
9 Fellows
NR
Transitions: Bundle
of evidence-based
interventions to
improve burnout
and professional
satisfaction that
were designed to fit
the fellowship
program
ESS, quality of life 6 mo 4
Continued on next page
SYSTEMATIC REVIEW ON PHYSICIAN BURNOUT
Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org 393
TABLE 1. Continued
Reference, year Country Study design
No. of
participants Population and setting Type of intervention Outcome Follow-up
Level
of evidence
b
Transitions (N[9), continued
Dunn et al,
56
2007
United States Noncontrolled
prospective
intervention study
22-32 Physicians
Primary care group
Transitions: Data-
guided interventions
and systematic
improvement
processes that
included (1)
leadership valuing
physician well-being
equal to quality of
care and financial
stewardship, (2)
physicians identifying
factors that
influenced well-
being, followed by
plans for
improvement with
accountability, and
(3) measuring the
well-being of
physicians regularly
using validated
instruments
ACP/ASIM survey on
physician satisfaction,
MBI
6y 4
Giannini et al,
57
2013
Italy Pre-post intervention
survey
71 Doctors
ICU
Transitions: Increase
in daily visiting time
to at least 8 h (policy
change)
MBI, STAI 6 mo, 12 mo 4
Hung et al,
25
2018 United States Pre-post intervention
survey
680 Physicians
46 Primary care
departments in a large
ambulatory care delivery
system
Teamwork/
Transitions: Lean-
based workflow
redesigns, which
included colocating
physician and
medical assistant
dyads, delegating
major
MBI 3 y 4
Continued on next page
MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES
394 Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org
TABLE 1. Continued
Reference, year Country Study design
No. of
participants Population and setting Type of intervention Outcome Follow-up
Level
of evidence
b
responsibilities to
nonphysician staff,
and mandating
greater coordination
and communication
among all care team
members
Lee et al,
58
2017
United States Pre-post intervention
survey
Baseline, 18; postin-
tervention, 15
Neuroradiology fellows
and neuroradiologists
Academic neuroradiology
practice, part of a larger
health care system with
6 hospitals and 80
outpatient imaging sites
Transitions: Image
interpretive and non
eimage interpretive
reading room
workflows
14-Question survey,
Likert scale rating
1-5
1mo 4
Linzer et al,
28
2015
United States Cluster RCT 166 (135 completed
the study)
Primary care physicians
(family and general
internists)
34 Clinics in Upper
Midwest and NYC
Teamwork/
Transitions:
Projects to improve
communication,
changes in
workflow, and
targeted quality
improvement
projects
Survey tools from
MEMO and PWS
12 mo, 18 mo 2b
Linzer et al,
29
2017
United States Cluster RCT 165 Primary care physicians
(family and general
internists)
34 Clinics in Upper
Midwest and NYC
Teamwork/
Transitions:
Quality
improvements
projects to improve
communication
between physicians,
workflow design,
and chronic disease
management
OWL 6 mo, 12 mo 2b
Technology (N[10)
Agha et al,
59
2010
United States NR 9 Pulmonary, rheumatology,
and endocrine
physicians
NR
Technology: To
measure the impact
of EHR use on
physician satisfaction
NR NR 4
Continued on next page
SYSTEMATIC REVIEW ON PHYSICIAN BURNOUT
Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org 395
TABLE 1. Continued
Reference, year Country Study design
No. of
participants Population and setting Type of intervention Outcome Follow-up
Level
of evidence
b
Technology (N[10), continued
Babbott et al,
60
2013
United States Prospective 422 Internal medicine and
family medicine
physicians
Technology:
Secondary analysis
on data from the
MEMO study in
which physicians and
office managers
completed
questionnaires about
their office practice,
including specific
EHR features the
office used
NR NR 4
Beam et al,
61
2017
United States Pre-post intervention
survey
158 Physicians
Neonatal ICU
Technology:
Computerized
physician order
entry
implementation
Job satisfaction 1 y 4
Ehrlich et al,
62
2016
United States Pre-post intervention
survey
25 Ophthalmologists
Large academic
ophthalmology
department
Technology: EHR
system
30-Question survey
using Likert scale
rating, job
satisfaction
24 mo 4
Heyworth et al,
63
2012
United States Pre-post intervention
survey
163 Primary care and specialty
NR
Technology: To
measure predictors
of physician
satisfaction following
EHR adoption
Massachusetts eHealth
Collaborative survey
Post-intervention 4
Joseph et al,
64
2017
United States Pre-post intervention
survey
NR Physicians
NR
Technology: The
impact of a brief,
intensive technology
deployment and
training intervention
that was aimed at
improving individual
clinician’sefficiency
in using EHR
NR NR 4
United States 25 Stress 6 mo 4
Continued on next page
MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES
396 Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org
TABLE 1. Continued
Reference, year Country Study design
No. of
participants Population and setting Type of intervention Outcome Follow-up
Level
of evidence
b
Lapointe et al,
65
2018
Pre-post intervention
survey
Internal medicine residents
591-Bed urban hospital
Technology: EHR-
based text paging
system to
communicate with
internal medicine
residents
Menachemi et al,
66
2009
United States Cross-sectional 4203 Primary care physicians and
clinical specialists
Outpatient settings
Technology: To
evaluate the
relationship
between physician
IT adoption and
practice satisfaction
Survey using Likert
scale questions on
job/practice
satisfaction
NA 4
Milenkiewicz,
67
2017
United States Pre-post intervention
survey
NR Physicians
Department of Addiction
Medicine at Kaiser
Permanente
Technology: To test
the usability of an
EHR tool to
improve and
standardize the
documentation
process
NR Post-intervention 4
Wylie et al,
68
2014 United States Cross-sectional 2365 Primary care physicians
Practice with more than 10
physicians
Technology: To
identify how EHR
use affected clinical
practice
Likert-type scale
questions regarding
how EHR affected
medical practice
NA 4
a
ACGME ¼Accreditation Council for Graduate Medical Education; ACP/ASIM ¼American College of Physicians/American Society of Internal Medicine; her ¼electronic health record; ESS ¼Epworth Sleepiness Scale; JSS ¼
Physician Job Satisfaction Scale; ICU ¼intensive care unit; IT ¼information technology; MBI ¼Maslach Burnout Inventory; MEMO ¼Minimizing Error, Maximizing Outcome; NA ¼not available; NR ¼not reported; NYC ¼
New York City; OWL ¼Office and Work Life measures; PWS ¼Physician Worklife Study; RCT ¼randomized controlled trial; STAI ¼State-Trait Anxiety Inventory; WTR ¼Working Time Regulations.
b
Oxford Centre for Evidence-based Medicine Levels of evidence
18
:1b¼individual RCT (with narrow confidence interval); 2b ¼individual cohort study (including low-quality RCT; eg, <80% follow-up); 4 ¼case series (and poor-
quality cohort and case control studies).
