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Figure.  Mini Z 2.0 Surveya
Mini Z 2.0 Surveya

aThe Mini Z was developed by Mark Linzer, MD and a team at Hennepin Healthcare, Minneapolis, Minnesota. The Mini Z survey tool can be used for research, program evaluation and education capacities without restriction. Permission for commercial or revenue-generating applications of the Mini Z must be obtained from Mark Linzer, MD, or the Hennepin Healthcare Institute for Professional Worklife prior to use (www.professionalworklife.com).

bIf you select option 1 or 2, please consider seeking assistance; call your insurance provider or employee assistance plan.

Table.  Overall and Sex-Specific Scores on Satisfaction, Stress, and Burnout and Risk Factors for Burnout Among Internists and Trainees Enrolled in a Well-being Champion Program
Overall and Sex-Specific Scores on Satisfaction, Stress, and Burnout and Risk Factors for Burnout Among Internists and Trainees Enrolled in a Well-being Champion Program
1.
Shanafelt  TD, West  CP, Sinsky  C,  et al.  Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017.   Mayo Clin Proc. 2019;94(9):1681-1694. doi:10.1016/j.mayocp.2018.10.023PubMedGoogle ScholarCrossref
2.
Khandelwal  A, Mehta  L, Lilly  S, Velagapudi  P.  The imperative of addressing clinician well-being.   J Am Coll Cardiol. 2020;75(1):118-121. doi:10.1016/j.jacc.2019.12.001PubMedGoogle ScholarCrossref
3.
Erickson  SM, Rockwern  B, Koltov  M, McLean  RM; Medical Practice and Quality Committee of the American College of Physicians.  Putting patients first by reducing administrative tasks in health care: a position paper of the American College of Physicians.   Ann Intern Med. 2017;166(9):659-661. doi:10.7326/M16-2697PubMedGoogle ScholarCrossref
4.
Olson  K, Sinsky  C, Rinne  ST,  et al.  Cross-sectional survey of workplace stressors associated with physician burnout measured by the Mini-Z and the Maslach Burnout Inventory.   Stress Health. 2019;35(2):157-175. doi:10.1002/smi.2849PubMedGoogle ScholarCrossref
5.
Linzer  M, Poplau  S, Babbott  S,  et al.  Worklife and wellness in academic general internal medicine: results from a national survey.   J Gen Intern Med. 2016;31(9):1004-1010. doi:10.1007/s11606-016-3720-4PubMedGoogle ScholarCrossref
6.
McMurray  JE, Linzer  M, Konrad  TR, Douglas  J, Shugerman  R, Nelson  K; The SGIM Career Satisfaction Study Group.  The work lives of women physicians results from the physician work life study.   J Gen Intern Med. 2000;15(6):372-380. doi:10.1111/j.1525-1497.2000.im9908009.xPubMedGoogle Scholar
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    1 Comment for this article
    EXPAND ALL
    EHR Is Responsible More than Any Other For Burnout.
    Edward Volpintesta, MD | retired general practitioner
    This informative article 1 adds to our knowledge of what causes burnout among physicians. Of the several stressors mentioned, it seems that EHR is the most insidious and pervasive.
    It causes distraction as physicians pluck away on their computers inputting information that adds nothing to patient care. It is time-consuming and takes time away from examining patients. It can lead to medical errors that harm patients and prompt liability suits.
    Dealing with EHR has been defined as physicians’ most onerous issue--their number one “pain point".2
    In addition EHR’s can adversely affect the ambiance of the physicians’ workplace as well. One study reported that in offices where EHR was used, physicians had less connection with one another and were less likely to see and help one another.3
    Clearly, EHR is transforming the practice of medicine. Its dehumanizing effects on physicians and patients has gone on for too long. Without clear data that it improves patient care and that it has become user-friendly to physicians it should be abolished.


    1.Evaluation of Work Satisfaction, Stress, and Burnout Among US Internal Medicine Physicians and Trainees October 14, 2020
    Mark Linzer, MD1; Cynthia D. Smith, MD2,9; Susan Hingle, MD3; et alSara Poplau, BA4; Richard Miranda, MD5; Rebecca Freese, MS6; Kerri Palamara, MD7,8 JAMA Netw Open. 2020;3(10):e2018758. doi:10.1001/jamanetworkopen.2020.18758
    2. Hawkins M. 2018 Survey of America’s Physicians: Practice Patterns & Perspectives. 2018.https://physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf.
    3. Gawande A. Association of Electronic Health Record Design and Use Factors With Clinician Stress and Burnout. New Yorker Magazine November 12, 201
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Research Letter
    Health Policy
    October 14, 2020

