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Physician Jessie Mahoney discusses her article “Ending burnout through structure, not gimmicks,” making the case that the most effective remedies for physician burnout are systemic changes—reasonable patient loads, thoughtful schedules, supportive leadership, and reduced clerical work—not token perks or quick fixes. Jessie highlights the essential role of lifestyle medicine, mindfulness, and coaching in sustaining physicians’ health and purpose, and warns against treating burnout as an individual failing instead of a cultural distress signal. She offers a layered approach combining institutional accountability, personal responsibility, and cultural evolution to create a medical environment where physicians can thrive and, in turn, deliver better patient care.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Jessie Mahoney, a pediatrician and certified coach. Today’s KevinMD article is “Ending burnout through structure, not gimmicks.” Jessie, welcome back to the show.

Jessie Mahoney: Thanks so much for having me.

Kevin Pho: All right. Tell us what your latest article is about.

Jessie Mahoney: It’s about the science of burnout. We know all these things, but we don’t do them. We often say it’s a systems issue, but we feel we can’t fix it. What can we do? I was asked by a client who had been on a retreat to give a talk to her emergency room colleagues about what helps with burnout and what they can actually do. That was where this came from: what was the science, what really worked, and was there anything that they could do?

In sharing that with her, it’s super important that we address the structural stuff; it has to be addressed. I don’t think we can fix burnout without addressing that. We also have to address the other things that we scientifically know help. We’ve done all these studies on burnout for years and years, and yet we often don’t do those things while waiting for the other. What we really found is we don’t do a whole lot; we just study it. The invitation of the article is really: what do we know? What can we do? What’s in our control, what’s not in our control? And maybe, what could we do first and how can we layer it so things actually begin to change?

Kevin Pho: So let’s start with some of the evidence that we’re talking about. What are some of the evidence-based practices that you’ve seen in studies that help with burnout?

Jessie Mahoney: Well, mindfulness. There are tons of studies that a mindfulness practice helps with burnout.

Kevin Pho: And what is that? What do you mean by that?

Jessie Mahoney: So, mindfulness can be a mindfulness practice, so it can be meditation, but it can also be anything that really works on your nervous system, like upregulating our parasympathetic nervous system. I think many people think mindfulness is hard, but it doesn’t have to be. Most of the studies are actually done on true meditation or mindfulness, and the studies show effects at 12 minutes because that’s what they picked to study. But I think most people believe that any minutes are better than no minutes, and it’s more of a dose effect.

The reason for this is not that you can meditate away your burnout or make all the problems go away. But when you upregulate your parasympathetic nervous system, you have more agency and control over your response to what’s happening. You can choose to respond to things that are in your control and not in your control and respond rather than react. You also have the agency to make other decisions that make things better for you.

I like to think of mindfulness not strictly as meditation, because there are a lot of studies about forest bathing, which is mindfulness, and how it impacts your physiology, and sound healing, and yoga, and all of these things. It isn’t that a yoga class or a meditation practice will fix things, but we have science to show that it helps you as an individual, and it’s in your control.

Kevin Pho: So when you talk about meditation, I’ve heard downloading an app, perhaps. Would that count?

Jessie Mahoney: It counts. I often tell people, don’t make it hard. If you don’t know meditation, download an app. Pick the one-minute, three-minute, or five-minute option, hit play, and do what they say. It’s better than nothing. I think what people find is the more they do it, they then begin to understand what it feels like to be mindful and how that feels different than their usual state of being.

What I like to say is it’s not the answer to burnout. But when we each change, then we’re capable of advocating in more effective ways for the structural changes that are needed, or we’re capable of being the leaders who are then able to make those structural human changes. Yes, burnout won’t go away without them, and I think that was what was critical to bring up in this article. If we don’t change moral injury, burnout is not going to go away, but we have to start somewhere.

Kevin Pho: All right, so what other evidence-based practices are there?

Jessie Mahoney: There’s lots of evidence around coaching and how physician coaching decreases burnout and improves quality of life. There are quite a few randomized controlled trials, and those have now been done in residencies, beyond residency, in lots of different settings, and with lots of different programs. We know that that work to sort of reprogram the way you think and respond in a more intentional way, in addition to mindfulness and pausing and creating space, does create change.

The way I like to think about that as well is when we are our healthier selves. Professional athletes have coaches so that they can respond in complex, challenging situations. We can learn to respond to the complex, challenging situation that is medicine very strategically, and that’s how we’ll be able to lead and advocate for change effectively. Maybe we can even change our own situations in big and small ways so that we are less burnt out and we have more capacity to advocate and even mandate changes that are necessary for safety, for example.