SYSTEMATIC REVIEW ON PHYSICIAN BURNOUT
Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org 397
eligible for full-text screening. Following full-
text screening, 50 citations were included in
the study,
19e68
of which 36 (72.0%) were
full-length articles
19,21e30,32,33,35,37,39,40,42,
44,45,47e52,54,56e58,61e63,65,66,68
and 14
(28.0%) were conference
abstracts.
20,31,34,36,38,41,43,46,53,55,59,60,64,67
Study and Physician Characteristics
Table 1 presents the characteristics of the 50
included studies.
19e68
Most (40) studies were
from the United States,
19-
e23,25e32,34,36e41,43e46,49e51,55,56,58e68
followed
by Europe (5),
33,47,52,54,57
Canada (2),
42,48
Egypt
(1),
53
and multinational (2).
24,35
Study designs
included randomized controlled trials
(10),
23,28,29,37,39,40,42,45,48,51
pre-post interven-
tion surveys
(24),
20e22,25,26,30e34,36,41,46,49,54,55,57,58,61e65,67
prospective studies (5),
43,44,50,56,60
cross-sectional
studies (7),
19,38,47,52,53,66,68
and other designs
(4).
24,27,35,59
The included studies evaluated inter-
ventions among primary care physicians and res-
idents (12),
19e21,23,25,26,28,29,38,56,60,68
inpatient
and outpatient secondary care physicians (eg,
intensive care, surgery)
(15),
22,27,30,32,33,35,39,42,55,57e59,61,62,67
residents
(eg, intensive care, internal medicine, neuroradi-
ology, pediatric) (13),
36,40,43,44,47e54,65
amixture
of primary and secondary care physicians
(3),
31,63,66
and groups of physicians with specialty
unspecified (7).
24,34,37,41,45,46,64
Measures of Burnout
The most frequently used measure of burnout (15
studies) was the Maslach Burnout Inventory
(MBI), a validated measure considered the crite-
rion standard for identifying
Records identified through
database searching
(N=588)
Additional records identified
through other sources
(N=96)
Records after duplicates removed
(N=633)
Records screened
(N=633)
Records excluded
(N=493)
Full-text articles excluded (N=90):
Not published in English (n=0)
Not published between 2007-2018
(n=4)
Not a primary analysis, systematic
review, or meta-analysis (n=14)
Does not pertain to physicians (n=9)
Did not report on an inter vention for
burnout (n=51)
Did not report on outcomes of
interest (n=12)
Full-text articles
assessed for eligibility
(N=140)
Studies included
(N=50)
Included Eligibility Screening Identification
FIGURE 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow dia-
gram
69
of literature search.
MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES
398 Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org
burnout.
25,33,37,38,40,42,44,45,48e51,53,56,57
Sixteen
studies developed their own surveys to measure
outcomes related to physician burnout including
job satisfaction, burnout, depersonalization, fatigue,
and stress.
19e21,23,26,27,30,32,52,54,58,61,62,65,66,68
Additional measures included the Physician Job
Satisfaction Scale,
22,37
Epworth Sleepiness
Scale,
49,55
Office and Work Life measures,
29
sur-
vey tools from the Minimizing Error, Maximizing
Outcome study and the Physician Worklife
Study,
28
scales derived from the National
Study of the Changing Workforce,
39
Massachu-
setts eHealth Collaborative survey,
63
and
American College of Physicians/American
Society for Internal Medicine physician satis-
faction survey.
56
Two studies
34,64
provided
qualitative findings, and 10 studies did not
report the instrument used to measure
burnout.
31,35,36,41,43,46,47,59,60,67
Characteristics of Organization-Directed
Interventions
Interventions were categorized into the
“4Ts,”a unique categorization created for
this study: Teamwork, Time, Transitions, and
Technology.Figure 2 provides an overview
of the types of interventions and number of
studies that fell into each category. Teamwork
involved initiatives to incorporate scribes into
EHR processes, expand team responsibilities,
and improve communication among physi-
cians. Studies about Time evaluated the
impact of duty hour limits, schedule changes,
and time-banking initiatives. Transitions
referred to workflow changes such as process
improvement initiatives or policy changes
within the organization. Technology related
to the implementation or improvement of
EHRs.
Thirty-eight of the 50 studies were
designed to measure the effect of an
organization-directed workplace intervention
on physician burnout, job satisfaction, or
stress. Eleven of the remaining 12 studies
(22.0%) employed a workplace modification
not specifically designed to address burnout
but included outcomes related to it (the 12th
study was a systematic review of several inter-
ventions that are included in the 50 studies we
assessed). Thirty-five of the 50 workplace in-
terventions (70.0%) successfully decreased
physician burnout or stress and/or improved
job satisfaction (Figure 3). A large proportion
of interventions pertaining to Teamwork and
Transitions had a positive impact on burnout,
whereas, interventions categorized as Time
and Technology had a less consistent overall
impact on burnout.
Use of scribes for EHR 10
7
3
7
6
1
8
1
7
3
Team-based care
Communication
Schedule adjustments
Duty hour restrictions
Time banking
Process improvement
Policy change
EHR implementation
Technology Transitions Time Teamwork
EHR improvement
FIGURE 2. Number of studies by intervention type. EHR ¼electronic health record.
SYSTEMATIC REVIEW ON PHYSICIAN BURNOUT
Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org 399
Study Quality
The evaluation of study quality using the Oxford
Centre for Evidence-based Medicine Levels
of Evidence
18
is shown in Table 1.Themajority
of the studies (40 [80.0%]) were categorized
as level 4 studies, which includes case series,
pretest and posttest single-arm, cross-sectional,
and poor-quality cohort
studies.
19e22,24e27,30e36,38,41,43,44,46,47,49,50,52e68
High-quality studies were limited to Teamwork,
Time,andTransitions interventions (Figure 3).
Teamwork
Twenty of the 50 included studies focused on
improving teamwork through team-based care
models, use of scribes to enter EHR data, and
encouraging communication between phys-
icians.
19e38
All of these subcategories of team-
work generally improved burnout,
satisfaction, and stress (Table 2). A cross-
sectional survey associated greater perceived
capabilities of the care team with lower preva-
lence of exhaustion and cynicism, a higher
likelihood to recommend the clinic as a place
to work, and greater feasibility of providing
primary care.
38
Expanding the duties of med-
ical assistants to add EHR documentation,
health coaching, or navigation and/or manage-
ment of population health and between-visit
care improved survey scores of professional
fulfillment
34
and practice satisfac-
tion.