    Evaluation of Work Satisfaction, Stress, and Burnout Among US Internal Medicine Physicians and Trainees

    Author Affiliations
    • 1Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota
    • 2Medical Education Division, American College of Physicians, Philadelphia, Pennsylvania
    • 3Department of Medicine, Southern Illinois University, Springfield
    • 4Hennepin Healthcare Research Institute, Minneapolis, Minnesota
    • 5Department of Medicine, Division of Graduate Medical Education, SCL Health, Saint Joseph Hospital, Denver, Colorado
    • 6Clinical and Translational Science Institute, Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis
    • 7Center for Physician Well-being, Massachusetts General Hospital, Boston
    • 8Department of Medicine, Harvard Medical School, Boston, Massachusetts
    • 9Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
    JAMA Netw Open. 2020;3(10):e2018758. doi:10.1001/jamanetworkopen.2020.18758
    Introduction

    The clinician burnout epidemic has prompted calls for action by many national organizations.1,2 Few baseline data are available on the state of burnout among internal medicine physicians and trainees.3 Beginning in 2015, we developed a Well-being Champion (WC) program through the American College of Physicians (ACP) to train leaders to support well-being and measure change throughout the ACP membership worldwide. Herein we describe the survey responses from 1305 internists and internal medicine trainees who participated in the program across 18 ACP chapters and identify potential contributors to burnout as well as sex-based differences in burnout.

    Methods

    This study was approved by the Partners Healthcare Institutional Review Board, which waived the requirement for informed consent because only deidentified data were used. A well-being curriculum was delivered (in 2018 and 2019) to approximately 150 ACP chapter-designated WC programs. To understand well-being among chapter members, some WC programs asked members to complete the Mini Z worklife survey. Some WC programs included residents, fellows, and students among those surveyed, whereas others did not. The Mini Z survey measures satisfaction, stress, and burnout and their risk factors, and it is validated against the Maslach Burnout Inventory.4 The most recent version of the Mini Z survey (2.0) (Figure) aligns positive scores for the 10 items with a possible summary score of 50. Two 5-item subscales have total scores of 25. A joyful workplace is defined by a summary score of 40 or higher; a supportive work environment is represented by a subscale score of 20 or higher (score range, 5-25) , and a reasonable work pace and stress level associated with electronic medical record (EMR) use is represented by a subscale score of 20 or higher. Data from 1305 Mini Z surveys were summarized using counts and frequencies with predetermined cutoffs.5 Multiple logistic regression models were used to assess risk factors of burnout and satisfaction. Risk factors of burnout included stress, work control, atmosphere (chaos), documentation time pressure, teamwork, values alignment, EMR work at home, and EMR frustration; these items were transformed from 5-point Likert scale responses to binary variables by grouping positive responses (eg, strongly agree and agree) and neutral and negative responses (eg, neither agree nor disagree, disagree, and strongly disagree). Sex-based differences in summary scores, burnout, satisfaction, and all of the previously mentioned risk factors for burnout were tested in separate, single logistic regression models. The level of statistical significance was P < .05.

    Results

    Response rates in the 8 chapters and 2 cohorts of WC programs for whom sampling data were available (n = 11 625) ranged from 2% to 76% (median 9.5%). Among 1270 respondents who indicated their sex, 665 were men (52.4%) and 605 were women (47.6%); 680 respondents (52.1%%) reported symptoms of burnout.

    For the single logistic regression models, the reference group was male. Although 938 of 1305 respondents (71.9) reported career satisfaction, the burnout level (52.1%) was high in this sample of ACP members. One-third of participants (n = 419) reported poor or marginal work control, and approximately one-half (n = 673) reported time pressure associated with EMR documentation (Table). In the regressions, burnout was associated with lack of work control (OR, 2.32 [95% CI, 1.66-3.26]; P < .001) and documentation time pressure (OR, 1.64 [95% CI, 1.20-2.24]; P = .002). Job satisfaction was associated with professional values alignment with those of clinical leaders (OR, 4.24 [95% CI, 3.05-5.81]; P < .001) and efficient teamwork (satisfactory to optimal) (OR, 2.47 [95% CI, 1.59-3.87]; P < .001). The odds of burnout among women were 56% higher compared with men (Table), and women had 61% lower odds of having a joyous workplace, 39% lower odds of having supportive work environments, and 61% lower odds of having a manageable work pace and manageable EMR-related stress.