The last bit that we sometimes forget is lifestyle medicine. There’s this huge trend in lifestyle medicine for patients. But if we don’t sleep as physicians, we will suffer from burnout and be more burnt out at much higher rates. If we don’t eat healthy, same thing. If we don’t move, same thing. Mindfulness and stress reduction are also part of lifestyle medicine. The connection and community piece is really important. In medicine, so many of us are in our silos because expectations are so overwhelming, and we feel alone and like we don’t belong for many reasons. So just getting back to those basics, the same things that we advocate for our patients, and making sure they apply to ourselves equally, can make a huge difference in burnout. We have science around those things. We know they make us healthier. They make us—I do not like the word “more resilient”—but they make us able to respond better to challenging situations. They won’t heal burnout, but without them, we can change the system and things won’t change for us either.

Then the other piece here is really culture change, and culture change can’t happen if we aren’t changing the culture ourselves. Each and every one of us, if we aren’t taking care of our own lifestyle medicine and our own health and wellness, the culture doesn’t change. If we don’t expect that of others, it doesn’t change. But none of us can do that from that burnt-out place.

The science really comes down to this: there’s a lot more science on the personal changes because most of the structural changes have not been made yet. To be fair, there are lots of new pilot programs that are being studied. Of course, if you have a reasonable expectation of the amount of work you can do and a reasonable number of patients you can see, and of course, if you’re not charting at home, and of course if we’re not being blamed for things that are out of our control, we will have less burnout. But those studies really haven’t been done because we haven’t gotten there yet.

Kevin Pho: So it sounds like it doesn’t have to be an either/or situation. There are some individual things that physicians can do to help with burnout, like you mentioned mindfulness, lifestyle medicine, and coaching. And we don’t have to just wait for the structural changes to help improve burnout. I just want to explicitly say that because a lot of people say that it is just structural changes that are the most effective in terms of reducing burnout. So you’re saying that there’s some evidence suggesting that there are some things that we can do individually as physicians to help as well.

Jessie Mahoney: And I personally believe those are what’s going to lead to the structural changes. Because when we as physicians are healthier and have more capacity to advocate strategically and have more room to be thoughtful and creative, that’s where some of these structural changes will ultimately happen. I also think the cultural piece, which ultimately comes out of that individual piece, is important. We’re all responsible for the culture in medicine. Sometimes we say it comes from above, but it also comes from within. If we each change, that culture will begin to change. When the tides shift and we’re all not willing to accept certain things, then structural changes happen.

Kevin Pho: And when you say structural changes, are we talking about things like AI scribes to decrease the burden of documentation, seeing fewer patients, more time? What kind of structural changes are we talking about specifically?

Jessie Mahoney: It’s literally all of those. I think we’re almost there with AI scribes. It hasn’t been implemented everywhere, but people have seen a tremendous shift. One of the things I notice is that we used to always say, “The better physicians are the ones who get their charts done and see patients at the same time.” Now that there’s AI, people are saying, “Oh no, actually, you use AI and you focus on the patients, and that is how you don’t have burnout.” That’s an example of how maybe we were gaslit in the past with those statements, and yet structural changes prove things that we already knew. So definitely AI scribes, and I’m sure there are a lot of other AI inventions and innovations that are going to help medicine tremendously.

I think reasonable human expectations for how many patients we can see and how much time it takes to see a patient are key. Perhaps even that old adage that putting in the time upfront with longer primary care appointments might avoid more illness and specialty care and, in the long run, save money. The issue is that medicine has become a business, so it’s being run by business people and not medical people. But those structural changes where we acknowledge that physicians are human and have human needs and human capacity—about how much call they can take and how many patients they can see—are important. And a real acknowledgement about what’s our responsibility and what responsibility could be done by others. I also like to think about our training and what we’re trained to do versus what others are trained to do. That seems to have gotten a bit muddled over time. So, clear structural change where we’re really looking at efficiency and optimization, but from a human standpoint, not from a “more is better” standpoint, because we know that more is not better.

Kevin Pho: Now for those health care administrators who may be listening to you, there may be a cynical perspective saying that if there’s so much evidence saying that individual changes can help with burnout, why do we have to make structural changes? For your advice to these health care administrators who may be listening to you, what would you like to see them do?