19,23,24,26,27,30,35
Notably, 9 of the 20
studies examined the impact of scribes, and
7 of the 9 studies examining the use of scribes
successfully improved clinic workflow effi-
ciencies.
20,21,23,24,26,27,30
Finally, providing
full-time clerical support for physician
order entry in primary care (n¼16) also
decreased weekly self-reported burnout (base-
line, 43%; 4-month follow-up, 14%; P¼not
reported).
20
The benefits of increasing physician-to-
physician communication by providing social
support through the availability of physical
spaces or allowing for more opportunities to
connect with their peers was evaluated in 2 tri-
als.
36,37
One of them, which randomized
1b
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100% 100% 100%
69%
80%
75%
0%
100%
88%
50%
2b
Te a m w o r k
(N=20)
Time
(N=14)
Transitions
(N=9)
Technology
(N=10)
41b2b 42b4 4
FIGURE 3. Proportion of interventions with a positive impact on burnout, stratified by intervention type
and quality of evidence. The x-axis represents the category of intervention and the study quality; the y-axis
represents the proportion of articles with a positive impact on reducing physician burnout or related
measures. Each bar describes the proportion of studies with a positive impact on physician burnout that
fell into the indicated level of quality and type of intervention. Levels of evidence: 1b ¼individual ran-
domized controlled trial (with narrow confidence interval); 2b ¼individual cohort study (including low-
quality randomized controlled trials; eg, less than 80% follow-up); 4 ¼case series (and poor-quality cohort
and case-control studies).
MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES
400 Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org
TABLE 2. Study Results Stratified by Outcome
a
Intervention category Reference, year
b
Burnout
c
Satisfaction
d
Stress
e
Teamwork
Team-based care Chapman & Blash,
19
2017 - [*-
Hung et al,
25
2018 [þþþ [þ[þþþ
Linzer et al,
28
2015 YþNS NS
Linzer et al,
29
2017 - [þþþ Yþþþ
Pierce et al,
31
2017 Y*--
Shaw et al,
34
2017 - NS -
Willard-Grace et al,
38
2017 Yþþ --
Use of scribes for EHR Contratto et al,
20
2016 Y*--
Contratto et al,
21
2017 Y*--
Danila et al,
22
2018 - NS -
Gidwani et al,
23
2017 - [þþþ -
Heaton et al,
24
2016 - [*-
Imdieke & Martel,
26
2017 - [þþþ -
Koshy et al,
27
2010 - [þþþ -
McCormick et al,
30
2018 - [þ-
Pozdnyakova et al,
32
2018 NS - -
Communication Linzer et al,
28
2015 NS [þNS
Quenot et al,
33
2012 NS - -
Was & Cornaby,
36
2016 - [*-
West et al,
37
2014 Yþ-NS
Time
Schedule adjustments Ali et al,
39
2011 Yþþ --
Garland et al,
42
2012 Yþ--
Lucas et al,
45
2012 Yþþþ --
Moeller & Walker,
46
2017 - [*-
Parshuram et al,
48
2015 NS - -
Shea et al,
51
2014 NS - -
Tucker et al,
52
2010 - - Yþþ
Duty hour restrictions Desai et al,
40
2018 Yþto Yþþþ Yþto þþþ -
Kim & Wiedermann,
43
2011 YþNS -
Landrigan et al,
44
2008 Yþþ NS -
Morrow et al,
47
2014 - - [*
Ripp et al,
49
2015 NS - -
Schuh et al,
50
2011 [þYþ-
Time banking Fassiotto & Maldonado,
41
2016 - [þ-
Transitions
Process improvement Albadry et al,
53
2014 Y*--
Amis & Osicki,
54
2018 - [*-
Callahan et al,
55
2018 - [þþ
Dunn et al,
56
2007 Yþþ NS -
Giannini et al,
57
2013 [þþ --
Hung et al,
25
2018 [þþþ [þ[þþþ
Lee et al,
58
2017 - [þþþ Yþþþ
Linzer et al,
28
2015 YþNS NS
Continued on next page
SYSTEMATIC REVIEW ON PHYSICIAN BURNOUT
Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org 401
participants by sex and specialty, compared
informal vs formal group curriculum to
enhance communication.
37
The curriculum
allowed physicians to share personal and pro-
fessional experiences, promote wellness and
mental health, and improve their understand-
ing of clinician-patient relationships. Deper-
sonalization, emotional exhaustion, and
overall burnout decreased substantially over
1 year in the group given the formal curricu-
lum and increased in the informal group
(P¼.03 and P¼.002, respectively).
37
Time
Fourteen studies evaluated the effect of inter-
ventions limiting working hours, modifying
work schedules, or promoting time banking
to relieve physician burnout or stress or
improve job satisfaction.
39e52
Of these, 8
(57.1%) reported a positive impact (Figure 3,
Table 2).
39,41e46,52
The effect on burnout of
restricting the number of hours physicians
are allowed to work, primarily residents or in-
terns, was examined in 6
studies.
40,43,44,47,49,50
Only 2 of these studies
found that limiting work hours alleviated
burnout.
43,44
Both studies evaluated outcomes
of the 2003 Accreditation Council for Grad-
uate Medical Education duty hour restrictions.
Additional studies that examined duty hour
restrictions using 2008 Institute of Medicine
and 2011 Accreditation Council for Graduate
Medical Education guidelines noted a higher
prevalence of burnout
49
and depersonaliza-
tion.
50
Similarly, according to a qualitative
evaluation of the 2009 UK Working Time Reg-
ulations (WTR), the WTR “actually increased
fatigue and stress”due to the pressure to get
the same amount of work done in a limited
time frame.
47
On the other hand, interns ran-
domized to receive 5 hours of protected time
to sleep while on call reported significantly
lower levels of MBI-assessed emotional
exhaustion and MBI-assessed depersonaliza-
tion over 6 consecutive 4-week periods.
51
Similarly, surveys of junior doctors found
that after 6 months of WTR compliance, those
working schedules that required 7 consecutive
nights experienced a greater accumulation of
fatigue when compared with those limited to
working just 3 or 4 nights in row.
52
A time-banking intervention for medical
school faculty found that institutional recogni-
tion of time spent on additional activities, such
TABLE 2. Continued
Intervention category Reference, year
b
Burnout
c
Satisfaction
d
Stress
e
Linzer et al,
29
2017 - [þþþ Yþþþ
Technology
EHR implementation Agha et al,
59
2010 - Y*-
Babbott et al,
60
2013 NS NS [þ
Beam et al,
61
2017 - [*-
Ehrlich et al,
62
2016 - NS -
Heyworth et al,
63
2012 - - [þ
Menachemi et al,
66
2009 - [þþ -
Wylie et al,
68
2014 - Yþ-
EHR improvement Joseph et al,
64
2017 - [*-
Lapointe et al,
65
2018 - [*Y*
Milenkiewicz,
67
2017 - [*-
a
The arrows indicate the directionality of the intervention on the effect of burnout, satisfaction, and stress. Improvements are denoted by green color where the associations
of the intervention on burnout or proxy measures were statistically significant. Red color indicates the intervention did not improve the burnout or proxy measure (by a
nonsignificant result) or resulted in detractions whereby the outcome measure worsened with the intervention. White content with dashes indicates no data were reported.
