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What if the electronic health record (EHR) said to doctors working late: "Hey, it's 11 p.m. Do you really have to respond to that email tonight or can it wait until the morning? You need your sleep so you don't burn out."

Sending a gentle electronic nudge like that directly to physicians still on their charts and answering patient emails late at night was among several suggestions for preventing physician exhaustion offered during a on Thursday hosted by the American Medical Association (AMA) as part of its ongoing efforts to combat the problem.

"This has been a tough 3 years for our profession, and many drivers of burnout remain," said AMA President Jack Resneck Jr., MD, the moderator of the webinar, which was entitled "#FightingForDocs: AMA Recovery Plan Webinar on Addressing Physician Burnout."

Those drivers include the so-called "tripledemic" of viral illness that is stretching practices and hospitals "too thin," and anti-science aggression and misinformation, especially "by some in positions of power and influence," along with a "well-coordinated onslaught of medical disinformation on social media and other channels," he said.

At the same time, other pressures are wearing doctors down. Resneck said physicians are fighting the "recent criminalization of comprehensive reproductive healthcare in many states." On top of that, physicians are wrestling with health plans' "bloated prior authorization obstacles" that force them to spend hours each week "fighting to get treatments approved while patient care is delayed and denied."

'Toxic Environment'

These factors have created a "toxic environment" that hampers the ability of physicians to do what drew them to medicine in the first place: delivering compassionate care, Resneck said.

"Burnout is real, and it's rising," he said, adding that a showed that nearly two-thirds of physicians experienced symptoms of burnout in 2021 and that one in five physicians intends to leave the practice within 2 years.

U.S. Surgeon General Vivek Murthy, MD, MBA, said many "structural changes" in the system prohibit clinicians from getting the care they should when they become overwhelmed.

"We have to ask, why is it so hard for people to step forward?" he said.

First, he explained, lower-income health workers don't always have insurance coverage. But there's also a cultural issue of stigma. "There's so many people in our profession who don't feel comfortable asking for help, or getting help when it's available," Murthy said.

Second, leaders of medical societies and hospitals and clinics who do get help should do so publicly, Murthy suggested. "It helps other clinicians see that it's okay ... [to] talk about their struggles. It doesn't make them weak. It actually makes them human, and other people can see themselves in them."

Third is the need to gather more data that show how "deeply clinicians across the board are affected by mental health concerns -- that it's not the concern of 1% or 2%," but rather the vast majority at some point experience depression or anxiety or struggle with managing stress or the loneliness and isolation that sometimes comes with work, he said.

Fourth is to revise state licensing processes to remove questions that "make you scared, potentially, to be honest about the fact that you've had to seek [mental health] care," Murthy said.

Resneck said some state licensing agencies have made progress toward this and now ask only if there is any current impairment, and not about something that happened, say, 5 years ago.

Prior Authorization

And about that prior authorization. Murthy noted that a Centers for Medicare & Medicaid Services' would, if finalized, prohibit Medicare Advantage (MA) plans from denying or delaying many procedures through prior authorization. It would require MA plans to approve care under Medicare's coverage decisions, and prohibit denials based on "internal, proprietary, or external clinical criteria." It also would require all MA plans to establish utilization management committees to ensure that policies are aligned with Medicare's coverage decisions.

"I've had, and all of us have had, our personal stories ... battling prior authorizations," Murthy said. It's hard enough sometimes to diagnose and determine a treatment, but then to "be denied the care ... because of a bureaucratic process that often feels like it's set up to inhibit care and prevent expenditures rather than improve quality of care -- it hurts patients and doctors and blow after blow, when you're struck by that day after day, it's tough and incredibly difficult to not lose faith sometimes in the system."

Murthy said a "heartbreaking" driver of burnout is the disinformation that has led patients to question scientists and clinicians to the point of vitriol lodged against their doctors.

"Imagine going to a job where we think there's an 80% chance that you're going to be abused. Who would want to come to work? Yet our colleagues continue to show up," Murthy said.

Email Now?

As to how to fix these issues, several wellness experts offered other solutions.

Anjalee Galion, MD, a pediatric neurologist and physician wellness officer at Children's Hospital of Orange County (CHOC) in Southern California, said it's so important for physicians to realize they need a good night's sleep to prevent burnout.

Galion noted that new research has shown that during sleep, "the brain is actually getting rid of the connections that you don't need, and helping strengthen the ones you do," so when a physician wakes up, "we have better executive function, better cognitive performance."

She said with leadership buy-in you can, with "gentle prompts," change the time a doctor responds to an email. "The Microsoft system will actually say, 'Hey, do you need to send this email now? Why don't you wait until business hours?'" Galion said. "You don't need to respond 24 hours a day, on Saturday night."

CHOC is also looking at the EHR as a tool to measure physician burnout by finding out how many clicks it takes to get through a patient chart. The digital platform can be seen not just as a tool to help patients, but also "as a mirror to see what's going on in our organization," Galion said.

Christine Sinsky, MD, AMA's vice president for professional satisfaction, said health systems must get away from the idea that burnout is the result of individual weakness. With 63% of physicians saying they experience burnout, it means it's not a problem that can be fixed by telling doctors to do yoga or mindfulness meditation, she said.

"We need to focus on fixing the workplace," and reduce administrative burden, Sinsky said. Health systems will pay more attention if they realize the return on investment, because burnout is costing the health system $4.6 billion a year.

For a system with 1,000 physicians, she said, "you're already investing over $13 million every single year just replacing those physicians who leave your organization, not for a better job, not for career advancement, but who leave because of burnout."

Nigel Girgrah, MD, PhD, chief wellness officer and medical director of liver transplantation at Ochsner Health in New Orleans, talked about the importance of leaders like himself opening up to their colleagues about their struggles with tough times, like the death of his son from cancer, and general anxiety during the first year of COVID.

He decided to write about his own struggles in a . He thought the response would be so-so. But hundreds of people reached out to him, sharing their own stories, he said, and many called it a call-to-action for clinicians to seek help. It destigmatized the problem and helped others reach out too, he said.

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