Jessie Mahoney: It’s because it’s not an either/or. They have to be together. If as physicians, we take care of ourselves and the system doesn’t change, it won’t work. And if the system changes and we don’t take care of ourselves, it won’t work. It’s because it’s such a complex, interrelated system. But the changes that need to be made at a systemic level are these reasonable human expectations of what’s possible, and also having physicians be responsible only for things that are actually in their control. So, really changing the way we look at what is good medicine. A lot of the things in medicine don’t fit into business, and so if health care administrators can really look at medicine as this unique, special entity and how we can make it work, it’s going to be different than your usual business economics.

Kevin Pho: Because I’m sure that you’re going to anticipate what they’re going to say, right? It’s, “Why do we have to spend millions to get an AI scribe?” or, “We can’t afford to see fewer patients because of financial constraints.” It’s probably easier just to tell everyone to download a meditation app. Are you hearing that type of response?

Jessie Mahoney: Absolutely, absolutely. Especially right now, because it’s like, “Well, we have budget issues and we’re losing funding.” So there’s really a lot more pressure on physicians to not do the things that help them. But I would say they can’t afford not to. The retention issues are really where we’re getting into trouble. If they can’t afford to do this, they’re not going to have physicians, or they’re going to have to spend the money on hiring new doctors and churning through them, which is very, very expensive. It’s so expensive to train and onboard a doctor that making some of these systemic changes, ultimately, is a little bit like preventive care in medicine: it saves you a lot of money down the line.

We really have to think structurally in an innovative way. What I’ve just seen over the years is we just pass the buck down. “We can’t do it now because there’s a pandemic. We can’t do it now because there’s financial hardship. We can’t do it now because we don’t have whatever.” There’s always a reason. Then we’re not making headway into this burnout, and yet we have science to show what helps. I do think that there are some programs now that are being trialed and piloted to show that they do help with burnout. So hopefully we will have some more science around that. But I also think that in medicine, we always wait for the science, and we cause a lot of human suffering in our systems. I don’t think that anybody can argue that having non-human expectations of humans doing a job is reasonable. The skyrocketing rates of burnout show that.

Kevin Pho: So just to be clear, for those individual physicians, we need to take responsibility as well. Give us the message that you would like to say to these physicians who say, “I don’t have time to meditate. I don’t have time to find a coach. I’m too busy. I’m seeing too many patients. I have a family to take care of.” What’s your message to the physicians who simply say they don’t have the time?

Jessie Mahoney: For these evidence-based approaches, they don’t have time not to, is what I would say. The cost of being burnt out is that you’re reactive, and you tend to have relationship problems. You have problems interacting with your kids. Your patient satisfaction scores are worse, and your efficiency is worse. While we are trained in medicine to push through and do more and more, we are actually becoming less efficient.

What I see is people who are mindful actually provide better care, higher quality of care, and at a lower cost. They have lower readmissions. There are studies to show this, and this is actually also evidence for why organizations should be paying attention and should fund and support this and give physicians time. If they’re going to do nothing structural, they could at least support this and fund it and make sure physicians have ways to access coaches and mindfulness tools—not just, “Here, download this app and fit it in in negative time,” but how can we work together to make these things happen?

The other way I like to think about it for individual physicians is, if nothing else, it’s going to make it better for you right now. If you want to sit and wait for organizations to change, you’re going to be miserable in the process. If you really care about yourself, your family, your patients, your teams, your colleagues, and the culture of medicine, taking this individual approach is going to help. It ultimately is what’s going to help you advocate effectively. I think that so many people are not advocating effectively because they’re burnt out, because they don’t have time, because they’re not mindful, and then we don’t make change and we sit in this spiral. This can be the first step to unwinding the snarled yarn ball, if you will. And if nothing else, you benefit.

We say you can’t create time, but mindfulness creates time. Coaching creates time. Notice how more efficiently we tend to move through our day if we’ve exercised or if we’ve eaten healthy, how you feel different, you have more energy. So I think really thinking the opposite: we don’t have time not to. The same message for organizations who say they don’t have enough money to do this, I would say it’s going to cost you a lot more not to.

Kevin Pho: We’re talking to Jessie Mahoney, pediatrician and coach. Today’s KevinMD article is “Ending burnout through structure, not gimmicks.” Jessie, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Jessie Mahoney: There’s science about burnout, and it’s both individual and structural. We can’t do just one; things won’t change. But also, we must start doing something rather than just waiting for the other person or other pockets to make the change. There are things that each pocket can do, and really if we do nothing and take no action, nothing will change.

Kevin Pho: Jessie, as always, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Jessie Mahoney: Thanks for having me.