EHR ¼electronic health record; NS ¼not significant; þ¼P<.05; þþ ¼ P<.01; þþþ ¼ P<.001; * ¼no Pvalue reported.
b
Shultz and Holmstrom
35
was not included in this table because it is a systematic review of several interventions. The relevant interventions are already included in the table
under the original author names.
c
Burnout includes overall burnout, emotional exhaustion, depersonalization, personal accomplishment, and cynicism.
d
Satisfaction includes outcomes reported as satisfaction, professional fulfillment, well-being, and joy of practice.
e
Stress includes outcomes reported as stress, psychological strain, and job distress.
MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES
402 Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org
as teaching, clinical service, and mentorship,
improved job satisfaction (P¼.02).
41
Transitions
Nine of the 50 identified studies (18.0%) evalu-
ated the effect of workflow changes in the work-
place.
25,28,29,53e58
Eight of these studies
reported that changes to workflow redesign,
including targeted quality improvement pro-
jects and separating workflows, had a substan-
tial and positive impact on physician burnout,
job satisfaction, and/or stress (Figure 3,
Table 2).
25,28,29,53e56,58
Quality improvement
interventions that improved processes ranged
from streamlining prescribing tasks, establish-
ing quality metrics, and changing workflows.
Interventions were often described as
evidence-based or utilized a specific methodol-
ogy such as Six Sigma. The highest-quality
study from this category observed a significant
improvement in physician burnout following
the implementation of quality improvement
initiatives in areas that are most taxing for phy-
sicians, including improved routine screening
processes and medication reconciliation
(P¼.02).
28
Additionally, high-quality evidence
revealed that physician satisfaction increased
(P<.001) and stress decreased (P<.001) with
quality improvement interventions.
29
Technology
Ten studies focused on technological interven-
tions to improve efficiencies in the workplace,
and all were centered around EHR health in-
formation technology.
59e68
Five (50%) of the
10 studies reported interventions that success-
fully improved burnout, satisfaction, and/or
stress (Figure 3,Table 2).
64e68
All 3 studies
with interventions evaluating EHR improve-
ments significantly improved satisfaction and
decreased stress (Table 2).
64,65,67
With the
exception of Menachemi et al,
66
interventions
of EHR implementation in a workflow gener-
ally worsened or had no effect on burnout or
its indicators.
59,60,63,66,68
Trends identified
within these studies included perceived insuf-
ficient training contributed to EHR ineffective-
ness; EHR use by the physician within clinic
visits negatively impacted patient-centered
communication; and physician characteristics
associated with less satisfaction included older
age (>55 years), male sex, and surgical spe-
cialties. Two studies concluded that EHR
adoption
63
and EHR systems with more fea-
tures have been associated with greater physi-
cian stress.
60
Similarly, higher keyboard use
was associated with poor physician satisfaction
regarding EHR use (P¼.04).
59
Some features of EHRs and their use were
assessed to provide insights. The authors
noted that physicians who were satisfied
with various applications of information tech-
nology, including EHR usage, personal device
assistant usage, use of email with patients, and
use of disease management software, were 4
times more likely to be satisfied with their
medical practice (odds ratio, 3.97; 95% CI,
3.29-4.81).
66
A 4-year longitudinal study
correlated the following with greater satisfac-
tion with EHR adoption by physicians
(n¼119): affordability of incorporating EHRs
into the practice, greater preintervention satis-
faction with their practice, and finding that the
EHR was easy to use.
63
More personal or pro-
fessional stress before EHR implementation
was correlated with greater EHR adoption
satisfaction.
63
Physicians who reported that
they use EHRs in more sophisticated ways
(eg, for more aspects of their practice, docu-
mentation, and prescription writing) were
more likely to view EHR adoption as
improving all aspects of clinical practice in a
cross-sectional study.
68
DISCUSSION
This systematic review identified 50 studies
evaluating the effect of organization-directed
workplace interventions on physician
burnout, of which 38 were designed specif-
ically to alleviate burnout or improve its asso-
ciated indicators, such as job satisfaction,
stress, emotional exhaustion, or fatigue. The
remaining interventions were not designed to
reduce burnout but captured outcomes related
to burnout. Interventions were stratified into 4
unique categories created for this study: Team-
work,Time,Transitions, and Technology. Work-
place changes promoting Teamwork including
the use of scribes or medical assistants to
reduce the clerical burden of EHR use were
the most frequent and successful
organization-driven interventions to decrease
burnout and improve job satisfaction. Other
successful interventions included process
improvement for workplace Transitions,
schedule adjustments and time banking
SYSTEMATIC REVIEW ON PHYSICIAN BURNOUT
Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org 403
(Time), and improvements to Technology
regarding the EHR.
Physician burnout is compounded by
recent changes to clinical practice. These mod-
ifications include an increase in clerical duties,
accountability for varied quality metrics, and
organizational changes to health care delivery
including new payment and delivery ap-
proaches, EHRs, and new EHR-generated
tasks like managing patient portal communi-
cations.
70,71
Studies have documented that
for every clinical hour spent with patients,
physicians spend nearly 2 additional hours
completing administrative tasks and data entry
in the EHR
72
with up to another 2 hours of
personal time at night.
72
Although the integra-
tion of EHRs was meant to enhance the coor-
dination and quality of care, it generated
unintended consequences that appear to raise
the risk of burnout.
17
Our review results suggest that relatively
few high-quality studies have evaluated the po-
tential benefits of Transitions to workflow in
relieving and preventing physician burnout.
One highly beneficial intervention was a change
in workflow that reassigned tasks from the
physician to medical assistants, nurses, and
physician assistants.
28
This modification to
the workflow supports the team-based care
approach to reduce burnout. Quality improve-
ment (lean) interventions identified in this
study to improve unit workflow were not
designed to improve burnout per se but were
particularly successful at improving measures
related to physician burnout. These successful
interventions acknowledged that leadership
support was required to redesign workflow
with the goal of increasing staff productivity
and efficiency.
Teamwork interventions consistently
improved physician burnout, satisfaction, and
stress. High-quality evidence provided the
value of Teamwork to improve clinic workflow
efficiency, such as timely and accurate medical
record completion. Our included studies did
not generally measure the effect of teamwork
on an intermediate outcome, such as out-of-
clinic time to complete clerical work. However,
2 low-quality studies noted that productivity
increases led to fewer hours spent on EHR
documentation outside of work.
