Organizations and practice environments, Article 2 of 2

by Jeremy Lazarus, MD, Past President, American Medical Association; and Alexander von Hafften, MD, Physician Health Committee, Alaska State Medical Association

This is the second of three articles on physician burnout. The first ran in the fourth-quarter 2021 issue of Colorado Medicine and the third will run in the second-quarter issue 2022. Burnout is a syndrome of emotional exhaustion, depersonalization, cynicism, detachment and sense of low personal accomplishment.(1) Approximately 50 percent of physicians and medical students were experiencing burnout prior to the COVID pandemic.(2,3)

Interventions to prevent burnout that are only directed at individual physicians and medical students are insufficient. This article summarizes a general framework for organizational and practice environment interventions to prevent and reduce physician and medical student burnout.

Physician and medical student vulnerability

Competitiveness, perfectionism and goal orientation are rewarded on the pathway to becoming a physician. Conscientiousness, obsessiveness, self-doubt and sense of responsibility are reinforced by medical training and clinical practice. These characteristics contribute to the belief that burnout is a deficit of individual resilience. Yes, some physicians and medical students may be vulnerable to burnout, but most physicians and medical students are very resilient. Burnout is an individual response to a systemic problem, not a deficit of individual resilience.

When beginning medical school, medical students have better well-being than age-group peers.(3) The risk for burnout begins early in medical training. During medical school, medical students have more symptoms of burnout than nonmedical graduate students.(3) Burnout increases during residency with prevalence rates between 41-90 percent.(3) The Accreditation Council for Graduate Medical Education (ACGME) duty hour limits have not improved sleep, reduced clinical errors or reduced burnout.(3)

Impacts on patients and organizations

Physician burnout decreases quality of care, patient safety and patient satisfaction; increases malpractice risk; and may increase hospital admissions and readmissions.(3,4,5,6) Physician burnout decreases physician engagement and productivity and increases early retirement and physician turnover.(3,7) Replacing a physician costs 2-3 times a physician’s annual salary. The mean cost to replace a physician is $500,000 to $1,000,000.(3,7)

Two common organization myths about physician burnout are: 1) creating a culture of physician wellbeing conflicts with other organization objectives, and 2) effective interactions are cost prohibitive.(8) Both myths are false.

Call to action

In 1989, the American College of Emergency Physicians (ACEP) raised the alarm about declining professional wellbeing. Since the 2000s, concern and momentum have increased. Organizations including the National Academy of Medicine (NAM), American Medical Association (AMA), American Association of Medical Colleges (AAMC), and the ACGME have led efforts to increase awareness of burnout and to improve the conditions and circumstances driving burnout.

In 2016, the AMA hosted a summit of leading health care organization CEOs. The CEOs unanimously concluded that physician burnout is a pressing issue of national importance for patients and the health care delivery system; and physician well-being is critical to the long-term clinical and financial success of health care organizations.(4)

In 2018, the Federation of State Medical Boards (FSMB) adopted a policy regarding physician wellness and burnout. The FSMB policy includes recommendations for state medical boards, state governments, the Centers for Medicare and Medicaid Services (federal CMS), accreditation organizations, insurers, EHR vendors, hospitals, employers, professional medical societies, training programs and physicians.(9)

Organization and practice environment

Shanafelt and Noseworthy summarized, “extensive evidence suggests that the organization and practice environment play critical roles in whether physicians remain engaged or burn out.”8 They use a five by seven matrix to illustrate how national, organizational, work unit and individual factors may contribute to burnout. Any specific factor contributes to at least one of seven dimensions driving burnout.

The seven dimensions include:(8)

  1. Workload and job demands
  2. Efficiency and resources
  3. Meaning in work
  4. Culture and values
  5. Control and flexibility
  6. Social support and community at work
  7. Work-life integration

In the same publication, Shanafelt and Noseworthy summarized interventions into nine organization strategies to reduce burnout.

The nine organization strategies include:(8)

  1. Acknowledge, assess physician well-being and burnout
  2. Select leaders who have the ability to listen, engage, develop and lead physicians
  3. Develop and implement targeted work unit interventions
  4. Cultivate community at work
  5. Incentivize quality of care and patient satisfaction rather than production
  6. Align values and strengthen culture consistent with organizational mission
  7. Promote flexibility and work-life balance
  8. Provide resources to promote resilience and self-care
  9. Institute, evaluate and fund evidence-based strategies to reduce burnout

Members of a specific work unit determine which dimension is most important and which strategies to implement.(8)


  1. Physician wellbeing is the foundation of health care quality and outcomes.
  2. Physician wellbeing is a shared responsibility and interventions must be comprehensive and sustainable.
  3. The organization and practice environment must have a culture of wellness for physicians as well as for patients.
  4. Reducing physician burnout begins by creating a culture of wellness, optimizing workflows and supporting personal resilience.
  5. Physician wellbeing must be measured and organizational leaders rewarded for improvements and accountable for decreases – just like other mission-critical goals.

Recommendations and resources to promote individual physician health and wellbeing

What resources are available for physicians regarding self-care and wellness? What resources are available for physicians feeling burned out? The third article will provide recommendations and resources to promote individual physician health and wellbeing.


  1. Maslach C, Jackson SE: The measurement of experienced burnout. Journal of Occupational Behavior 2:99-113, 1981
  2. Dyrbye LN, Shanafelt, CA, Sinsky PF et al: Burnout among health care professionals: A call to explore and address this underrecognized threat to safe, high-quality care. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC, 2017
  3. American Psychiatric Association. APA Wellbeing Ambassador Toolkit Physician Burnout and Depression: Challenges and Opportunities, Slide 16, January 2018
  4. Noseworthy J, Madara J, Cosgrove D, et al: Physician burnout is a public health crisis: A message to our fellow health care CEOs [Internet]. Health Affairs. March 2017
  5. Shanafelt, TD: Enhancing meaning in work: prescriptions for preventing physician burnout and promoting-patient centered care. JAMA 302(12):1338-1340, 2009
  6. Shanafelt, TD, Balch CM, Bechamps G, et al: Burnout and medical errors among American surgeons. Ann Surg 251(6):995-1000, 2010
  7. Shanafelt T, Goh J, Sinsky C: The business case for investing in physician well-being. JAMA Internal Medicine 177(12):1826-1821, 2017
  8. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clinic Proceedings 92(1):129–46, 2017
  9. Federation of State Medical Boards, Policy 2018. Physician wellness and burnout. 2018. Available from:

This article was originally published in the Alaska State Medical Association (ASMA) bimonthly newsletter, Heartbeat.

It has been reprinted with permission.

Categories: Communications, Colorado Medicine, Resources, Initiatives, Physician Wellbeing Resource Center