    Discussion

    Although most of the surveyed ACP members reported career satisfaction (71.9%), burnout levels were high. Risk factors of burnout included documentation time pressure and lack of work control, whereas satisfaction was associated with alignment of professional values with those of the respondents’ clinical leaders and efficient teamwork. As in previous studies,6 female clinicians had higher odds of burnout than male clinicians, and were less likely to describe supportive environments or manageable work conditions. This study is limited by the absence of demographic data other than sex and the need for additional validation of the Mini Z 2.0 survey. Although the study is also limited by nonrandom sampling, data from this cohort of ACP members may still be generalizable to other populations for assessment of sex-based differences in potential associations between work conditions and burnout.

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    Article Information

    Accepted for Publication: July 19, 2020.

    Published: October 14, 2020. doi:10.1001/jamanetworkopen.2020.18758

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Linzer M et al. JAMA Network Open.

    Corresponding Author: Mark Linzer, MD, Department of Medicine (G5), Hennepin Healthcare, 701 Park Ave, Minneapolis, MN 55415 (Mark.Linzer@hcmed.org).

    Author Contributions: Dr Linzer and Ms Frees had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Linzer, Smith, Hingle, Poplau, Miranda, Palamara.

    Acquisition, analysis, or interpretation of data: Linzer, Hingle, Poplau, Miranda, Freese.

    Drafting of the manuscript: Linzer, Hingle, Miranda, Freese, Palamara.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Linzer, Freese.

    Obtained funding: Linzer.

    Administrative, technical, or material support: Linzer, Smith, Hingle, Poplau, Palamara.

    Supervision: Linzer, Smith, Hingle, Palamara.

    Conflict of Interest Disclosures: Dr Linzer reported receiving grants from the American College of Physicians (ACP) during the conduct of the study; grants from the American Medical Association (AMA), the Institute for Healthcare Improvement, the Agency for Healthcare Research and Quality, and the American Board of Internal Medicine Foundation outside the submitted work; serving as a consultant to Harvard University and CRICO Medical Malpractice insurer; and receiving honoraria for grand rounds lectures. Dr Smith reported spousal employment by Merck and is an employee of the ACP. Ms Poplau reported receiving grant support from the ACP for the Well-being Champion training program and a grant from the AMA for burnout prevention research programs. Ms Freese reported receiving a grant from the National Institutes of Health during the conduct of the study. Dr Palamara reported receiving consulting fees and travel reimbursement for work with the ACP. No other disclosures were reported.

    Funding/Support: This study was supported by the ACP and by the National Institutes of Health’s National Center for Advancing Translational Sciences grant No. UL1TR002494 (Ms Freese).

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health’s National Center for Advancing Translational Sciences.

    Additional Contributions: Cheryl Rusten, MPA, and Clare Sipler, BA, from the ACP, contributed to the data collection and organization of the annual training sessions. Maria L. Walter, MSOD, from the ACP, performed data management and obtained follow-up data from Well-being Champions. They were paid as staff from ACP on this project, but not specifically for their contributions to this article.

    References
    1.
    Shanafelt  TD, West  CP, Sinsky  C,  et al.  Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017.   Mayo Clin Proc. 2019;94(9):1681-1694. doi:10.1016/j.mayocp.2018.10.023PubMedGoogle ScholarCrossref
    2.
    Khandelwal  A, Mehta  L, Lilly  S, Velagapudi  P.  The imperative of addressing clinician well-being.   J Am Coll Cardiol. 2020;75(1):118-121. doi:10.1016/j.jacc.2019.12.001PubMedGoogle ScholarCrossref
    3.
    Erickson  SM, Rockwern  B, Koltov  M, McLean  RM; Medical Practice and Quality Committee of the American College of Physicians.  Putting patients first by reducing administrative tasks in health care: a position paper of the American College of Physicians.   Ann Intern Med. 2017;166(9):659-661. doi:10.7326/M16-2697PubMedGoogle ScholarCrossref
    4.
    Olson  K, Sinsky  C, Rinne  ST,  et al.  Cross-sectional survey of workplace stressors associated with physician burnout measured by the Mini-Z and the Maslach Burnout Inventory.   Stress Health. 2019;35(2):157-175. doi:10.1002/smi.2849PubMedGoogle ScholarCrossref
    5.
    Linzer  M, Poplau  S, Babbott  S,  et al.  Worklife and wellness in academic general internal medicine: results from a national survey.   J Gen Intern Med. 2016;31(9):1004-1010. doi:10.1007/s11606-016-3720-4PubMedGoogle ScholarCrossref
    6.
    McMurray  JE, Linzer  M, Konrad  TR, Douglas  J, Shugerman  R, Nelson  K; The SGIM Career Satisfaction Study Group.  The work lives of women physicians results from the physician work life study.   J Gen Intern Med. 2000;15(6):372-380. doi:10.1111/j.1525-1497.2000.im9908009.xPubMedGoogle Scholar
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