30,52
In-room
clinical and clerical support provided by medi-
cal assistants or scribes particularly for EHR
completion have reduced burnout, reallocated
time for clinical care, and improved face-to-
face patient interactions.
23,24,26,27,30,35
In sup-
port of these findings, a recent Veterans Health
Administration study determined that physi-
cian burnout was more prevalent when tasks
and responsibilities were not shared with other
team members.
73
Better communication among
staff is part of optimizing workflow, with results
from a prospective study revealing that commu-
nication improvement among staff and physi-
cians was especially effective at reducing
burnout.
28,29
Other successful Teamwork inter-
ventions supported peer-to-peer communica-
tion. Providing physicians with a sense of
community bolstered by a culture of apprecia-
tion, support, and engagement can help reduce
burnout.
37
Executive leadership can encourage
this type of professional environment by
providing protected time that allows physicians
to enhance their professional development and
engage with colleagues. This review identified a
limited number of studies evaluating
organization-directed interventions aimed at
promoting professional training and support
at work. Results from a randomized controlled
trial suggest that providing physicians with
employer-allocated support (time and sponsor-
ship) for small-group discussions focused on
mindfulness, reflections, shared experience,
and small-group learning improved empower-
ment and engagement and reduced depersonal-
ization.
37
Despite the paucity of robust studies
evaluating the benefits of leadership-driven
physician support programs, available evidence
suggests that fostering professional develop-
ment through discussion groups and training
can alleviate burnout and enhance the quality
of care.
Time interventions had mixed results on
physician burnout. One frequently mentioned
organization-directed intervention is the
impact of nationally imposed physician and
resident work hour restrictions on burnout.
In the United States, the Accreditation Council
for Graduate Medical Education has recom-
mended that residents work a maximum of
80 hours per week, with the goal of support-
ing resident well-being, furthering their educa-
tion, and improving patient safety. However,
while addressing exhaustion and burnout of
residents remains essential, the reported bene-
fits of working hour limits varied. Only 2 of
MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES
404 Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org
the 6 studies that evaluated work hour limits
for residents reported a lower rate of
burnout.
43,44
Residents or interns reported
that while working time decreased, workload
did not, which ultimately worsened stress
and fatigue.
47
Therefore, interventions focused
on restricting working hours may not be effec-
tive in reducing burnout if they only alter this
one factor and fail to address the other organi-
zational factors contributing to burnout.
Successful Technology interventions were
limited to the improvement of EHR-related
health information technology use. Even
though health information technology is
significantly contributing to burnout, there is
hope that Technology may be a remedy. The
role of clinicians has continuously evolved
over the past 2 decades from writing notes
on paper to transcribing notes. Future studies
may examine the value of leveraging voice
recognition systems to add notes to a patient’s
medical record or using digital health technol-
ogy components like clinical decision support
tools or machine learning for the augmenta-
tion of patient care.
Strengths and Limitations
To our knowledge, this is the first systematic re-
view focused exclusively on the effect of
organization-directed workplace interventions
on physician burnout. Unlike previous re-
views,
16,74
our review included 11 interventions
(22.0%) not designed to decrease burnout but
that measured burnout indicators as an indirect
outcome of system changes. As a result, this sys-
tematic review has included more workplace
intervention studies compared with earlier re-
views and taken a more explorative evaluation
of these organization-directed interventions that
could affect physician burnout. Our comprehen-
sive evaluation established the “4Ts”framework
(Teamwork,Transitions,Time,andTechnology)
to address physician burnout interventions in
the workplace, which may clarify the approach
and emphases of future research.
The findings from the systematic review are
limited primarily by differences among the
included studies. Given the range of study de-
signs, study settings, interventions, and out-
comes measured, it is not possible to compare
the effectiveness of individual workplace
changes. Follow-up times were of generally of
short duration (range, 1 week to 7 years).
Furthermore, the study results are restricted
by the limited quality of the included studies,
with 40 of the articles (80.0%) ranked as level
4 according to the Oxford Centre for
Evidence-based Medicine Levels of Evidence
18
(Table 1). All Technology studies were of poor
quality. Limited studies identified in our review
had both a robust design and used validated in-
struments to measure burnout, such as the MBI.
Additionally, few studies employed bivariate or
multivariate analyses to group individuals by
study variables. Lastly, because 14 (28.0%) of
the included studies are conference abstracts,
there is incomplete information on the study
population, interventions, and methodology,
which made it difficult to fully evaluate the
study results and quality.
Future Directions
The future of high-quality affordable care in
the United States depends on a large and dedi-
cated supply of physicians. This supply is
potentially threatened by the growing preva-
lence of physician burnout, which has signifi-
cant consequences for the health of both
physicians and patients, as well as the sustain-
ability of the health care system. Physician
burnout has expanded the health system per-
formance triple aim (improved population
health and patient care with lower costs)
75
to
the quadruple aim (triple aim plus improving
the work life of health care professionals).
76
As an example, comprehensive care can sup-
port both the triple and quadruple aims in pri-
mary care; comprehensiveness of practice
among family physicians was associated with
improved outcomes
77
and lower costs, and a
causal link between scope of practice and
physician wellness was identified.
70
In regard
to the workplace, practice redesigns that
extend the scope of practice or encourage phy-
sicians to spend more than 20% of their time
on a meaningful activity
78
may help to achieve
the quadruple aim.
The most efficacious strategy to alleviate
physician burnout will target organization-
directed changes rather than the level of the in-
dividual. Given the negative consequences of
burnout, it is imperative that executive leader-
ship within health care organizations support
the implementation of evidence-based inter-
ventions
79
that encourage Teamwork, manage
working Time requirements, Transition
SYSTEMATIC REVIEW ON PHYSICIAN BURNOUT
Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org 405
workflows, and improve Technology. However,
there may be additional information required to
understand how the workplace environment
contributes to physician burnout. The National
Academy of Medicine outlines potential organi-
zational, practice, financial, and regulatory
environment considerations to identify
increased risk of burnout.
80
Recently, a collaborative report of distin-
guished Massachusetts institutions issued a call
to action to fight physician burnout.
81
It was rec-
ommended that every major health care organi-
zation appoint an executive-level chief wellness
officer to champion burnout reduction and its
etiology. And echoing our findings, it was recom-
mended that EHR standards be improved with
strong focus on usability and open health care
application programming interfaces to better
customize system workflows and interfaces to
allow agility. Moreover, the American College
of Physicians has put forth 7 recommendations
to mitigate the adverse effects of excessive admin-
istrative tasks on physicians, patients, and the
health care system.
82
The recommendations are
alignedwiththefindings from this study,
including a focus on streamlining administrative
tasks and reducing high volumes of clerical work.
CONCLUSION
Over the past decade, most workplace interven-
tion research studied attempts to alleviate
burnout by streamlining workflow via team-
based interventions, promoting teamwork to
provide patient care and offering professional
growth and support opportunities, being mind-
ful of physician schedules and reducing their
workload, and improving use of the EHR.Dif-
ferences among studies make it difficult to
directly compare the effectiveness of each type
of intervention. However, evidence from high-
quality studies suggests that streamlining work-
flows, providing leadership-driven professional
support opportunities, and reducing the
administrative burden of EHRs through team-
based care by the use of scribes and medical as-
sistants generally improve physician burnout.
ACKNOWLEDGMENTS
We thank Dr Charles Turkelson and Dr Nicole
Fusco for careful review of the submitted
manuscript.
SUPPLEMENTAL ONLINE MATERIAL
Supplemental material can be found online at
http://www.mcpiqojournal.org. Supplemental
material attached to journal articles has not
been edited, and the authors take responsibil-
ity for the accuracy of all data.
Abbreviations and Acronyms: EHR = electronic health
record; MBI = Maslach Burnout Inventory; WTR = Working
Time Regulations
Grant Support: This study was funded by IBM Watson
Health.
Potential Competing Interests: The authors report no
competing interests.
Correspondence: Address to Kelly Jean Craig, PhD, IBM
Watson Health, 75 Binney St, Cambridge, MA 02142
(kelly.jean.craig@ibm.com).
REFERENCES
1. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout
and satisfaction with work-life balance in physicians and the
general US working population between 2011 and 2014 [pub-
lished correction appears in Mayo Clin Proc. 2016;91(2):276].
Mayo Clin Proc. 2015;90(12):1600-1613.
2. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psy-
chol. 2001;52:397-422.
3. Linzer M, Manwell LB, Williams ES, et al. Working conditions in
primary care: physician reactions and care quality. Ann Intern
Med. 2009;151(1):28-36. W6-W9.
4. Agency for Healthcare Research and Quality. Physician Burnout.
Rockville, MD: Agency for Healthcare Research and Quality;
2017. AHRQ Publication No. 17-M018-1-EF.
5. Shanafelt T, Goh J, Sinsky C. The business case for investing
in physician well-being. JAMA Intern Med. 2017;177(12):
1826-1832.
6. Sinsky CA, Dyrbye LN, West CP, Satele D, Tutty M,
Shanafelt TD. Professional satisfaction and the career plans of
US physicians. Mayo Clin Proc. 2017;92(11):1625-1635.
7. Montgomery AJ, Bradley C, Rochfort A, Panagopoulou E.
A review of self-medication in physicians and medical students.
Occup Med (Lond). 2011;61(7):490-497.
8. Schernhammer ES, Colditz GA. Suicide rates among physicians:
a quantitative and gender assessment (meta-analysis). Am J Psy-
chiatry. 2004;161(12):2295-2302.
9. Shanafelt TD, Noseworthy JH. Executive leadership and physi-
cian well-being: nine organizational strategies to promote
engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):
129-146.
10. Balch CM, Oreskovich MR, Dyrbye LN, et al. Personal conse-
quences of malpractice lawsuits on American surgeons. JAm
Coll Surg. 2011;213(5):657-667.
11. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and med-
ical errors among American surgeons. Ann Surg. 2010;251(6):
995-1000.
12. Zhang Y, Feng X. The relationship between job satisfaction,
burnout, and turnover intention among physicians from urban
state-owned medical institutions in Hubei, China: a cross-
sectional study. BMC Health Serv Res. 2011;11:235.
13. Landon BE, Reschovsky JD, Pham HH, Blumenthal D. Leaving
medicine: the consequences of physician dissatisfaction. Med
Care. 2006;44(3):234-242.
MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES
406 Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org
14. Sibbald B, Bojke C, Gravelle H. National survey of job satisfac-
tion and retirement intentions among general practitioners in
England. BMJ. 2003;326(7379):22.
15. Buchbinder SB, Wilson M, Melick CF, Powe NR. Estimates of
costs of primary care physician turnover. Am J Manag Care.
1999;5(11):1431-1438.
16. Panagioti M, Panagopoulou E, Bower P, et al. Controlled inter-
ventions to reduce burnout in physicians: a systematic review
and meta-analysis. JAMA Intern Med. 2017;177(2):195-205.
17. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting
physician professional satisfaction and theirimplications for patient
care, healthsystems, and health policy. Rand Health Q.2014;3(4):1.
18. Oxford Centre for Evidence-based Medicine eLevels of Evi-
dence (March 2009). Centre for Evidence-Based Medicine web-
site. https://www.cebm.net/2009/06/oxford-centre-evidence-
based-medicine-levels-evidence-march-2009/. Accessed June
20, 2019.
19. Chapman SA, Blash LK. New roles for medical assistants in
innovative primary care practices. Health Serv Res. 2017;
52(suppl 1):383-406.
20. Contratto EC, Estrada C, Romp KG, Agne A, Willett LL. The
impact of physician order entry clerical support on physician
satisfaction and productivity [abstract]. J Gen Intern Med.
2016;31(2, suppl):S912-S913.
21. Contratto E, Romp K, Estrada CA, Agne A, Willett LL. Physician
order entry clerical support improves physician satisfaction and
productivity. South Med J. 2017;110(5):363-368.
22. Danila MI, Melnick JA, Curtis JR, Menachemi N, Saag KG. Use of
scribes for documentation assistance in rheumatology and
endocrinology clinics: impact on clinic workflow and patient
and physician satisfaction. J Clin Rheumatol. 2018;24(3):116-121.
23. Gidwani R, Nguyen C, Kofoed A, et al. Impact of scribes on physi-
cian satisfaction, patient satisfaction, and charting efficiency: a ran-
domized controlled trial. Ann Fam Med. 2017;15(5):427-433.
24. Heaton HA, Castaneda-Guarderas A, Trotter ER, Erwin PJ,
Bellolio MF. Effect of scribes on patient throughput, revenue,
and patient and provider satisfaction: a systematic review and
meta-analysis. Am J Emerg Med. 2016;34(10):2018-2028.
25. Hung DY, Harrison MI, Truong Q, Du X. Experiences of pri-
mary care physicians and staff following lean workflow redesign.
BMC Health Serv Res. 2018;18(1):274.
26. Imdieke BH, Martel ML. Integration of medical scribes in the pri-
mary care setting: improving satisfaction. J Ambul Care Manage.
2017;40(1):17-25.
27. Koshy S, Feustel PJ, Hong M, Kogan BA. Scribes in an ambula-
tory urology practice: patient and physician satisfaction. J Urol.
2010;184(1):258-262.
28. Linzer M, Poplau S, Grossman E, et al. A cluster randomized
trial of interventions to improve work conditions and clinician
burnout in primary care: results from the Healthy Work Place
(HWP) Study. J Gen Intern Med. 2015;30(8):1105-1111.
29. Linzer M, Poplau S, Brown R, et al. Do work condition interven-
tions affect quality and errors in primary care? results from the
Healthy Work Place Study. J Gen Intern Med. 2017;32(1):56-61.
30. McCormick BJ, Deal A, Borawski KM, et al. Implementation of
medical scribes in an academic urology practice: an analysis of
productivity, revenue, and satisfaction. World J Urol. 2018;
36(10):1691-1697.
31. Pierce RG, Anoff D, Cumbler E, et al. A team-based and organiza-
tional framework for fostering resilience and well-being in aca-
demic hospital medicine. Paper presented at: American
Conference on Physician Health; October 12-13, 2017; San Fran-
cisco, CA. Abstract book, pp 1-2. Stanford Medicine website,
https://med.stanford.edu/content/dam/sm/CME/documents/
brochures/2017/ACPH-Abstract-Book-FULL.pdf.Accessed
September 11, 2019.
32. Pozdnyakova A, Laiteerapong N, Volerman A, et al. Impact of
medical scribes on physician and patient satisfaction in primary
care. J Gen Intern Med. 2018;33(7):1109-1115.
33. Quenot JP, Rigaud JP, Prin S, et al. Suffering among carers work-
ing in critical care can be reduced by an intensive communica-
tion strategy on end-of-life practices. Intensive Care Med. 2012;
38(1):55-61.
34. Shaw JG, Brown-Johnson C, Chan G, Mahoney M, Winget M.
Physician burnout and joy of practice: early mixed-methods
findings from the implementation of Stanford Primary Care 2.
0 [abstract]. J Gen Intern Med. 2017;32(suppl 2):S272.
35. Shultz CG, Holmstrom HL. The use of medical scribes in health
care settings: a systematic review and future directions. JAm
Board Fam Med. 2015;28(3):371-381.
36. Was A, Cornaby T. The ideal gas lounge: boosting resident happi-
ness with empowerment and common space improvements. Paper
presented at: International Conference on Physician Health
September 18-20, 2016. Boston, MA.
37. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to pro-
mote physician well-being, job satisfaction, and professional-
ism: a randomized clinical trial. JAMA Intern Med. 2014;
174(4):527-533.
38. Willard-Grace R, Knox M, Huang B, Bodenheimer T,
Grumbach K. Clinician perception of team support, burnout
and “doability”of primary care. Paper presented at: American
Conference on Physician Health; October 12-13, 2017; San
Francisco, CA. Abstract book, p 20. Stanford Medicine website,
https://med.stanford.edu/content/dam/sm/CME/documents/
brochures/2017/ACPH-Abstract-Book-FULL.pdf. Accessed
September 11, 2019.
39. Ali NA, Wolf KM, Hammersley J, et al; Midwest Critical Care
Consortium. Continuity of care in intensive care units: a
cluster-randomized trial of intensivist staffing. Am J Respir Crit
Care Med. 2011;184(7):803-808.
40. Desai SV, Asch DA, Bellini LM, et al; iCOMPARE Research
Group. Education outcomes in a duty-hour flexibility trial in in-
ternal medicine. N Engl J Med. 2018;378(16):1494-1508.
41. Fassiotto MA, Maldonado YA. A time banking system to support
workplace flexibility. Paper presented at: International Conference
on Physician Health September 18-20, 2016. Boston, MA.
42. Garland A, Roberts D, Graff L. Twenty-four-hour intensivist
presence: a pilot study of effects on intensive care unit patients,
families, doctors, and nurses. Am J Respir Crit Care Med. 2012;
185(7):738-743.
43. Kim H, Wiedermann B. Have Accreditation Council for Graduate
Medical Education duty hour limits made a difference? a re-
examination of resident sleep, mental health,education, and safety
seven years la ter [abstra ct]. JInvestigMed. 2 011;59:630 -631.
44. Landrigan CP, Fahrenkopf AM, Lewin D, et al. Effects of the
Accreditation Council for Graduate Medical Education duty
hour limits on sleep, work hours, and safety. Pediatrics. 2008;
122(2):250-258.
45. Lucas BP, Trick WE, Evans AT, et al. Effects of 2- vs 4-week
attending physician inpatient rotations on unplanned patient re-
visits, evaluations by trainees, and attending physician burnout: a
randomized trial. JAMA. 2012;308(21):2199-2207.
46. Moeller MF, Walker C. Practice refresh: A 1-month interven-
tion to rebuild physician efficiency and wellness. Paper pre-
sented at: American Conference on Physician Health;
October 12-13, 2017; San Francisco, CA. Abstract book, pp
27-28. Stanford Medicine website, https://med.stanford.edu/
content/dam/sm/CME/documents/brochures/2017/ACPH-
Abstract-Book-FULL.pdf. Accessed September 11, 2019.
47. Morrow G, Burford B, Carter M, Illing J. Have restricted working
hours reduced junior doctors' experience of fatigue? a focus
group and telephone interview study. BMJ Open. 2014;4(3):
e004222.
48. Parshuram CS, Amaral AC, Ferguson ND, et al; Canadian Crit-
ical Care Trials Group. Patient safety, resident well-being and
continuity of care with different resident duty schedules in
the intensive care unit: a randomized trial. CMAJ. 2015;187(5):
321-329.
SYSTEMATIC REVIEW ON PHYSICIAN BURNOUT
Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org 407
49. Ripp JA, Bellini L, Fallar R, Bazari H, Katz JT, Korenstein D. The
impact of duty hours restrictions on job burnout in internal
medicine residents: a three-institution comparison study. Acad
Med. 2015;90(4):494-499.
50. Schuh LA, Khan MA, Harle H, et al. Pilot trial of IOM duty hour
recommendations in neurology residency programs: unin-
tended consequences [published correction appears in
Neurology. 2011;77(18):1712]. Neurology. 2011;77(9):883-887.
51. Shea JA, Bellini LM, Dinges DF, et al. Impact of protected sleep
period for internal medicine interns on overnight call on
depression, burnout, and empathy. J Grad Med Educ. 2014;
6(2):256-263.
52. Tucker P, Brown M, Dahlgren A, et al. The impact of junior
doctors' worktime arrangements on their fatigue and well-be-
ing. Scand J Work Environ Health. 2010;36(6):458-465.
53. Albadry AA, Sleem AN, Montasser NA, Naggar E-SAE. Effect of
quality improvement intervention on occupational burnout in Man-
soura University Hospitals, Egypt. Paper presented at: WELL-Med
Conference May 28-June 1, 2014. Alexandroupolis, Greece.
54. Amis SM, Osicki THE. Can patient safety be improved by
reducing the volume of "inappropriate prescribing tasks"
handed over to out-of-hours junior doctors? Int J Gen Med.
2018;11:105-112.
55. Callahan S, Enfield KB, Sturek J, et al. An innovative, evidence-
based, fellow-driven bundle to improve professional satisfaction
and wellness [abstract]. Am J Resp Crit Care Med. 2018;197:
A4498.
56. Dunn PM, Arnetz BB, Christensen JF, Homer L. Meeting the
imperative to improve physician well-being: assessment of an
innovative program. J Gen Intern Med. 2007;22(11):1544-1552.
57. Giannini A, Miccinesi G, Prandi E, Buzzoni C, Borreani C; ODIN
Study Group. Partial liberalization of visiting policies and ICU
staff: a before-and-after study. Intensive Care Med. 2013;
39(12):2180-2187.
58. Lee MH, Schemmel AJ, Pooler BD, et al. Radiology workflow dy-
namics: how workflow patterns impact radiologist perceptions of
workplace satisfaction. Acad Radiol. 2017;24(4):483-487.
59. Agha Z, Roter D, Laud P, et al. Patient-centered communica-
tion and physicians use of electronic medical records. J Gen
Intern Med. 2010;25(suppl 3):S344.
60. Babbott S, Manwell L, Brown R, et al. Electronic health records
and physician stress in primary care: results from the MEMO
Study. J Am Med Inform Assoc. 2014;21:e100-e106.
61. Beam KS, Cardoso M, Sweeney M, Binney G, Weingart SN.
Examining perceptions of computerized physician order entry
in a neonatal intensive care unit. Appl Clin Inform. 2017;8(2):
337-347.
62. Ehrlich JR, Michelotti M, Blachley TS, et al. A two-year longitu-
dinal assessment of ophthalmologists' perceptions after imple-
menting an electronic health record system. Appl Clin Inform.
2016;7(4):930-945.
63. Heyworth L, Zhang F, Jenter CA, et al. Physician satisfaction
following electronic health record adoption in three Massachu-
setts communities. Interact J Med Res. 2012;1(2):e12.
64. Joseph C, Ross E, Tuyen L. Rebooting the joy of practice ¼clin-
ical/operational leadership þworkflow standardization þtech-
nology. Paper presented at: American Conference on Physician
Health; October 12-13, 2017; San Francisco, CA. Abstract
book, pp 29-30. Standord Medicine website, https://med.
stanford.edu/content/dam/sm/CME/documents/brochures/
2017/ACPH-Abstract-Book-FULL.pdf. Accessed September
11, 2019.
65. Lapointe R, Bhesania S, Tanner T, Peruri A, Mehta P. An inno-
vative approach to improve communication and reduce
physician stress and burnout in a university affiliated residency
program. J Med Syst. 2018;42(7):117.
66. Menachemi N, Powers TL, Brooks RG. The role of information
technology usage in physician practice satisfaction. Health Care
Manage Rev. 2009;34(4):364-371.
67. Milenkiewicz RV. The less clicks the better: improving the docu-
mentation workflow process for physicians. Paper presented at:
American Conference on Physician Health; October 12-13,
2017; San Francisco, CA. Abstract book, pp 97-98. Stanford
Medicine website, https://med.stanford.edu/content/dam/sm/
CME/documents/brochures/2017/ACPH-Abstract-Book-FULL.
pdf. Accessed September 11, 2019.
68. Wylie MC, Baier RR, Gardner RL. Perceptions of electronic
health record implementation: a statewide survey of physicians
in Rhode Island. Am J Med. 2014;127(10). 1010.e21-e27.
69. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group.
Preferred reporting items for systematic reviews and meta-
analyses: the PRISMA statement. Ann Intern Med. 2009;151:
264-269.
70. Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Burnout among
health care professionals: a call to explore and address this
underrecognized threat to safe, high-quality care. NAM Perspec-
tives. 2017. https://doi.org/10.31478/201707b.
71. Bohman B, Dyrbye L, Sinsky CA, et al. Physician well-being: the
reciprocity of practice efficiency, culture of wellness, and per-
sonal resilience. NEJM Catalyst website, https://catalyst.nejm.
org/physician-well-being-efficiency-wellness-resilience/. Published
April 26, 2017. Accessed February 9, 2018.
72. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in
ambulatory practice: a time and motion study in 4 specialties.
Ann Intern Med. 2016;165(11):753-760.
73. Kim LY, Rose DE, Soban LM, et al. Primary care tasks associated
with provider burnout: findings from a Veterans Health Admin-
istration survey. J Gen Intern Med. 2018;33(1):50-56.
74. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to
prevent and reduce physician burnout: a systematic review and
meta-analysis. Lancet. 2016;388(10057):2272-2281.
75. Bazemore A, Petterson S, Peterson LE, Phillips RL Jr. More
comprehensive care among family physicians is associated
with lower costs and fewer hospitalizations. Ann Fam Med.
2015;13(3):206-213.
76. Berwick DM, Nolan TW, Whittington J. The triple aim: care,
health, and cost. Health Aff (Millwood). 2008;27(3):759-769.
77. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of
the patient requires care of the provider. Ann Fam Med. 2014;
12(6):573-576.
78. Shanafelt TD, West CP, Sloan JA, et al. Career fit and burnout
among academic faculty. Arch Intern Med. 2009;169(10):99 0-995.
79. Suchman AL. The influence of health care organizations on
well-being. West J Med. 2001;174(1):43-47.
80. Weidner AKH, Phillips RL Jr, Fang B, Peterson LE. Burnout and
scope of practice in new family physicians [published correction
appears in Ann Fam Med. 2018;16(4):289]. Ann Fam Med. 2018;
16(3):200-205.
81. Jha AK, Iliff AR, Chaoui AA, Defossez S, Bombaugh MC, Miller YA.
A Crisis in Health Care: A Call to Action on Physician Burnout.Wal-
tham, MA: Massachusetts Medical Society, Massachusetts Health
and Hospital Association, Harvard T.H. Chan School of Public
Health, and Harvard Global Health Institute; 2019.
82. Erickson SM, Rockwern B, Koltov M, McLean RM; Medical Prac-
tice and Quality Committee of the American College of Physi-
cians. Putting patients first by reducing administrative tasks in
health care: a position paper of the American College of Phy-
sicians. Ann intern Med. 2017;166(9):659-661.
MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES
408 Mayo Clin Proc Inn Qual Out nDecember 2019;3(4):384-408 nhttps://doi.org/10.1016/j.mayocpiqo.2019.07.006
www.mcpiqojournal.org
